COUGH

OUTLINEDefinition

Mechanism

Importance

History

Classification

Physical examination

Tests and diagnosis

Associated symptoms

Complications

Treatment

DEFINITIONCough is an explosive expiration that provides a normal protective mechanism for clearing the tracheobronchial tree of secretions and foreign material, which is associated with a characteristic sound.

MECHANISM

The shearing forces that develop aid in the elimination of mucus

and foreign materials

IMPORTANCE1) Defense mechanism (physiological natural reflex):

Providing a normal protective mechanism for clearing the tracheobronchial tree free of secretions and foreign material

2) Complication of its force:Excessive coughing can be exhausting; can be complicated by vomiting, syncope, muscular pain or rib fractures; and can aggravate abdominal or inguinal hernias , urinary incontinence and Uterine prolapse

3) Symptom of disease:Associated with many medical diseases and conditions

4) Transmit infections to others by air droplets diseases that are commonly spread by coughing or sneezing include:

Bacterial Meningitis Chickenpox Common cold Influenza Mumps Strep throat Tuberculosis Measles Rubella Whooping cough

HISTORY1) Onset and Duration:

Acute: < 3weeks

Subacute: 3-8 weeks

Chronic: > 8 weeks

2) Character :Bovine with Hoarsness: Left recurrent laryngeal nerve palsy causing left vocal cord paralysis due to CA Lung

Barking with Hoarsness and Stridor: Acute Epiglottitis, Laryngitis, CA Larynx

Wheezy: COPD, Asthma

3) Timing and associated features: Nocturnal: Asthma, CHF

Early Morning: Bronchiectasis, Chronic Bronchitis, Asthma

Recumbent: Postnasal drip (PND), CHF, Gastroesophageal reflux disease (GERD)

Change position (Standing): Bronchiectasis

4) With or without sputum:Dry cough - without sputum:

Causes of dry cough (Asthma, Viral infection of respiratory system, Interstitial Lung Disease)

Productive cough - with sputum:

Causes of productive cough (Respiratory Infections, COPD, Bronchiectasis)

• With or without blood:Hemoptysis - with blood

Hemoptysis (bloody sputum):

If with purulent and long standing sputum:

Chronic bronchitis (small amount of blood)

Bronchiectasis (large amount of sputum)

If with fever, recent, recent onset, SOB:

Pneumonia

If + LOA, LOW, H/O smoking:

Bronchial carcinoma

If sputum is pink in color and frothy:

Pulmonary edema

If sudden onset:

Pulmonary embolism, acute RT infections

PHYSICAL EXAMINATION – PERCUSSION

1) Of chest:Hyperresonance (COPD)

Dullness (consolidation, pleural thickening)

Stony dull (pleural effusion)

2) Liver dullness

3) Cardiac dullness

PHYSICAL EXAMINATION – AUSCULTATION

1) Decreased breath sounds:

COPD

Pleural effusion

Pneumothorax

Pneumonia

Large neoplasm

Pulmonary collapse

2) Bronchial breath sounds:Lung consolidation (common)

Localized pulmonary fibrosis

Lung collapse

Pleural effusion

uncommon

TESTS AND DIAGNOSIS

The medical history and physical examination help to determine which tests should be ordered.

Imaging tests

CXR: lung cancer and pneumonia

CT: cavities for pockets of infection

Lung function tests:These simple, noninvasive tests measure how much air your lungs can hold and how fast you can exhale. This test is required to diagnose asthma.

Lab tests:If the mucus that is coughed up is discolored, the doctor may want to test a sample of it for bacteria.

Scope tests:• cellular abnormalities

• as well as biopsy

CLASSIFICATION OF COUGH

1) Acute Cough: < 3 Weeks Duration

2) Subacute Cough: 3 - 8 Weeks Duration

3) Chronic Cough: > 8 Weeks Duration

1) Acute Cough (Differential Diagnosis): Upper respiratory tract infections (URTI):

• Viral syndromes

• Sinusitis

• Pertussis URTI triggering exacerbations of chronic lung disease e.g. Asthma/ COPD Pneumonia

Left ventricular heart failure Foreign body aspiration

Red flags in acute coughSymptoms:

