Cough and expectoration
? Coughing is an essential defense mechanism
that it prevents the airways from the foreign
substance and clear the excretion of respiratory
tract,
? Coughing is a reflex,permanent and frequent
coughing indicates an abnormality,
Mechanism
? Extrathoracic cough receptors ( located in nose
oropharynx larynx and upper trachea)
? intrathoracic cough receptors ( located in low
trachea and large central bronchi)
? Afferent ( vague,trigeminal,superior laryngeal,
glosso-pharyngeal nerves )
? Efferent
? recurrent laryngeal nerve --- closure of glottis
? corticospinal tract and peripheral nerves -------
contraction of thoracic and abdominal musculature,
The cough reflex
A deep breath---glottic closure---relaxation of
diaphragm,contraction of expiratory muscle---
positive thoracic pressure--suddenly release of
glottis open---thoracic positive pressure airflow
out--- cough reflex
Etiology
? Respiratory
? pleural disease
? cardiovascular disease
? central nerve system factor
Respiratory disease
Stimulator --- extra and intrathoracic --- from
nose,oropharynx --- bronchi --- cough reflex,
such as,
1.inhalation of foreign material
2.inflammation of respiratory tract
3.bleeding of respiratory tract
4.tumor of respiratory tract
Pleural Disease
Such as,
? pleurisy,thoracic effusion
? pleural biopsy or pleuracentisis
Cardiovascular Disease
? Mitral stenosis --- left heart failure ---
pulmonary edema --- trausudate or exudate
--- stimulates intra-thoracic-cough receptor
--- cough
? Embolism of pulmonary can cause
pulmonary venous pressure elevate ---
pulmonary edema ---transudate or exudate
---stimulates intra thoracic cough receptor
---cough
Central nerve system
? Inflammatory of CNS can cause coughing
? such as,encephalitis and meningitis
Expectoration
Expectoration is a pathological phenomenon
that human being remove the pathological
secretion from respiratory system by means
of coughing
Expectoration
? The daily quantity of bronchial secretions
produced by a normal person is unknown,
But it is sufficiently small to be removed
by mucocillary action alone,
? Cough and expectoration are not required
Expectoration
? Excessive production
? Altered physical properties
? Deficient clearance
These factors cause the secretions
accumulate in the tracheobronchial
system and cause expectoration,
Expectoration
Mechanical,chemical,physical and allergic
factors can cause respiratory mucosa edema,
congestion and cause transudate or exudate
then cough and expectoration appears
Expectoration
Such as,
1) Inflammation include virus,bacteria,fungus
can cause coughing and expectoration,
2)Acute left heart failure can cause pulmonary
edema and pink foamy sputum,
Manifestation
? Character of cough
? The duration and pattern of cough
? The tone quality of cough
? The character and volume of sputum
Character of cough
? Cough without sputum---unproductive or dry
cough mainly in the patient of acute pharyngitis,
early stage of bronchitis,pleurisy and TB,
? Cough with sputum is called productive,
It is caused by pneumonia,chronic
bronchitis,bronchiectasis,lung abscess
and cavitious TB
The character and volume of sputum
? clear,white,gray sputum--chronic bronchitis
? tenacious sticky mucoid sputum -----
asthmatics(occasionally with bronchial cast)
? foul-smelling purulent sputum--bronchiectasis
? sputum with calcific particles -----
broncholithoptysis
The duration and pattern of cough
? Cough initiated suddenly --- acute upper airway
infection
? Chronic cough --- chronic bronchitis,bronchial
asthma and TB
? Paroxysmal cough --- whooping cough,bronchi
compressed by tumor and TB
The duration and pattern of cough
? Periodic cough --- chronic bronchitis
bronchiectasis related to the change of body
position,
? Nocturnal cough---asthma,TB,chronic heart
failure--associated with the vagal excitation
at night,
The tone quality of cough
? It means the change of the sound and may
suggest the the location of pathology,
?,breaking” cough --- epiglottal disease
?,brassy” cough --- tracheal airways
?,hacking” or,cleaning of throat”--postnasal
discharge
?,barking”or,croupy”--laryngeal disease,
The tone quality of cough
? Hoarseness with cough --- larynto-tracheal
bronchitis or impaired the function of recurrent
laryngeal nerve,as from aneurysm of the aorta,
left atrial enlargement,mediastinal malignancy.
