Documente Academic
Documente Profesional
Documente Cultură
• Definition of
Cough
• Impact
• Mechanism
• Approach to a
patient with
cough
• Complications
• Treatment
• Specific
What is
cough?
What is
cough?
A forced
expulsive
maneuver,
usually against
a
closed glottis
and which is
associated with
a characteristic
BTS Guidelines, Thorax 2006: 61 (Suppl 1):i1 –i24.
Impact of Cough
• An important airway defense mechanism
• An explosive expiration
that provides a normal
protective mechanism
for clearing the tracheo-
bronchial tree of
secretions and foreign
material
• Coughing helps protect
the lungs against
aspiration Cough pellet
Impact of Cough
• When excessive or bothersome, cough is
one of
the most common complaints motivating
patients to seek medical attention
throughout the world
• Heralds a disease or disorder
• Chronic cough is a common diagnostic and
therapeutic problem
Impact of Cough
• Discomfort from the cough itself and its
complications
• Associated with a marked deterioration in
quality
of life and interference with normal lifestyle
• Psychosocial dysfunction returns to normal with
successful treatment
Chronic Cough is a
Disease
• it is inappropriate to minimize a
patient's complaint of chronic
cough and/or advise him/her to
"live with it" since chronic cough is
associated with adverse effects on
his/her quality of life and it can be
successfully treated in most
patients who adhere to treatment
Arch Intern Med. 1998;158:1657-1661
Magnitude of the Problem
• ? Cost of treating chronic cough
• IMS, 2004:
Sales of expectorants P 2.5 B
Sales of antitussives P 193.7 M
Sales of nasal decongestants P 1.7 B
Sales for Ascof P 38.2 M
• Population-Based Prevalence?
Foreign studies: 3 to 40%
Magnitude of the Problem
• 1989 Rural Survey (Victoria, Laguna): 10%
chronic bronchitis
• 1991 Urban Survey (Paco, Manila): 24.6% had
“cough which was chronic or present at time of
interview”
• 2002 3 Urban Cities, young patients: 13% had
cough persisting > 2 weeks
• Chronic cough is a common problem among
Filipinos
Impact of Cough
• An important factor in
the
spread of infection
Mechanism
of Cough
One can voluntarily
inhibit himself from coughing.
C.True
D. False
Mechanism of Cough:
Initiation
• Voluntary
• Reflexive
Mechanism of Cough: Reflex
Pathway
Cough phases
• Inspiratory
• Compressive
• Expulsive (Expiratory or
Explosive)- 1st cough sound heard
• Recovery
Flow and Subglottic Pressures
During The Phases of Cough
C. Glottic closure
D. Compressive
E. Expiratory
McCool, F. D. Chest 2006;129:48S-53S
Mechanism of Cough: Reflex
Pathway
Irritant Triggers
• Exogenous
Source
Smoke, dust,
fumes, foreign
bodies
• Endogenous
Source
upper airway
mucus, gastric
Cough: involves a complex reflex arc
that begins with irritation of a
receptor
Afferent Limb Cough Center
and Receptors (integrated in the
(RARs, C fibers) Effectors
medulla oblongata)
/ Superior
Laryngeal
/ Recurrent
Laryngeal
Approach to
the Patient
with Cough
Duration of Cough
Estimating the duration of cough is crucial
in
narrowing the list of etiologies
ACCP/ ERS Consensus Guidelines (in
contrast to
Harrison’s)
• Acute Cough : < 3 weeks
• Sub-Acute Cough: lasting 3 – 8 wks
• Chronic Cough: > 8 wks
Etiology of Cough
Any disorder
resulting in
inflammation,
constriction,
infiltration or
compression of the
upper or lower
airways and the
lung parenchyma
Anatomic Diagnostic Protocol
• Systematic evaluation of
the afferent limb of the
cough reflex
• Detailed history to obtain
valuable clues, with
attention to associated
symptoms and includes
occupational Hx and
environmental exposure
• Thorough PE, including
ENT examination
• Targeted laboratory
examination; at least a
CXR for patients with
Anatomic Diagnostic Protocol
• Narrows DDX to specific
ENT, pulmonary and
extra-pulmonary causes
• Provides
recommendations for
targeted and successful
therapy
• Standard of evaluation
and management since
1981
• Adapted by ACCP
Laboratory Work Up
of Cough
• Chest Radiograph
Can identify the presence of chest wall,
pleural, lung parenchymal and