Haemoptysis Breathlessness Fever Chest Pain Weight Loss

Signs: Tachypnoea Cyanosis Dull chest Bronchial Breathing Crackles

THINK pneumonia, lung cancer, LVF

GET a CHEST X-Ray

2) Subacute Cough: Postinfectious:

A cough that begins with an cute respiratory tract infection and is not complicated * by pneumonia

• * Not complicated = normal lung exam normal chest X-ray

• Resolve without treatment

• Cause: PND or tracheobronchitis

• Indication for CXR: with automated biopsy needle (ABN) lung exam

Sinusitis Asthma

3) Chronic Cough (Differential Diagnosis): SMOKER (Abnormal Chest X-ray):

• COPD: Chronic Bronchitis, Emphysema

• CA Lung

NON-SMOKER (Normal Chest X-ray):

• Drug (ACEI- Angiotensin Converting Enzyme Inhibitor- Captopril)

• PND-Post Nasal Drip

• Asthma-Cough Variant Asthma

• GERD - Gastroesophageal regurgitation disease

ASSOCIATED SYMPTOMS

Fever, recent symptoms, SOB Pneumonia

Postnasal drip, sinus congestion, headache UACS (Upper Airway Cough Syndrome) When asked to cough, they clear the throat

Wakes a patient up: Cardiac failure, GERD, Asthma

Worse in morning: COPD

h/ o stroke, neurogenic dysphagia : Aspiration pneumonia

Wheezing: Asthma (episodic wheezing) FB/ Tumor (monophonic wheezing – intraluminal obstruction)

Burning chest pain: GERD

Pleuritic chest pain: PE, Pneumonia

LOA, LOW, h/ o smoking: Lung carcinoma

Appears after meal/ drinking: GERD Tracheo-esophageal fistula (rare)

Joint pain, dry eyes, LN enlargement: SLE, SJOGREN (with interstitial lung dss)

COMPLICATIONSCardiovascular:

Arterial hypotension Loss of consciousness Rupture of subconjunctival, nasal and anal veins Dislodgement/malfunctioning of intravascular catheters Bradyarrhythmias, tachyarrhythmias

Neurologic: Cough syncope Headache Cerebral air embolism CSF rhinorrhea Acute cervical radiculopathy Malfunctioning ventriculoatrial shunts Seizures Stroke due to vertebral artery dissection

Gastrointestinal: Gastroesophageal reflux events Hydrothorax in peritoneal dialysis Malfunction of gastrostomy button Splenic rupture Inguinal hernia

Genitourinary: Urinary incontinence Inversion of bladder through urethra

Musculoskeletal: From asymptomatic elevations of serum creatine

phosphokinase to rupture of rectus abdomens muscles Rib fractures

Respiratory: Pulmonary interstitial emphysema, with potential risk of pneumatosis intestinalis, pneumomediastinum,

pneumoperitoneum, pneumoretroperitoneum, pneumothorax, subcutaneous

emphysema Laryngeal trauma Tracheobronchial trauma (e.g., bronchitis, bronchial rupture) Exacerbation of asthma Intercostal lung herniation

Coughs can be treated in a variety of ways, depending on the cause of the cough. For most healthy adults, most treatments will involve

self-care.

TREATMENT:

Self-TreatmentA cough that is cased by virus cannot be treated with antibiotics. You can, however, soothe it in the following ways:

Use decongestant sprays to unblock the nose and ease breathing Elevate your head with extra pillows when sleeping Use cough drops to soothe the throat Avoid irritations, including smoke and dust

Gargle hot saltwater regularly to remove mucus and soothe the throat Keep hydrated by drinking plenty of water Add honey or ginger to hot tea to relieve the cough and clear the airway

AntihisMedications used to treat cough may include:tamines and decongesta:

These drugs are standard treatment for allergies and postnasal .

Inhaled asthma drugs:

The most effective treatments for asthma-related cough are inhaled medications that reduce inflammation and widen the airways.

Antibiotics:

If a bacterial infection is causing the cough, antibiotics will be prescribed.

Acid blockers:

When lifestyle changes don't take care of acid reflux, patient may be treated with medications that block acid production. Some people need surgery to resolve the problem.

Cough suppressants:

If the reason for your cough can't be determined, the doctor may prescribe a cough suppressant, especially if the cough is interfering with your sleep.

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