? Inspiratory stridor --- upper airway obstruction
The tone quality of cough
? Cough with hemoptysis also raises the
possibility of a malignant process,
bronchiectasis,lung abscess,chronic
bronchitis,
The associated clinical features
? cough with fever --- acute respiratory
infection including measles,pneumonia,
influenza,lung abscess,TB,pleurisy,
? cough with chest pain --- plural cavity
involve,heart disease,pneumonia,pleurisy,
bronchogenic carcinoma,
The associated clinical features
? cough with dyspnea -------- edema of larynx,
larynx tumor,chronic obstructive pulmonary
disease,sever pneumonia,TB,massive pleural
effusion,pulmonary congestion,pneumothorax
and pulmonary edema,
? cough with quantitative purulent sputum ---
bronchiectasis,lung abscess,bronchi-fistula,
The associated clinical features
? Cough with hemoptysis --- bronchiectasis,
TB,lung tumor,lung abscess,mitral stenosis.
? cough with clubbed fingers --- bronchiectasis,
TB,lung abscess,carcinoma of lung,thoracic
empyema,
The associated clinical features
? Cough with wheeze --- bronchial asthma,
cardiac asthma,foreign body in trachea
and bronchi,
Complication of cough
? pneumomediastinum
? posttussic emesis
? tussic syncope
? rib fracture
? spontaneous pneumothorax
? bullous emphysema
? abdominal hernias
Any change in character or
pattern of a chronic cough
warrants immediate diagnostic
evaluation,with special attention
directed towards the detection of
bronchogenic carcinoma,
Hemoptysis
? Hemoptysis is the expectoration of blood
from airway blow larynx,
? Hemoptysis patients should be examined
the nose,mouth and upper respiratory tract
to be found the hemorrhagic spot,
Hemoptysis
? the quantity of blood may vary from streaks
and flecks in the sputum to massive
hemorrhage,
? minimal bleeding may be an early indicator
of the presence of serious bronchopulmonary
disease,
? hemorrhages of even moderate degree may
life threatening,
Hemoptysis
? About 50 percent of the chest films of the
hemoptysis patient show no abnormalities
or only minimal nonspecific change,
? Hemoptysis may be the initial or the sole
symptom of bronchopulmonary disease,
These factors sometimes cause the
dignostic problem,
Etiology
1.Bronchial disease
2.lung disease
3.cardiovascular disease
4.constitutional disease
1.Bronchial disease
? hemoptysis occur in bronchiectasis,chronic
bronchitis,endobronchial tuberculosis and
bronchogenic carcinoma,
? Also occur in the benign bronchogenic tumor,
bronchiectasis,foreign body,bronchogenic
nonspecific ulceration,
1.Bronchial disease
? The inflammatory process lead to the increase
the permeability of capillary and rapture of
vessels in bronchial mucosa and then induce
hemoptysis,
? blood-streaked sputum occasionally occur in
the course of acute bronchitis,
2.Lung disease
? The sputum of pneumococcal pneumonia is
described as,rusty” in appearance,
? Pulmonary TB is the common cause of the
hemoptysis,
? Cavitious TB may cause the expectoration
of frank blood from pulmonary cavity,
2.Lung disease
? Lung abscess may be related to putrid smelling
sputum and expectoration of blood,
? hemoptysis occur in 25 percent of the patient
of pulmonary embolism and infarction,
? pulmonary fungi and parasite infection may also
serve as the sources of hemoptysis,
3.Cardiovascular disease
? Pink frothy sputum --- acute pulmonary edema
? blood streaked sputum--acute pulmonary congestion
blood comes from pulmonary capillaries which
ruptured under high intravascular pressure,
3.Cardiovascular disease
? Hemoptysis due to mitral stenosis is frequently
induced by physical exercise or excitement,
Blood comes from a break in the pulmonary
veins which have ruptured under high pressure,
The bleeding is due to rupture of endobronchial
vessels that from collateral channels between the
bronchial veins and pulmonary venous system,
The bleeding tend to subside as the veins adapt
to high pressure and as pulmonary arteriolar
disease develops,
3.Cardiovascular disease
? Many pulmonary emboli do not lead to pulmonary
infarction,when they do,frank hemoptysis occurs
in the minority of instance,
? when hemoptysis occur in the pulmonary infarction
