cough

I M COUGHING MY LUNGS UP DOC

Im 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

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Common Causes of Cough

Acute Infections
Tracheobronchitis Bronchopneumonia Viral pneumonia Exacerbation of COPD bronchitis Pertussis

Tumors
Bronchogenic carcinoma Alveolar cell carcinoma Benign airway tumors Mediastinal tumors

Chronic Infections
Bronchiectasis Tuberculosis Cystic fibrosis

Foreign Bodies Middle Ear Pathology Cardiovascular Diseases

Left ventricular failure Pulmonary infarction Aortic aneurysm (thoracic)

Airway Diseases
Asthma Chronic bronchitis Chronic postnasal drip

Other Diseases
Reflux esophagitis Recurrent aspiration Endobronchial sutures

Parenchymal Diseases
Chronic interstitial lung fibrosis Emphysema Sarcoidosis

Drugs
ACE inhibitors COPD,

Cough reflex

cough

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 Duration

Differential 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 Cough

Identify 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 Signs Tachypnoea Cyanosis Dull chest Bronchial Breathing Crackles

    

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


ACTIONS Examine Chest Chest X-Ray if signs or smoker Measure of airflow obstruction ie peak flow -one off peak flow -serial spirometry

Don t want to miss lung cancer

Post Infectious Cough

A cough that begins with an acute respiratory tract infection and is not complicated* by pneumonia
*Not complicated = Normal lung exam and normal chest Xray

Post Infectious cough will resolve without treatment Cause = Postnasal drip or Tracheobronchitis

Postinfectious Cough
Following an acute respiratory infection, at least 3 weeks- 8 weeks, 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/or an inspiratory whooping sound judge other factors < considering therapy UACS lower airway GERD Except for bacterial sinusitis or early in B. pertussis infection, antibiotics have no role.

Chronic Cough

Chronic Upper Airway Cough Syndrome

The Committee unanimously recommends that the term (UACS) be used in preference to when discussing cough associated with upper airway conditions because It is unclear whether the mechanism(s) of cough is postnasal drip or direct irritation or inflammation of the cough receptors in the upper airway

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 infection 2. Nasal steroid for 8wks 3. Sedating antihistamines 4. Antileukotrienes eg montelukast 5. Saline lavage 6. ENT opinion

Asthma
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 cough is established only after resolution of cough with specific therapy

Asthma
initially treated with a standard antiasthma regimen of inhaled bronchodilators and corticosteroids When refractory, an assessment of airway inflammation should be performed persistent airway eosinophilia aggressive antiinflammatory therapy A leukotriene receptor antagonist before systemic corticosteroids

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

Two Mechanisms a. Aspiration to larynx/ trachea b. Acid in distal oesophagus stimulates vagus and cough reflex

Gastro-oesophageal Reflux Symptoms

Cough Features Throat clearing Worse at night / rising On eating Reflex hypersensitivity CXR -normal or hiatus hernia Spirometry normal

GI Symptoms
If Aspiration main mechanism Heart burn Waterbrash/ Sour taste Regurgitation Morning Hoarseness If Vagal - NO GI symptoms

Gastro-oesophageal Reflux
Reflux may be due to Medications or Foods
Drugs and foods that reduce lower esophageal sphincter (LES) pressure and can cause increased reflux include: Theophylline Oral adrenergic agonists NSAIDs Ascorbic acid Calcium Channel Blockers Chocolate Caffeine Peppermint Alcohol Fat

Gastro-oesophageal Reflux Investigation

 Oesophageal pH monitoring for 24 hours (+diary)
95% sensitive and specific 95%

 Ba swallow not sensitive enough  Endoscopy - may confirm but false -ve rate

Endoscopy can show GORD, but cannot confirm GORD as the cause of cough.

Slice of Life and Suzanne S. Stensaas

GED GED

profile of patient with chronic cough due to GERD:

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

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 chronic Cough; objective investigation for GERD recommended 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 made unless there is no clinical or radiographic evidence of pneumonia, and the common cold, acute asthma, or an exacerbation of COPD have been ruled out . For patients with a putative diagnosis of acute bronchitis, routine treatment with antibiotics is not justified and should not be offered.

Chronic Bronchitis
chronic cough and sputum expectoration occurring on most days for at least 3 months and for at least 2 consecutive years should be given a diagnosis of chronic bronchitis when other respiratory or cardiac causes of chronic productive cough are ruled out. stable patient suddenly experiences a sudden clinical deterioration with increased sputum volume, sputum purulence and/or worsening of shortness of breath, this is referred to as an acute exacerbation of chronic bronchitis, as long as conditions other than acute tracheobronchitis are ruled out

Chronic Bronchitis avoidance of personal tobacco use, passive smoke exposure, and other environmental irritants. For stable patients: Short-acting inhaled agonists, inhaled ipratropium, oral theophylline and combined inhaled long-acting agonists and inhaled corticosteroids may improve cough For an acute exacerbation: bronchodilators ( agonist and/or ipratropium), oral antibiotics, and oral or in severe cases IV corticosteroids are useful but their effects on cough have not been systematically evaluated.

