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aproach to cough


									      APPROACH TO COUGH
            Dr. Isagani C. Rodriguez FPCP, FPCCP                        NOVEMBER 3,2010

 A voluntary or involuntary protective reflex to remove secretions
   and foreign materials from the airways

Deep inspiration  glottis closure, relaxation of diaphragm, muscle
contraction against closed glottis  marked increase in intrathoracic
pressure  narrowing of trachea  glottis opens  large pressure
differences produce rapid flow rates through the trachea  cough
reflex (elimination of mucus and foreign material)

   Cough center at the brainstem coordinates:
        o Inspiratory gasp
        o Valsalva’s against closed glottis
        o Expiratory balst as vocal cords abduct
        o Post-tussive prolonged inspiration
   Nerves involved in cough reflex:
        o Afferent: Trigeminal, Glossopharyngeal, Superior
             Laryngeal, Vagus N (Sensory nerves of
             tracheobronchial tree)
        o Efferent: Recurrent laryngeal and spinal nerves
        o C6-C7 injury can possibly cause cough

          o Acute cough: Lasts for 2 weeks or less
             - Life threatening diagnosis should be treated
             - Infections are the most common cause of acute
                  cough (URTI – above the trachea, LRTI – below
NOTE: Arnold’s nerve inside the ear can provoke cough when
                                                                                     o    Subacute cough: 2-8 weeks duration
                                                                                          - Post-infectious stage: - when the infection, fever
                                                                                              and cold are gone and the patient still coughs
                                                                                          - Normal CXR: Pertussis/Bronchitis
                                                                                          - WHO: in tropics, if patient has cough lasting for two
                                                                                              weeks should be screened for TB
                                                                                     o    Chronic cough: 8 weeks or more
                                                                                          -    If the patient doesn’t still show improvement
                                                                                              proceed to more invasive techniques
                                                                                                     24 hour esophageal pH Monitoring
                                                                                                     Barium esophagogram
                                                                                                     Sinus imaging –when looking for upper
                                                                                                          airway problems
                                                                                                     HRCT
                                                                                                     EKG
                                                                                                     Environmental assessment

                                                                                    Pathologic Cough
                                                                                      A reflex cough caused by a disease
                                                                                      Beneficial only if it clears secretions
                                                                                      Socially discrediting; increase sensitivity of cough reflex

                                                                                    Valsalva’s maneuver and post-tussive inspiration can
                                                                                        cause tussive syncope

