Cough

Last updated 13.02.13

 

Index

 

Definition

- Explosive expiration which cleans & protects tracheobroncial tree from secretions & foreign material

- Refelx response to stimulation of receptors in upper airways

 

Features

- One of most common reasons to present to health care

- Airway receptor stimulation from

-  Irritant chemicals, fumes, particles: smoking..

-  Secretions, tumours or foreign bodies in airways

-  Narrowing of airways by bronchospasm, inflammation or compression: asthma, bronchiolitis..

-  Distortion of airways: pulmonary fibrosis, pleural effusion

- Acute <3/52

-  URTI: common cold, Pertusis, bacterial sinusitis

-  Pneumonia, PE, CCF

- Chronic > 3/52

-  Smoker: COPD, bronchogenic Ca

-  Postnasal drip (upper airway cough syndrome), asthma, GORD, ACEI

-  Post infective cough, Pertusis, Mycoplasma infection

-  Foreign body

 

Causes

- Respiratory

-  URTI

-  Epiglotitis

-  Croup

-  Bronchiolitis

-  Acute Bronchitis

-  Pertusis

-  Asthma

-  COPD: chronic or acute exacerbation

-  TB

-  Pneumonia

-  CF

-  Bronchiectasis

-  Lung abscess

-  PE

-  Pulmonary fibrosis

-  Goodpastures

-  Bronchogenic Ca

-  Pneumothorax

- Cardiac

-  APO (CCF..)

-  Mitral stenosis

- Foreign body

- Meds

-  ACEI

-  Beta Blockers if Hx of Asthma

-  Some meds may cause interstitial fibrosis: Methotrexate..

- GORD

- Recurrent laryngeal n. palsy: goitre, nodule

- Tracheoesophageal fistula

- External compression: aortic aneurysm, mediastinal Ca, enlarged lymph nodes

- Psychogenic or cerebral: not from lung receptor stimulation

 

Associated S/S

- SOB, increased WOB

- History

-  Sick contacts

-  Travel overseas

- Fever: TB, pneumonia, URTI, lung abscess, PE..

- Prodromal coryza

-  URTI, Croup, Bronchiolitis

-  Pertusis

-  Asthma, COPD, acute bronchitis

- Cough

-  Chronic & dry: ACEI, GORD, pulmonary fibrosis

-  Awakens at night: GORD, CCF, asthma

-  + SOB/PND: CCF, APO

-  Absent during sleep: psychogenic

-  Bovine: Pertusis (chronic), recurrent laryngeal n. palsy

-  Paroxysms & barking/bovine: Pertusis

-  Barking: Croup (+/- stridor)

-  Post prandial: GORD, tracheosophageal fistula

-  Haemoptysis: Ca, Pneumonia, COPD, TB..

-  Seasonal: asthma

- Weight loss: Ca, TB

- Crackles: pneumonia, APO/CCF

- Stridor: Foreign body, Epiglotitis, URTI, Croup

- Wheeze

-  Asthma, Bronchiolitis

-  CCF, APO

- Apnoea: Bronchiolitis

- Orthopnoea: CCF

- Sputum

-  Inspect if possible

-  Increase in volume or purulence: COPD exacerbation

-  Foul odour & dark: lung abscess

-  Pink & frothy: CCF, APO

-  Large volume green/yellow sputum: CF, bronchectasis, pneumonia

- Child

-  Paediatric Chest Exam

-  Increased WOB: Dx severity rather than cause

-  Grunting, nasal flaring: consider pneumonia

 

Complications

- Rib fractures, chest wall tenderness

- Flushed face, fatigue

- Haemoptysis

- Scleral injection/haemorrhage (esp. children)

-  DDx Shaken Baby Syndrome (SBS)

- Urinary incontinence

- Cough syncope

 

Ix

- Immunisations

-  Paeds up to date

-  Elderly: influenza, pneumococcal

- Medication Hx: esp ACEI

- Smoking Hx

- Resp Exam

- +/- Cardio Exam

- CXR

-  Pneumothorax

-  Consolidation: pneumonia, TB..

-  Pleural effusion, pulmonary congestion: APO, CCF

-  Mass lesion: Ca, foreign body

-  Locaslised infiltration: pneumonia, TB

-  Diffuse alveolar disease, interstitial fibrosis

-  Brochiectasis

-  Hyperexpansion: asthma, COPD

- Spirometry

-  COPD, asthma, interstitial fibrosis

- +/- D-Dimer: to exclude PE

- +/- Sputum culture

-  Pus, haemoptysis, eosinophils, culture (AFB, Gram stain)

- +/- atypical serology: atypical pneumonia (Mycoplasma..)

- +/- NPA: Pertusis

- +/- CT–Chest

- +/- Bronchoscopy

 

Mx

- Immunisations

- Quit smoking regardless of cause of cough

- Mx as per cause

- Generally considered better to remove sputum than to suppress cough

- Non-specific Mx

-  Persistant cough becomes self perpetuating as damaged mucosa is sensitive to irritants

-  Avoid exposure to irritants

-  Sedating antihistamines for sleep at night

-  PPI if suspecting GORD

-  Consideration of short term cough suppressant

-  Codeine phosphate 25-30mg PO 3-6/24

-  Consideration of low dose corticosteroid

-  Severe, intractable cases nebulised lignocaine to break cycle: must not eat or drink for 2hrs post

-  Lignocaine 2% 2ml Nebs 5-10min QID PRN up to 1 week

 

 

 

References

 

eTG – Cough 2010