cough

I’m Coughing my lungs up Doc

Impact of cough

an important defense mechanism that helps clear excessive secretions and foreign material from the airways

an important factor in the spread of infection

most common symptoms for which patients seek medical attention and spend health-care dollars

Definition of cough

deep inspiration followed by a strong expiration against a closed glottis, which then opens with an expulsive flow of air, followed by a restorative inspiration

Acute InfectionsTracheobronchitisBronchopneumoniaViral pneumoniaExacerbation of COPD bronchitisPertussis

Chronic InfectionsBronchiectasisTuberculosisCystic fibrosis

Airway DiseasesAsthmaChronic bronchitisChronic postnasal drip

Parenchymal DiseasesChronic interstitial lung fibrosisEmphysemaSarcoidosis

-- Common Causes of Cough

TumorsBronchogenic carcinomaAlveolar cell carcinomaBenign airway tumorsMediastinal tumors

Foreign BodiesMiddle Ear PathologyCardiovascular DiseasesLeft ventricular failurePulmonary infarctionAortic aneurysm (thoracic)

Other DiseasesReflux esophagitisRecurrent aspirationEndobronchial sutures

DrugsACE inhibitorsCOPD,

Cough reflexcough

Cough reflex

Stages of cough

Coughy names

Brazy cough- Trachitis Bovine cough- R.L.N palsy Bubbly cough- sputum in the airways Prolonged wheezy cough- Emphysema Paroxysoms of cough without sputum

production - airway reactivity Paroxysoms of cough foll,. by

prolonged stridulous inspiration - pertussis

Hacking- dry irritable cough in URI Staccato- whooping cough or

chlamydial inf Nocturnal-

asthma,GERD,UACS,pul.edema. Croupy- harsh ,hoarse cough in

laryngeal inf. Suppressed- pleurisy Barking- hysteria

Classification of Cough

Three Categories of Cough Acute Cough = < 3 Weeks Duration Subacute Cough = 3 – 8 Weeks Duration Chronic Cough = > 8 Weeks Duration

Acute Cough

Acute Cough <3/52 DurationDifferential Diagnosis

Upper Respiratory Tract infections:Viral syndromes, sinusitis viral / bacterial

URTI triggering exacerbations of Chronic Lung Disease eg Asthma/ COPD

Pneumonia Left Ventricular Heart Failure Foreign Body, Aspiration pieural

Managing Acute CoughIdentify High Risk groups

Acute Cough Can be 1st Indicator of

Serious Disease eg Lung ca, TB, Foreign Body, Allergy, Interstitial Lung disease

‘Chronic cough always preceded by acute cough’.

Red Flags in Acute Cough

Symptoms Haemoptysis Breathlessness Fever Chest Pain Weight Loss

SignsTachypnoea

CyanosisDull chest

Bronchial BreathingCrackles

THINK pneumonia, lung cancer, LVF

GET a CHEST X-Ray

Treatment of Simple Acute Cough

Benign course -reassure Cough can distress Voluntary cough

suppression -linctuses/ drinks

Suppression of cough -dextromethorphan, menthol, sedating antihistamines & codeine

Sub-Acute Cough

Sub-acute Cough 3-8 weeks

Likely Diagnoses Postinfectious Bacterial Sinusitis Asthma Start of Chronic Cough

Don’t want to miss lung cancer

ACTIONS

•Examine Chest

•Chest X-Ray if signs or smoker

•Measure of airflow obstruction

ie peak flow -one off

peak flow -serial

spirometry

Post Infectious Cough

A cough that begins with an acuterespiratory tract infection and is not

complicated* by pneumonia

*Not complicated = Normal lung exam and normal chest X-ray

Post Infectious cough will resolve without treatment

Cause = Postnasal drip or Tracheobronchitis

Postinfectious Cough Following an acute respiratory infection, at least 3 weeks- 8weeks, consider the diagnosis of postinfectious cough.– Chest radiograph must be normal– If > 8weeks, consider other – Always consider the possibility of B. pertussis infection paroxysms of coughing associated with post-tussive vomiting, and/oran inspiratory whooping sound judge other factors < considering therapy– UACS– lower airway– GERD Except for bacterial sinusitis or early in B. pertussisinfection, antibiotics have no role.