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            Intrathoracic pressure squeezing the thorax               (-) Airway hyper-responsiveness
            pneumothorax; rupture of small vessels in the eye             (+) Eosinophils in sputum
            (conjuctival haemorrhages)                                    Form of pure allergy of airways to certain element
           Vena cava is compressed   Venous pressure                 Must review occupational exposure
            Intracranial pressure Tussive headache (every time           DOC: inhaled corticosteroids, oral steroids if uncontrolled
            you cough)                                                    Avoid causal allergens or sensitizers when identified
           Stressful cough (forceful coughing)  chest wall or
            abdominal wall muscle strain, rib fracture,                4. GASTROESOPHAGEAL REFLUX DISEASE (GERD)
            pneumothorax                                                About 10-20% of chronic cough
           Soreness, urinary incontinence, exhaustion                  Cough may be the sole manifestation of GERD
    Causes                                                              Usually suspected among non-smokers with normal CXR
       1. UPPER AIRWAY COUGH SYNDROME                                   When the cough gets worse when the patient lay down – a
        Post-Nasal Drip Syndrome (PNDS) is the common                     good indicator
           cause of UACS                                                Diagnosis:
        It accounts for 87% of cough                                           o 24-hour esophageal pH monitoring-better yield
        Usually from rhinitis (allergic, perennial, nonallergic,                    than esophagoscopy and Barium
           vasomotor), nasopharyngitis, sinusitis                                    esophagoscopy
        Classic PNDS symptom/l sensation of liquid moving                      o Diagnosis in retrospect when treatment against
           down the throat associated with tickling sensation at the                 GERD eliminated cough
           back of the throat, cough and clearing of secretions         Mechanism:
           (irritating stimulus that provokes the cough)                        o Stimulation of receptors at distal esophagus which
        Sign: Cobblestone appearance of oropharyngeal                               also increases bronchial inflammation
           mucosa Waldeyer’s ring from stimulation of submucosal        Treatment
           lymphoid tissue                                                      o Antireflux diet (High CHON, Low Fat);
        Mechanism of PNDS:                                                     o no eating or drinking for 2-3 houres (gastric
                  o Stimulation of irritant receptors in the                         emptying time) before lying down or bedtime;
                       esophagus and pharynx by mucus or                        o no caffeine, ethanol or chocolate
                       secretions from nasal passages that trigger              o H2 agonists, proton pump inhibitors,
                       cough                                                         metoclopramide, domperidone (properistalsis
        Treatment: antihistamines (if from allerfy), decongestant,                  agents)
           inhaled corticosteroid, nasal spray, antibiotics                     o Smoking cessation
        Differential Diagnosis: GERD                                           o elevation of head while sleeping by putting 20 cm
                                                                                     blocks under the head or pillow
      Usually among asthmatics with no wheezing present               5. CHRONIC BRONCHITIS (COPD)
      No wheezing because it affects the large airways                 Cough and sputum production for 3 months in a year for 2
      About 29% of chronic cough                                           consecutive years
      Cough is dry, round the clock, worsened by airway                From chronic irritation and inflammation
          inflammation (Respiratory Tract Infection), allergens,        5% of chronic cough
          exercise, cold air                                            Usually affects smokers; tobacco smoke inhibit ciliary activity
      Diagnosis: As in asthma, by demonstration of reversible              and reduces mucociliary clearance; tracheobronchial
          airway obstruction; if normal, bronchoprovocation test is         glands, goblet cells become hyperplastic  mucus
          positive                                                          secretion
      Mechanisms:                                                      Cough is necessary to continually clear secretions and avoid
               o Less airway stimulation required to trigger cough          infection = a necessity to drain the secretions
               o Mechanical changes in inflamed airways stimulate       Diagnosis:
                     cough reflex; inflammation in large airways                 o HX, PFT= persistent airway obstruction even with
                     irritate abundant receptors present                               bronchodilator
               o Absence of wheezing indicates inflammation             Treatment:
                     mainly in large airways                                     o Smoking cessation is most important—better
      Treatment:                                                                      outcome than combined bronchodilators
               o Remove allergens, avoid triggers                                      (anticholinergics and β2 agonists), expectorants,
               o Inhaled steroids, inhaled β2 agonists, theophylline                   empiric antibiotics
      Differential diagnosis
               o Chronic Bronchitis (COPD); β2 agonists improves       6. BRONCHIECTASIS
                     cough but not bronchial hyperactivity              Abnormal irreversible dilation of airways usually as aftermath
                                                                            of infection- scars left by the infection
     3. NON-ASTHMATIC EOSINOPHILIC BRONCHITIS (NAEB)                    Most have dry cough unless ecstatic areas are actively
      Normal CXR                                                           infected; sputum usually copious or hemoptysis may
      Normal Pulmonary Function Test (PFT)                                 supervene
      (-) Evidence of variable airflow obstruction                     A form of chronic bronchitis

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      Diagnosis                                                                Usually among patients on ACE inhibitor, for CHF or
             o Demonstration of abnormally dilated airways by                      hypertension
                 bronchography or high-resolution CT scan                       Cough in ~6-14% of patients receiving ACE
             o Dry bronchiectasis-usually in Patient with history of            Onset cough 3-4 weeks up to 1 year from initiation of drug
                 TB; affects URT                                                May mimic GERD; worse at night or in supine position
             o Wet bronchiectasis- lower RT; secretions are not                 More common in females and non-smokers
                 easily expelled                                                Mechanism:
      Treatment                                                                        o Accumulation of bradykinin, histamine,
             o Bronchodilator, antibiotics, surgical removal of                              prostaglandin
                 bronchiectatic areas if hemoptysis recurred or is                      o ACE inhibitor may also induce rhinitis, angiodema,
                 life threatening                                                            asthma attacks
                                                                                Treatment:
     7. POST-INFECTIVE BRONCHIAL                                                       o Reduce dose (only diminishes cough)
          HYPERRESPONSIVENESS                                                          o PG inhibitors (e.g. indomethacin may diminish
      From chronic inflammation following an infective process,                            cough)
          usually viral                                                                o Theophylline, Na cromoglycate may help but not in
      May be the first clue in patients eventually diagnosed with                          all patients
          asthma                                                                       o If no other medication may be given to the patient,
      Like asthma, it responds to bronchodilators and steroids;                            withdraw drug—only reliable remedy and may be
          asthma suspected, signs and symptoms recur after                                  changed with other agents
          treatment is removed