of the heart failure patient,the blood sputum usually
appears within a few hours to a day after the embolus,
and this is due to necrosis and hemorrhages into the
alveoli,
3.Cardiovascular disease
? Hemoptysis is also associated with
congenital cardiac disease and aortic
aneurysms
4.Constitutional disease
? Blood spitting may also occur in the patients
suffering from certain blood dyscrasias,such as
hemophilia,leukemia and infectious disease,
connective tissue disease,
Clinical manifestation
1.the patient’s age,
2.the amount of coughing up blood,
3.color and character,
1.The patient’s age
? Hemoptysis is often seen in pulmonary TB,
bronchiectasis and rheumatic heart disease
(mitral stenosis) for most youth,
? Cancer is now the disease that patients think
of when they expectorate blood,just as it
was TB 50 years ago,
1.The patient’s age
? Elder patient with bloody sputum or streaked
of bloody sputum,especially in the males with
long history of smoking.cancer should be taken
into account,
? Patients close contact with TB suffer,TB should
be considered,
1.The patient’s age
? Paragonimiasis may suspected in the people
with history of eating raw or improperly cooked
crabs or crayfish,
? Epidemic hemorrhagic fever,leptospirosis also
can cause hemoptysis,they are endemic disease,
2.The amount of coughing up blood
? Hemoptysis can be classified into three groups
according to the amount of coughing blood,
Massive,expectoration > 500ml/24hr,
Moderate,500ml> expectoration >100ml/24hr
minimal,expectoration <100ml/24hr
2.The amount of coughing up blood
massive hemoptysis often occurs in pulmonary
TB cavity,chronic lung abscess and bronchiectasis,
3.Color and character,
? To a hemoptysis patient,it is necessary to
ascertain the exact nature of the sputum,
the sputum must be examined both grossly
and microscopically,
3.Color and character
It is useful to determine whether the material
that is coughed up contains large amount of
liquid blood,which is indicates brisk bleeding,
or whether it contains small amount of dark or
clotted blood,which would indicate slow bleeding
from low-pressure vessels or subsiding bleeding,
3.Color and character
? Brisk bleeding is commonly associated with
specific focal ulceration of the bronchus,such
as bronchogenic carcinoma,a foreign body,
bronchiectasis or a bleeding aortic aneurysm,
? Slow bleeding strongly suggests venous bleeding
which is more likely to be the result of increased
in blood flow through the bronchial venous system
such as may occur as a result of mitral stenosis or
bronchiectasis,
Accompanying symptom
? Hemoptysis with fever,pulmonary tuberculosis,
pneumonia,lung abscess,lopeospirosis,epidemic
hemorrhagic fever,bronchogenic carcinoma,
? Hemoptysis with chest pain,lobar pneumonia,
pulmonary infarction,pulmonary TB,lung cancer,
Accompanying symptom
? Hemoptysis with putrid sputum:lung abscess
cavitious TB,bronchiectasis,
? Hemoptysis with irritating cough:bronchogenic
carcinoma,mycoplasma pneumonia,
Accompanying symptom
? Hemoptysis with skin and mucosa bleeding,
hematological disease,epidemic hemorrhagic
fever,rheumatism,leptospirosis,
? Hemoptysis with jaundice:leptospirosis,lobar
pneumonia,pulmonary infarction,
The distinction between
hemoptysis and hematemsis
H e m o p t y s i s H e m a t e m e s i s
H i s t o r y, T, B,b r o n c h i e c t a s i s U l c e r,c i h r r o s i s
P r e s y m p t o m, C o u g h,c h e s t d i s c o m f o r t a b l e V o m i t,n a u s e a,e p i g a s t r i c
d i s c o m f o r t
M o d e o f
e x p e c t o r a t i o n,
B l o o d s p i t t i n g V o m i t i n g
C o l o r o f b l o o d, B r i g h t r e d D a r k r e d a n d b l a c k
M a t e r i a l m i x e d
w i t h b l o o d,
M i x e d w i t h a i r b u b b l e a n d
s p u t u m
C o n t a i n f o o d d e b r i t s g a s t r i c
j u i c e
Ph A l k a l i n e A c i d
m e l e n a No
O c c a s i o n a l l y s w a l l o w e d
Y e s
M a y c o n t i n u e f o r s e v e r a l
d a y s
? Coughing is an essential defense mechanism
that it prevents the airways from the foreign
substance and clear the excretion of respiratory
tract,
? Coughing is a reflex,permanent and frequent