Chronic Cough

Chronic Upper Airway

It is unclear whether the mechanism(s) of cough is

postnasal drip or

direct irritation or inflammationof the cough receptors in the upper airway

Cough Syndrome

Post-Nasal Drip

Symptoms: ‘something

dripping’ frequent throat

clearing nasal congestion /

discharge posture

Causes Allergic rhinitis Non-allergic

rhinitis Vasomotor rhinitis Chronic bacterial

sinusiits

Post Nasal Drip Treatment

Options:1. Exclude /treat

infection2. Nasal steroid for 8wks3. Sedating

antihistamines4. Antileukotrienes eg

montelukast5. Saline lavage6. ENT opinion

Cough +dyspnea + wheezing (Cough-variant asthma) When nondiagnostic,methacholine challenge performed – If methacholine challenge cannot be performed,empiric therapy given;[ exclude NAEB.] However, a diagnosis of asthma as the cause of coughis established only after resolution of cough withspecific therapy

Asthma

initially treated with a standard antiasthmaregimen of inhaled bronchodilators andcorticosteroids– When refractory, an assessment of airway inflammation should be performedpersistent airway eosinophiliaaggressive antiinflammatorytherapy A leukotriene receptor antagonistbefore systemic corticosteroids

Asthma

Gastro-oesophageal Reflux

GORD accounts alone or in combination for 10-40% of chronic cough

Two Mechanismsa. Aspiration to larynx/

tracheab. Acid in distal

oesophagus stimulates vagus and cough reflex

Gastro-oesophageal Reflux Symptoms

GI Symptoms

If Aspiration main mechanism

Heart burnWaterbrash/ Sour tasteRegurgitationMorning Hoarseness

If Vagal - NO GI symptoms

Cough Features

Throat clearingWorse at night / risingOn eatingReflex

hypersensitivity

CXR -normal or hiatus hernia

Spirometry normal

Gastro-oesophageal Reflux

Reflux may be due to Medications or Foods Reflux may be due to Medications or Foods

Drugs and foods that Drugs and foods that reducereduce lower esophageal lower esophagealsphincter (LES) pressure and can cause increasedsphincter (LES) pressure and can cause increasedreflux include:reflux include:

TheophyllineTheophylline Chocolate ChocolateOral Oral ββ adrenergic agonists adrenergic agonists Caffeine CaffeineNSAIDsNSAIDs Peppermint PeppermintAscorbic acidAscorbic acid Alcohol AlcoholCalcium Channel BlockersCalcium Channel Blockers Fat Fat

Gastro-oesophageal RefluxInvestigation Oesophageal pH monitoring for 24 Oesophageal pH monitoring for 24 hours (+diary) hours (+diary) 95% sensitive and specific 95%95% sensitive and specific 95%

Ba swallow not sensitive enoughBa swallow not sensitive enough

Endoscopy - may confirm but false -Endoscopy - may confirm but false -ve rateve rate

Endoscopy can show GORD, but Endoscopy can show GORD, but cannot cannot

confirm GORD as the cause of cough.confirm GORD as the cause of cough.

GED

© Slice of Life and Suzanne S. Stensaas

GED

– Chronic cough– Not exposed to environmental irritants nor smoke– Not taking an ACEI– Chest radiograph is normal or near normal and stable– Symptomatic asthma has been ruled out– UACS has been ruled out– NAEB has been ruled out

profile of patient with chronic cough due to GERD:

GERD – Dietary and lifestyle modifications– Acid suppression therapy, and– prokinetic therapy – response assessed ,1 -3months. When empiric regimen fails, GERD not ruled out as a cause of chronicCough; objective investigation for GERDrecommended because– empiric therapy may not have been intensive enough– medical therapy may have failed– surgery may be considered

Chest X-Ray and Differential of Cough

Normal CXR Gastro-oesophageal

reflux Post-nasal Drip Smokers cough/

Chronic Bronchitis Asthma COPD Bronchiectasis Foreign body

Abnormal CXR Left ventricular

failure Lung cancer Infection/ TB Pulmonary fibrosis Pleural effusion

Acute Bronchitis cough with or without phlegm up to 3 weeks.