      Chronic cough occurs in 90% of lung Ca due to                            Β2 agonists used in hypertension, angina, ―nervous
          endobronchial involvement or atelectasis; ―recent change                 palpitation‖, hyperthyroidism, other cardiac conditions
          in character of cough‖ usually due to lung Ca                         Mechanism:
      Small lesions including adenomas directly stimulate cough                       o Suppresses the predominant sympathetic tone of
          receptors; CXR may be normal                                                       airways responsible for bronchodilation
      When lesions become bigger, may be seen as nodules and                          o Patients with hyperactive airways are very
          may block airways causing atelectasis.                                             susceptible
      Bronchoscopy + Biopsy is diagnostic but rarely helpful if CXR              Treatment: Withdraw or change drug
          is normal                                                               Contraindication for COPD patients
      CT scan is more helpful if more common causes are
          eliminated and serial CXRs remain normal                             13. PSYCHOGENIC DRUG
      Treatment                                                                  Arrived at by exclusion
               o Surgery, radio treatment, chemotherapy depending                 Characteristic absence of nocturnal cough
                    if Ca is malignant or benign                                  Occurs when patient is tense or uncomfortable, not
                                                                                     when asleep; signs of emotional difficulties, secondary
     9. RESTRICTIVE LUNG DISEASE                                                     gain; cough sounds forced, usually barking, honking
      From disease of pleura, chest wall, diaphragm, pulmonary                      which can perpetuate cycles of irritation
          interstitium resulting in reduced lung volume
                                                                               Etiology                Clues                Confirm
      Lack of stimulation to stretch receptors induces cough (thus     UACS                     Concomitant        ―Cobblestone‖
          cough suppression is an interplay of stimulation and                                   upper airway       oropharynx in PNDS
          inhibition of receptors; lack of excess stimulation cough)                            pathology
      Concomitant submucosal infiltration (e.g. sarcoidosis) may       Cough variant asthma     Like asthma,       Spirometry, trial of
          trigger cough reflex                                                                   without            bronchodilators,
      Treatment: Address underlying disease to control cough.                                   wheezing,          bronchoprovocation
          Given steroids, when fibrotic—peel off the fibrotic tissues                            cough worse at
     10. RECURRENT ASPIRATION                                           GERD                     Cough worse at     Pharyngeal/esophageal
      Problematic cough reflex                                                                  nighttime          pH monitoring, empiric
      Chronic cough usually among elderly with CNS problems                                                        therapy
         (CVA or stroke) or swallowing problems; gag reflex usually     Chronic bronchitis       Sputum x 3         Spirometry
                                                                                                 mos x 2 yrs;
                                                                                                 ronchi, smoker
      Oral secretions or contents find their way to tracheobronchial   Bronchiectasis           Cough, copious     Bronchography, HRCT
         tree                                                                                    sputum,            scan
      Recurrent pneumonia or pulmonary abscess may be present                                   persistent
      Treatment: Address underlying problem                                                     pneumonic
      Percutaneous Endoscopic Tracheotomy (PET)
                                                                        Drug-induced             ACEI or β          Discontinue drug
                                                                                                 blocker user
     11. DRUG-INDUCED COUGH: ACE INHIBITORS                             Pulmonary tumor          New or change      CXR, Fisher optic
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                          in cough           bronchoscopy, CT scan            At its onset, were there associated symptoms suggestive of a
                          (smoker),                                            respiratory infection?
                          hemoptysis                                          Is it seasonal or associated with wheezing?
Restrictive lung          Non-productive     CXR, stipling, mosaic            Is it associated with symptoms suggestive of postnasal drip (nasal
disease                   cough              pattern: static lung              discharge, frequent throat clearing, a "tickle in the throat") or
                                             volume                            gastroesophageal reflux (heartburn or sensation of regurgitation)?
Post-infective            Persistent         Trial of bronchodilation          However, the absence of such suggestive symptoms does not
hyperresponsiveness       cough after a                                        exclude either of these diagnoses.
                          previous URTI                                       Is it associated with fever or sputum? If sputum is present, what is
                          usually viral                                        its character?
Aspiration                Elderly,           Barium swallow,                  Does the patient have any associated diseases or risk factors for
                          swallowing         esophageal motility study         disease (e.g., cigarette smoking, risk factors for infection with HIV,
                          problems,                                            environmental exposures)?
                          esophageal                                          Is the patient taking an ACE inhibitor?
Psychogenic               (-) Nocturnal      By exclusion                 B. PE
                          cough;                                           Postnasal drip: examine oropharynx for oropharyngeal mucus or
                          emotional                                            erythema or a cobblestone appearance of the mucosa
                          difficulties; 2°                                 Palpation:
                          gain                                                  o Check for areas of tenderness – in cases of chest pain; do
                                                                                       not prove
FROM 2012 trans:                                                                o Tactile fremitus (there is NO VOCAL FREMITUS!!!)
Etiology                                                                                  Palpable vibrations transmitted through
A. Exogenous Source – smoke, dust, fumes, foreign bodies                                      bronchopulmonary tree to the chest wall as the
B. Endogenous Origin – upper airway secretion, gastric contents                               patient is speaking
Affect receptors in upper airway (pharynx and larynx) or in lower respi                       Ask patient to say ―ninety-nine‖ or ―tres tres‖
tract                                                                      Note symmetry
 Cough triggered by upper airway secretions (postnasal drip or                o Prominent in interscapular area then lower lung fields
      gastric contents) may persist                                            o Often more prominent on the right side than on the left
 Cough associated with GERD – vagally mediated; due to irritation             o Disappears below diaphragm
      of upper airway receptors or to aspiration of gastric contents       Auscultation:
 Prolonged irritation à airway inflammation à cough                      - Breath (lung) sounds:
C. Diseases resulting in airway:                                               o Vesicular – soft and low pitched; heard over most of both
 Inflammation – infections                                                          lungs
           o Viral/Bacterial bronchitis                                        o Bronchovesicular – heard in the 2-3rd interspace
           o Bronchiectasis                                                    o Bronchial - louder and higher in pitch; heard in the
           o Pertussis infection - produces prolonged/persistent                     manubrium
                cough                                                          o Tracheal – very loud and harsh sound; heard over trachea
 Constriction                                                            - Adventitious (added) sounds:
           o Asthma                                                            o Inspiratory stridor – indicative of airway disease
                            Common cause of cough                             o Rhonchi or expiratory wheezing – lower airway disease
                            Cough in the absence of wheezing or               o Inspiratory crackles – involves pulmonary parenchyma (refer
                            dyspnea (cough-variant asthma)                           above for diseases)
 Infiltration – neoplasms and granulomatous diseases                                      o Coarse – in small airways
           o Bronchogenic CA                                                               o Fine – lung parenchyma
           o Carcinoid tumor                                              - Transmitted voice sounds
           o Endobronchial sarcoidosis                                         o Increased tran                   -filled lung has become airless
           o Tuberculosis                                                                  o Bronchophony
 Compression – extrinsic masses                                                                                                          -nine‖
           o Lymphoma                                                                      o Egophony
           o Mediastinal tumors
           o Aortic aneurysm (rarely)                                                                  as ―ay‖
                                                                                         o    Whispered Periloquy
D. Parenchymal lung diseases                                                                                                            -nine‖ or
 Interstitial lung disease                                                                              ―one-two-three‖
 Pneumonia                                                               C. Chest X-ray
 Lung abscess                                                             Important findings:
 Pulmonary edema                                                          Presence of an intrathoracic mass lesion
                                                                           Localized pulmonary parenchymal opacification Diffuse interstitial
E. Congestive Heart Failure (CHF)                                             or alveolar disease
 Cough may be secondary to interstitial and peribronchial edema          
                                                                                                                       ts sarcoidosis
F. Drug: Angiotensin-converting enzyme (ACE) inhibitors
 Non-productive cough                                                    D. Pulmonary Function Testing
 May be related to accumulation of bradykinin or substance P (both        For assessment of functional abnormalities that accompany
     degraded by ACE)                                                         certain disorders producing cough
                                                                           Forced expiratory flow rates – demonstrate reversible airflow
APPROACH TO PATIENT                                                           obstruction characteristic of asthma
A. History                                                                 Methacholine or cold-air inhalation – used when asthma is
 Is the cough acute, subacute, or chronic?                                   considered but flow rates are N