Non-Asthmatic Eosinophilic Bronchitis

eosinophilic airway inflammation, similar to asthma. In contrast to asthma, not associated with variable airflow limitation or airway hyperresponsiveness. the differences in functional associations are related to differences in localization of mast cells within the airway wall There is smooth muscle infiltration in asthma There is epithelial infiltration in non-asthmatic eosinophilic bronchitis

Non-Asthmatic Eosinophilic Bronchitis

chronic cough with normal cxr normal spirometry, and no evidence of airway hyperresponsiveness. Diagnosis- eosinophilic airway Inflammation 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 persistent unless treated; occasionally, patients my require longterm prednisone therapy

Bronchiectasis
0-4% Most cases in adults are idiopathic; however, in the absence of an obvious cause, a diagnostic evaluation for an underlying disorder will reveal such a disorder up to 47% of the time and treatment for the underlying disorder may slow or halt the progression of airway disease up to 15% of the time. In patients with suspected bronchiectasis without a characteristic chest radiograph, HRCT is the diagnostic procedure of choice (specificity and sensitivity > 90%

Non-Bronchiectatic Suppurative Airway Disease

bronchiolitis. When the more common causes of cough have been ruled out, consider non-bronchiectatic suppurative airway Diseases in patients with Incompletely or irreversible airflow limitation, small airways disease 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 specific underlying 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 by a malignancy, even when the chest radiograph is normal, bronchoscopy is indicated.

Cough From Aspiration Due to Oral-Pharyngeal Dysphagia

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

ACE-Inhibitors and Chronic Cough

Incidence: 5-20% Onset: one week to six months Mechanism Bradykinin or Substance P increase Usually 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 (including Tourettes syndrome) and uncommon causes of chronic cough, and cough improves with behavior modification or psychiatric therapy. unexplained cough.

Chronic Interstitial Pulmonary Disease

may be a presenting or complicating feature. IPF, sarcoidosis, and hypersensitivity pneumonitis IPF, there is an associated sensitivity to capsaicin & sputum levels of nerve growth factor and brain-derived neurotropic factor suggesting a functional upregulation of sensory neurons of the lung

Occupational and Environmental Considerations in the Cough Patient

Chronic Cough Due to TB and Other Infections

Peritoneal Dialysis and Cough

22% compared to 7% in patients on hemodialysis. Although both groups frequently receive medications which can potentially trigger cough such as ACEIs and blockers and both groups are at increased risk for fluid overload and pulmonary edema, the increased risk associated with peritoneal dialysis most likely relates to GERD that can be initiated or exacerbated by increased intraperitoneal pressures.

In immunocomprimised
 the initial diagnostic algorithm is the same as that for immunocompetent persons
< 200 cells/ L or > 200 cells/ L 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 Chronic Cough

Until uncommon causes have been ruled out, the diagnosis of unexplained cough should not be made. The workup is never done unless a chest CT scan and bronchoscopy 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 Diagnosis

Common Differentials

Lung Disease
-normal CXR -abnormal CXR

Gastro -Oesophageal Reflux

Post-nasal Drip
-allergic rhinitis -bacterial sinusitis

Non-structural ACE-Inhibitors Tobacco Habit Cough

Cause of Cough

Table 29.4

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Treatments for Cough

Treatment

Treating the Specific Underlying Cause(s)

Asthma, cough variant asthma Eosinophilic bronchitis Allergic rhinitis and postnasal drip Bronchodilators and inhaled corticosteroids Inhaled corticosteroids; leukotriene inhibitors 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 inhibitor Discontinue 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) Persistent cough, particularly nocturnal Persistent, intractable cough due to terminal incurable disease Simple linctus Opiates (codeine or pholcodeine) Opiates (morphine or diamorphine) Local anesthetic aerosol Cough in children Simple linctus (pediatric)

Cough Suppressant and Protussive Pharmcologic Therapy

Mucolytic agents not in patients with bronchitis. Zinc preparations are not to colds Peripheral and central antitussive agents - chronic bronchitis Opioids in lung cancer protussive agents are effective cough clearance (amiloride in CF; hypertonic saline in Bronchitis) 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 lung cancer Protussive therapy is intended to enhance cough effectiveness to promote clearance of airway secretions

Nonpharmacologic Airway Clearance Therapy

the principal strength of diagnostic testing is in ruling out suspected possibilities. The principal limitation is that a positive test result cannot necessarily be relied on to establish the diagnosis; a positive test result has not been able to consistently predict a favorable response to specific therapy. A positive test result, by itself, is not diagnostic of the cause of cough unless a favorable response to therapy is witnessed.

Potential Complications from Excessive Cough 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 Cervical disc prolapse

Musculoskeletal Complications
Intercostal muscle pain Rupture of rectus abdominis muscle Increase in serum creatine phosphokinase

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 of respiratory muscle strength Coughing clears secretions, food particles and foreign substances The cough assist increases the flow of air out, which helps the client 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 need tracheotomies (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 motionsensing transducers, electrodes, a microphone, and a 3-axis accelerometer into a lightweight, washable vest that is available for patients 5 years of age. Using integrated input from the motion sensors and microphone, the frequency and intensity of cough can 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 can be uploaded to the manufacturer, VivoMetrics, Inc, for analysis using specialized software.

 Role of cough in ACUTE MI ?