coughing indicates an abnormality,
Mechanism
? Extrathoracic cough receptors ( located in nose
oropharynx larynx and upper trachea)
? intrathoracic cough receptors ( located in low
trachea and large central bronchi)
? Afferent ( vague,trigeminal,superior laryngeal,
glosso-pharyngeal nerves )
? Efferent
? recurrent laryngeal nerve --- closure of glottis
? corticospinal tract and peripheral nerves -------
contraction of thoracic and abdominal musculature,
The cough reflex
A deep breath---glottic closure---relaxation of
diaphragm,contraction of expiratory muscle---
positive thoracic pressure--suddenly release of
glottis open---thoracic positive pressure airflow
out--- cough reflex
Etiology
? Respiratory
? pleural disease
? cardiovascular disease
? central nerve system factor
Respiratory disease
Stimulator --- extra and intrathoracic --- from
nose,oropharynx --- bronchi --- cough reflex,
such as,
1.inhalation of foreign material
2.inflammation of respiratory tract
3.bleeding of respiratory tract
4.tumor of respiratory tract
Pleural Disease
Such as,
? pleurisy,thoracic effusion
? pleural biopsy or pleuracentisis
Cardiovascular Disease
? Mitral stenosis --- left heart failure ---
pulmonary edema --- trausudate or exudate
--- stimulates intra-thoracic-cough receptor
--- cough
? Embolism of pulmonary can cause
pulmonary venous pressure elevate ---
pulmonary edema ---transudate or exudate
---stimulates intra thoracic cough receptor
---cough
Central nerve system
? Inflammatory of CNS can cause coughing
? such as,encephalitis and meningitis
Expectoration
Expectoration is a pathological phenomenon
that human being remove the pathological
secretion from respiratory system by means
of coughing
Expectoration
? The daily quantity of bronchial secretions
produced by a normal person is unknown,
But it is sufficiently small to be removed
by mucocillary action alone,
? Cough and expectoration are not required
Expectoration
? Excessive production
? Altered physical properties
? Deficient clearance
These factors cause the secretions
accumulate in the tracheobronchial
system and cause expectoration,
Expectoration
Mechanical,chemical,physical and allergic
factors can cause respiratory mucosa edema,
congestion and cause transudate or exudate
then cough and expectoration appears
Expectoration
Such as,
1) Inflammation include virus,bacteria,fungus
can cause coughing and expectoration,
2)Acute left heart failure can cause pulmonary
edema and pink foamy sputum,
Manifestation
? Character of cough
? The duration and pattern of cough
? The tone quality of cough
? The character and volume of sputum
Character of cough
? Cough without sputum---unproductive or dry
cough mainly in the patient of acute pharyngitis,
early stage of bronchitis,pleurisy and TB,
? Cough with sputum is called productive,
It is caused by pneumonia,chronic
bronchitis,bronchiectasis,lung abscess
and cavitious TB
The character and volume of sputum
? clear,white,gray sputum--chronic bronchitis
? tenacious sticky mucoid sputum -----
asthmatics(occasionally with bronchial cast)
? foul-smelling purulent sputum--bronchiectasis
? sputum with calcific particles -----
broncholithoptysis
The duration and pattern of cough
? Cough initiated suddenly --- acute upper airway
infection
? Chronic cough --- chronic bronchitis,bronchial
asthma and TB
? Paroxysmal cough --- whooping cough,bronchi
compressed by tumor and TB
The duration and pattern of cough
? Periodic cough --- chronic bronchitis
bronchiectasis related to the change of body
position,
? Nocturnal cough---asthma,TB,chronic heart
failure--associated with the vagal excitation
at night,
The tone quality of cough
? It means the change of the sound and may
suggest the the location of pathology,
?,breaking” cough --- epiglottal disease
?,brassy” cough --- tracheal airways
?,hacking” or,cleaning of throat”--postnasal
discharge
?,barking”or,croupy”--laryngeal disease,
The tone quality of cough
? Hoarseness with cough --- larynto-tracheal
bronchitis or impaired the function of recurrent
laryngeal nerve,as from aneurysm of the aorta,
left atrial enlargement,mediastinal malignancy.