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          o     Demonstrate hyperreactivity of airways to a
                bronchoconstrictive stimulus
    Lung volume and diffusing capacity – for demonstration of
     restrictive pattern (often seen in diffuse interstitial lung diseases)

E. Sputum
 Gross and microscopic examination
 Purulent – chronic bronchitis, bronchiectasis, pneumonia, lung
 Blood in sputum - chronic bronchitis, bronchiectasis, pneumonia,
     lung abscess, endobronchial tumor
 >3% eosinophil – eosinophilic bronchitis
 Gram stain, Acid fast and Culture – demonstrate infectious agent
 Sputum cytology – diagnosis for pulmonary malignancy

F. Treatment and Management
 Depends on underlying cause
 Elimination of exogenous or endogenous triggers
 Treatment of specific RTI
 Bronchodilators for potentially reversible airflow obstruction
 oInhaled glucocorticoids for eosinophilic bronchitis
 Chest physiotherapy – to enhance clearance of secretions in
 Tx of endobronchial tumors or interstitial lung disease
 Chronic unexplained cough: nasal ipatropium spray (to treat
     unrecognized postnasal drip)
 If ineffective, use tx for asthma, nonasthmatic eosinophilic bronchitis
and GERD

Symptomatic/Nonspecific therapy should be considered when:
(1) the cause of the cough is not known or specific treatment is not
possible, and
(2) the cough performs no useful function or causes marked discomfort
or sleep disturbance.
 Irritative, non-productive cough – antitussive agent (codeine,
      nonnarcotics like dextromethorphan
 Cough productive of significant quantities of sputum should
      usually NOT be suppressed
          o retention of sputum in the tracheobronchial tree may
                interfere with the distribution of alveolar ventilation and
                the ability of the lung to resist infection

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