A diagnosis of acute bronchitis should not be madeunless there is no clinical or radiographic evidence ofpneumonia, and the common cold, acute asthma, or anexacerbation of COPD have been ruled out .

For patients with a putative diagnosis of acutebronchitis, routine treatment with antibiotics is notjustified and should not be offered.

Chronic Bronchitis chronic cough and sputumexpectoration occurring on most days for at least 3months and for at least 2 consecutive years should begiven a diagnosis of chronic bronchitis when otherrespiratory or cardiac causes of chronic productivecough are ruled out. stable patient suddenly experiences asudden clinical deterioration with increased sputumvolume, sputum purulence and/or worsening ofshortness of breath, this is referred to as an acuteexacerbation of chronic bronchitis, as long asconditions other than acute tracheobronchitis are ruled out

Chronic Bronchitis avoidance of personal tobacco use, passive smokeexposure, and other environmental irritants. For stable patients:– Short-acting inhaled Β agonists, inhaled ipratropium, oraltheophylline and combined inhaled long-acting Β agonists andinhaled corticosteroids may improve cough

For an acute exacerbation:bronchodilators (Β agonistand/or ipratropium), oral antibiotics, and oral or in severecases IV corticosteroids are useful but their effects on coughhave not been systematically evaluated.

Non-AsthmaticEosinophilic Bronchitis eosinophilicairway inflammation, similar to asthma.– In contrast to asthma, not associated with variable airflowlimitation or airway hyperresponsiveness.– the differences infunctional associations are related to differences inlocalization of mast cells within the airway wallThere is smooth muscle infiltration in asthmaThere is epithelial infiltration in non-asthmatic eosinophilicbronchitis

Non-AsthmaticEosinophilic Bronchitis chronic cough with normal cxrnormal spirometry, and no evidence of airwayhyperresponsiveness.– Diagnosis- eosinophilic airwayInflammation inhaledcorticosteroids– The dose and duration of treatment differ– When a causal allergen or occupational sensitizer is identified,avoidance is the best treatment The condition can be transient, episodic, or persistentunless treated; occasionally, patients my require longtermprednisone therapy

Bronchiectasis 0-4% Most cases in adults are idiopathic; however, in theabsence of an obvious cause, a diagnostic evaluation foran underlying disorder will reveal such a disorder up to47% of the time and treatment for the underlyingdisorder may slow or halt the progression of airwaydisease up to 15% of the time.

In patients with suspected bronchiectasis without acharacteristic chest radiograph, HRCT is the diagnosticprocedure of choice (specificity and sensitivity > 90%

Non-BronchiectaticSuppurative Airway Disease bronchiolitis.

When the more common causes of cough have been ruledout, consider non-bronchiectatic suppurative airwayDiseases in patients with– Incompletely or irreversible airflow limitation, small airwaysdisease on HRCT, or purulent secretions on bronchoscopy. Direct signs: airway dilation or wall thickening; “tree-in-bud”

Indirect signs: air-trapping (mosaic attenuation on expiration)– Successful management depends upon identification of the specificunderlying disorder. Lung biopsy may be required.

Lung Tumors Cough and productive cough > 65%and > 25% of patients yet 0-2% of all patients

– Risk factors include heavy smoker with new onset cough;a change in the characteristics of a pre-existing cough;hemoptysis; exposure to passive cigarette smoke, asbestos,radon; COPD, and family history of lung cancer

In patients with a suspicion of airway involvement bya malignancy, even when the chest radiograph isnormal, bronchoscopy is indicated.