mediastinal lesions or abnormalities
Chronic Cough
Nonsmoking Adults
Not on ACEI
Normal/ Near Normal CXR
Laboratory Work Up of Cough
• Sputum Analysis
gross and microscopic examination
purulent: chronic bronchitis,
bronchiectasis,
pneumonia or lung abscess do G/S,
C/S
blood in the sputum: rule out
endobronchial
tumor
eosinophilia: asthma or nonasthmatic
eosinophilic bronchitis (NAEB)
Specialized Laboratory Studies
To Work Up Cough
• Paranasal/Sinus X-Ray Series/ Screening
CT
Scan of the Sinuses
Upper airway cough syndrome (UACS)
• 24-hour Esophageal pH monitoring
Gastroesophageal Reflux Disease (GERD)
• Bronchoprovocation Test
Cough-Variant Asthma
• Pulmonary Function Test/ Spirometry
Differentiate Restrictive and Obstructive
DOs
Detect Reversible versus Non-reversible
Specialized Laboratory Studies
To Work Up Cough
•Fibreoptic Bronchoscopy
Endobronchial tumors
• High-resolution CT Scan of the Chest
Chest tumors, interstitial lung diseases
• 2-D Echocardiography with or without
Doppler
Studies
Congestive heart failure
Approach to Acute
Coughfirst step is to decide
• The most important
whether the acute cough is potentially a
reflection of a serious illness, or, as is usually
the case, a manifestation of a non-life-
threatening, transient condition
• Possible causes:
URTI, including the Common Cold –
most common
Lower respiratory tract infection/
Pneumonia
Exacerbation of a pre-existing condition
e.g.,
COPD, bronchiectasis, allergic
rhinitis Chest 2006; 129:222S–231S
Approach to Sub-Acute Cough
• The first step is to determine whether or not
the
cough has followed an obvious preceding
respiratory infection
• If the subacute cough does not appear to be
postinfectious in nature, it should be
evaluated and managed as if it were a
chronic cough
• If post-infectious, consider:
Post-Infectious Cough with BHR
Atypical causes of RTI/ pneumonia
including
Pertussis, PTB, atypicalChest pneumonia,
2006; 129:222S–231S.
Chronic Cough Approach to Chronic
ACEI
Cough Stop ACEI
Cough gone
Hx / PE
Cough persists
Chest radiograph
Normal Abnormal
Abnormality
may not be Order accordingly to likely clinical
related to possibility
Avoid irritant cough Sputum cytology, HRCT scan, modified BaE,
bronchoscopy, cardiac studies
25.0
20.3
20.0
15.2
15.0
10.1
10.0
6.8
5.1
5.0 3.8 3.8 3.0
1.7
0.8
0.0
Asthma
PNDS
PTB
COPD/ CB
PostInfx Cough
Bronchiectasis
Pneumonia
GERD
ACEI-induced
Pulmonary CA
CHF
Others
Causes of Chronic Cough
80.0
67.5
70.0
60.0
50.0
%
40.0
29.5
30.0
20.0
10.0 2.5
0.0
1 2 3
Number of Causes
9.6%
6.5%
49.1%
24.3%
Specific Cough Therapy
• Definitive treatment: treat the
underlying cause!
• elimination of the inciting agent,
whenever possible
Non-Specific Cough Therapy
• when the cause is unknown or
specific Rx is not possible
• the cough performs no useful
function or causes marked discomfort
Non-Specific Cough Therapy
1. Antitussive or Cough
Suppressant
• drugs that increase the latency or
threshold
of the cough center, e.g., codeine,
dextromethorphan
• drugs that affect the afferent limb of
the
Non-Specific Cough Therapy
2. Protussive
• enhance cough effectiveness by
promoting the clearance of airway
secretions and loosen mucus
• indicated in cystic fibrosis,
bronchiectasis,
pneumonia and postoperative
atelectasis
• pharmacologic agents e.g., nebulized
saline solution, erdosteine
Non-Specific Cough
Therapy
2. Protussive
• mechanical aids- for
patients with
neuromuscular or
neurologic diseases
intermittent/ episodic
nocturnal cough
identifiable triggers
family history of asthma and/or atopy
presence of wheezing
relief with bronchodilators
resolves with inhaled steroids
GERD
Post-Infectious Cough
• Cough that has been present for at least
3 weeks following symptoms of an acute
respiratory infection
• Includes post viral BHR
• Trial of inhaled ipratropium (Grade B)
• Use of Inhaled ICS if inhaled ipratropium
ineffective (Grade E/B)
• Central acting antitussives such as
codeine or dextromethorphan should be
considered when other measures fail
(Grade E/B)
Post-Infectious Cough