? Inspiratory stridor --- upper airway obstruction
The tone quality of cough
? Cough with hemoptysis also raises the
possibility of a malignant process,
bronchiectasis,lung abscess,chronic
bronchitis,
The associated clinical features
? cough with fever --- acute respiratory
infection including measles,pneumonia,
influenza,lung abscess,TB,pleurisy,
? cough with chest pain --- plural cavity
involve,heart disease,pneumonia,pleurisy,
bronchogenic carcinoma,
The associated clinical features
? cough with dyspnea -------- edema of larynx,
larynx tumor,chronic obstructive pulmonary
disease,sever pneumonia,TB,massive pleural
effusion,pulmonary congestion,pneumothorax
and pulmonary edema,
? cough with quantitative purulent sputum ---
bronchiectasis,lung abscess,bronchi-fistula,
The associated clinical features
? Cough with hemoptysis --- bronchiectasis,
TB,lung tumor,lung abscess,mitral stenosis.
? cough with clubbed fingers --- bronchiectasis,
TB,lung abscess,carcinoma of lung,thoracic
empyema,
The associated clinical features
? Cough with wheeze --- bronchial asthma,
cardiac asthma,foreign body in trachea
and bronchi,
Complication of cough
? pneumomediastinum
? posttussic emesis
? tussic syncope
? rib fracture
? spontaneous pneumothorax
? bullous emphysema
? abdominal hernias
Any change in character or
pattern of a chronic cough
warrants immediate diagnostic
evaluation,with special attention
directed towards the detection of
bronchogenic carcinoma,
Hemoptysis
? Hemoptysis is the expectoration of blood
from airway blow larynx,
? Hemoptysis patients should be examined
the nose,mouth and upper respiratory tract
to be found the hemorrhagic spot,
Hemoptysis
? the quantity of blood may vary from streaks
and flecks in the sputum to massive
hemorrhage,
? minimal bleeding may be an early indicator
of the presence of serious bronchopulmonary
disease,
? hemorrhages of even moderate degree may
life threatening,
Hemoptysis
? About 50 percent of the chest films of the
hemoptysis patient show no abnormalities
or only minimal nonspecific change,
? Hemoptysis may be the initial or the sole
symptom of bronchopulmonary disease,
These factors sometimes cause the
dignostic problem,
Etiology
1.Bronchial disease
2.lung disease
3.cardiovascular disease
4.constitutional disease
1.Bronchial disease
? hemoptysis occur in bronchiectasis,chronic
bronchitis,endobronchial tuberculosis and
bronchogenic carcinoma,
? Also occur in the benign bronchogenic tumor,
bronchiectasis,foreign body,bronchogenic
nonspecific ulceration,
1.Bronchial disease
? The inflammatory process lead to the increase
the permeability of capillary and rapture of
vessels in bronchial mucosa and then induce
hemoptysis,
? blood-streaked sputum occasionally occur in
the course of acute bronchitis,
2.Lung disease
? The sputum of pneumococcal pneumonia is
described as,rusty” in appearance,
? Pulmonary TB is the common cause of the
hemoptysis,
? Cavitious TB may cause the expectoration
of frank blood from pulmonary cavity,
2.Lung disease
? Lung abscess may be related to putrid smelling
sputum and expectoration of blood,
? hemoptysis occur in 25 percent of the patient
of pulmonary embolism and infarction,
? pulmonary fungi and parasite infection may also
serve as the sources of hemoptysis,
3.Cardiovascular disease
? Pink frothy sputum --- acute pulmonary edema
? blood streaked sputum--acute pulmonary congestion
blood comes from pulmonary capillaries which
ruptured under high intravascular pressure,
3.Cardiovascular disease
? Hemoptysis due to mitral stenosis is frequently
induced by physical exercise or excitement,
Blood comes from a break in the pulmonary
veins which have ruptured under high pressure,
The bleeding is due to rupture of endobronchial
vessels that from collateral channels between the
bronchial veins and pulmonary venous system,
The bleeding tend to subside as the veins adapt
to high pressure and as pulmonary arteriolar
disease develops,
3.Cardiovascular disease
? Many pulmonary emboli do not lead to pulmonary
infarction,when they do,frank hemoptysis occurs