Cough From Aspiration Due toOral-Pharyngeal Dysphagia

acute stroke [> 33%], cervical spine surgery [>40%]– Cough while eating may indicate aspiration; but, aspirationmay be clinically silent– patients with dysphagia should undergo videofluoroscopic orflexible endoscopic evaluation of swallow to identify appropriatetreatment– Patients with a reduced level of consciousness are at high risk

ACE-Inhibitors and Chronic CoughIncidence: 5-20%Onset: one week to six monthsMechanism

Bradykinin or Substance P increaseUsually metabolized by ACE) PGE2 accumulates and vagal

stimulation. Treatment: switch to Angiotensin II

Receptor Blockers (ARBs)

Habit, Tic, and Psychogenic Cough in Adult and Pediatric Populations

ruling out tic disorders (includingTourette’s syndrome) and uncommon causes of chroniccough, and cough improves with behavior modification orpsychiatric therapy.

– unexplained cough.

Chronic Interstitial PulmonaryDisease

may be a presenting orcomplicating feature.

IPF, sarcoidosis, andhypersensitivity pneumonitis

IPF, there is an associated ↑ sensitivity to capsaicin &sputum levels of nerve growth factor and brain-derivedneurotropic factor suggesting a functional upregulation ofsensory neurons of the lung

Occupational and EnvironmentalConsiderations in the Cough Patient

Chronic Cough Due to TBand Other Infections

Peritoneal Dialysis and Cough

22% compared to 7%in patients on hemodialysis.– Although both groups frequently receive medicationswhich can potentially trigger cough such as ACEIs andΒ blockers and both groups are at increased risk forfluid overload and pulmonary edema, the increasedrisk associated with peritoneal dialysis most likelyrelates to GERD that can be initiated or exacerbatedby increased intraperitoneal pressures.

In immunocomprimised

the initial diagnostic algorithm is the same as that for immunocompetent persons

< 200 cells/μL or > 200 cells/μL with unexplained fever, weight loss, or thrush who have unexplained cough should be suspected of having Pneumocystis pneumonia, tuberculosis, and other opportunistic infections, and should be evaluated accordingly

Uncommon Causes of ChronicCough

– Until uncommon causes have been ruled out, the diagnosis ofunexplained cough should not be made.

– The workup is never done unless a chest CT scan andbronchoscopy have been performed and are normal.

– Evaluate for the possibility of drug-induced cough and consider therapeutic trial of withdrawal

Uncommon -Pulmonary causes• Tracheobronchomalacia• Tracheobronchomegaly• Airway stenosis/str/F.B• Broncholithiasis• Pulmonary Langerhans cell histiocytosis  • Pulmonary alveolar proteinosis • Pulmonary alveolar microlithiasis• pulmonary edema  • Pulmonary embolism• Lymphangioleiomyomatosis • Connective tissue disorders ‡  • Vasculitides• Miscellaneous (eg, vocal cord dysfunction, surgical

sutures in airways)  

Uncommon-Non-pulmonary causes High altitude   Tonsillar hypertrophy   Thyroid disorders (goiter, thyroiditis Esophageal disorders

(tracheoesophageal and bronchoesophageal fistula

Inflammatory bowel diseases (eg, Crohn disease and  ulcerative colitis

Mediastinal masses  Drug-induced cough

Unexplained chronic cough—20%

Diagnosis by exclusion

Making the DiagnosisCommon Differentials

Gastro-Oesophageal

Reflux

Post-nasal Drip-allergic rhinitis

-bacterial sinusitis

Lung Disease-normal CXR

-abnormal CXR

Non-structural

ACE-Inhibitors

Tobacco

Habit Cough

Cause of Cough Treatment

Treating the Specific Underlying Cause(s)

Asthma, cough variant asthma Bronchodilators and inhaled corticosteroids

Eosinophilic bronchitis Inhaled corticosteroids; leukotriene inhibitors

Allergic rhinitis and postnasal drip Topical nasal steroids and antihistamines

  Topical nasal anticholinergics (with antibiotics, if indicated)

Gastroesophageal reflux Conservative measures

  H2-Histamine antagonist or proton pump inhibitor

Angiotensin-converting enzyme inhibitorDiscontinue and replace with alternative drug such as angiotensin II receptor antagonist

Chronic bronchitis/chronic obstructive pulmonary disease (COPD) Smoking cessation

  Treat for COPD

Bronchiectasis Postural drainage

  Treat infective exacerbation and airflow obstruction

Infective tracheobronchitis Appropriate antibiotic therapy

  Treat any postnasal drip

Symptomatic Treatment (Only After Considering the Cause of Cough)

Acute cough likely to be transient (e.g., upper respiratory viral infection)

Simple linctus

Persistent cough, particularly nocturnal Opiates (codeine or pholcodeine)

Persistent, intractable cough due to terminal incurable disease Opiates (morphine or diamorphine)

  Local anesthetic aerosol

Cough in children Simple linctus (pediatric)

Table 29.4   -- Treatments for Cough

Cough Suppressant and ProtussivePharmcologic Therapy

– Mucolytic agents not in patients with bronchitis.– Zinc preparations are not to colds– Peripheral and central antitussive agents - chronic bronchitis – Opioids in lung cancerprotussive agents are effective – cough clearance (amiloride in CF; hypertonic saline inBronchitis)– DNAse is not effective -cf

When the etiology of cough is unknown

When specific therapy requires a period of time before it can work

When specific therapy will be ineffective, as in inoperable lungcancer

Protussive therapy is intended to enhance cougheffectiveness to promote clearance of airway secretions

Nonpharmacologic AirwayClearance Therapy

theprincipal strength of diagnostic testing is in rulingout suspected possibilities. The principal limitation isthat a positive test result cannot necessarily be reliedon to establish the diagnosis; a positive test result hasnot been able to consistently predict a favorableresponse to specific therapy. A positive test result, byitself, is not diagnostic of the cause of cough unless afavorable response to therapy is witnessed.

Respiratory Complications

Pneumothorax

Subcutaneous emphysema

Pneumomediastinum

Pneumoperitoneum

Laryngeal damage

Cardiovascular Complications

Cardiac dysrhythmias

Loss of consciousness

Subconjunctival hemorrhage

Central Nervous System Complications

Syncope

Headaches

Cerebral air embolism

 Potential Complications from Excessive Cough

Musculoskeletal Complications

Intercostal muscle pain

Rupture of rectus abdominis muscle

Increase in serum creatine phosphokinase

Cervical disc prolapse

Gastrointestinal Complications

Esophageal perforation

Other Complications

•Social embarrassment

Depression

Urinary incontinence

Disruption of surgical wounds

Petechiae

Purpura

Efficacy of Therapy

health-related quality-of-life instruments

tussigenic challenges flow-volume loops cough counting over 24 h

The benefits of Cough Assist? Clients with Neuromuscular conditions have a weak cough due to loss ofrespiratory muscle strength Coughing clears secretions, food particles and foreign substances The cough assist increases the flow of air out, which helps theclient to cough Combats fatigue and discomfort from manual assisted coughing Possible Prophylactic use – maintains lung tissue compliance/flexibility Future research may suggest that clients may not needtracheotomies (Bach, 2004) Possibility of preventing and shortening hospital visits Improved quality of life and prolonged life (Bach,2000)

Basic I.S. Maneuver• Slow, deep breath in to total lung capacity (ideal)• 5 to 10 second breath hold• Coughing– between breaths– at end of treatment• Causes increased transpulmonary pressure gradient• Further expansion of alveoli above current amount

A New Device Enables Quantitative Cough Assessment• The LifeShirt® incorporates motion-sensing transducers, electrodes,a microphone, and a 3-axis accelerometer into a lightweight, washable vest that is available forpatients ≥5 years of age.• Using integrated input from the motion sensors and microphone, the frequency and intensity of coughcan be measured with a high degree of accuracy • The device discards events such as throat-clearing, sneezing, sighing, or talking.• Time-stamped data are stored on a compact flash card housed within the recorder and canbe uploaded to the manufacturer, VivoMetrics, Inc, for analysis using specialized software.•

Role of cough in ACUTE MI ?