in the minority of instance,
? when hemoptysis occur in the pulmonary infarction
of the heart failure patient,the blood sputum usually
appears within a few hours to a day after the embolus,
and this is due to necrosis and hemorrhages into the
alveoli,
3.Cardiovascular disease
? Hemoptysis is also associated with
congenital cardiac disease and aortic
aneurysms
4.Constitutional disease
? Blood spitting may also occur in the patients
suffering from certain blood dyscrasias,such as
hemophilia,leukemia and infectious disease,
connective tissue disease,
Clinical manifestation
1.the patient’s age,
2.the amount of coughing up blood,
3.color and character,
1.The patient’s age
? Hemoptysis is often seen in pulmonary TB,
bronchiectasis and rheumatic heart disease
(mitral stenosis) for most youth,
? Cancer is now the disease that patients think
of when they expectorate blood,just as it
was TB 50 years ago,
1.The patient’s age
? Elder patient with bloody sputum or streaked
of bloody sputum,especially in the males with
long history of smoking.cancer should be taken
into account,
? Patients close contact with TB suffer,TB should
be considered,
1.The patient’s age
? Paragonimiasis may suspected in the people
with history of eating raw or improperly cooked
crabs or crayfish,
? Epidemic hemorrhagic fever,leptospirosis also
can cause hemoptysis,they are endemic disease,
2.The amount of coughing up blood
? Hemoptysis can be classified into three groups
according to the amount of coughing blood,
Massive,expectoration > 500ml/24hr,
Moderate,500ml> expectoration >100ml/24hr
minimal,expectoration <100ml/24hr
2.The amount of coughing up blood
massive hemoptysis often occurs in pulmonary
TB cavity,chronic lung abscess and bronchiectasis,
3.Color and character,
? To a hemoptysis patient,it is necessary to
ascertain the exact nature of the sputum,
the sputum must be examined both grossly
and microscopically,
3.Color and character
It is useful to determine whether the material
that is coughed up contains large amount of
liquid blood,which is indicates brisk bleeding,
or whether it contains small amount of dark or
clotted blood,which would indicate slow bleeding
from low-pressure vessels or subsiding bleeding,
3.Color and character
? Brisk bleeding is commonly associated with
specific focal ulceration of the bronchus,such
as bronchogenic carcinoma,a foreign body,
bronchiectasis or a bleeding aortic aneurysm,
? Slow bleeding strongly suggests venous bleeding
which is more likely to be the result of increased
in blood flow through the bronchial venous system
such as may occur as a result of mitral stenosis or
bronchiectasis,
Accompanying symptom
? Hemoptysis with fever,pulmonary tuberculosis,
pneumonia,lung abscess,lopeospirosis,epidemic
hemorrhagic fever,bronchogenic carcinoma,
? Hemoptysis with chest pain,lobar pneumonia,
pulmonary infarction,pulmonary TB,lung cancer,
Accompanying symptom
? Hemoptysis with putrid sputum:lung abscess
cavitious TB,bronchiectasis,
? Hemoptysis with irritating cough:bronchogenic
carcinoma,mycoplasma pneumonia,
Accompanying symptom
? Hemoptysis with skin and mucosa bleeding,
hematological disease,epidemic hemorrhagic
fever,rheumatism,leptospirosis,
? Hemoptysis with jaundice:leptospirosis,lobar
pneumonia,pulmonary infarction,
The distinction between
hemoptysis and hematemsis
H e m o p t y s i s H e m a t e m e s i s
H i s t o r y, T, B,b r o n c h i e c t a s i s U l c e r,c i h r r o s i s
P r e s y m p t o m, C o u g h,c h e s t d i s c o m f o r t a b l e V o m i t,n a u s e a,e p i g a s t r i c
d i s c o m f o r t
M o d e o f
e x p e c t o r a t i o n,
B l o o d s p i t t i n g V o m i t i n g
C o l o r o f b l o o d, B r i g h t r e d D a r k r e d a n d b l a c k
M a t e r i a l m i x e d
w i t h b l o o d,
M i x e d w i t h a i r b u b b l e a n d
s p u t u m
C o n t a i n f o o d d e b r i t s g a s t r i c
j u i c e
Ph A l k a l i n e A c i d
m e l e n a No
O c c a s i o n a l l y s w a l l o w e d
Y e s
M a y c o n t i n u e f o r s e v e r a l
d a y s
