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Cough, Emergency Medicine

Basics

Description

- A sudden spasmodic contraction of the thoracic cavity resulting in violent release of air from the lungs and usuallyaccompanied by a distinctive sound: - Deep inspiration - Glottis closes - Expiratory muscles contract - Intrapulmonary pressures increase - Glottis opens - Air expiration at high pressure - Secretion and foreign material excretion - Vocal cord vibration with tracheobronchial walls, lung parenchyma, and secretions

- Defense mechanism to clear the airway of foreign material and secretions: - Voluntary or involuntary - Involuntary coughing regulated by the vagal afferent nerves: - Voluntary coughing under cortical control allowing for inhibition or voluntary cough - Because of cortical control, placebos can have a profound effect on coughing.

- Indications for CXR: - Suspicion of foreign body ingestion - Suspect aspiration

- Sputum production: - Frothy (pulmonary edema) - Mucopurulent - Suggestive of bacterial pneumonia or bronchitis but also seen with viral infections - Rust colored (pneumococcal pneumonia) - "Currant jelly"Ł (Klebsiella pneumonia) - Hemoptysis

- Malignancy: - Weight loss - Poor appetite - Fatigue

- Vital signs - Abnormal breath sounds: - Absence or decreased: Reduced airflow vs. overinflation - Rales (crackles): Popping or rattling when air opens closed alveoli: - Rhonchi: Snoring-like sounds when large airways are obstructed - Wheezes: High-pitched sounds produced by narrowed airways - Stridor: Upper airway obstruction

- EKG: - History of cardiac disease - Associated chest pain or abnormal vital signs - Lack of infectious symptoms

- Ill appearing - Change in chronic cough - Continued cough after discontinuation of ACE inhibitor

- Antitussives: - Codeine: 10-20 mg (peds: 1-1.5 mg/kg/d) PO q4-6h - Dextromethorphan: 10-20 mg (peds: 1 mg/kg/d) PO q6-8h - Hydrocodone: 5-10 mg (peds: 0.6 mg/kg/d q6-8h) PO q6-8h

- Use pillows to keep head elevated at night. - Seek care immediately with: - Chest pain - Coughing blood - Shortness of breath - Fainting

  • A sudden spasmodic contraction of the thoracic cavity resulting in violent release of air from the lungs and usuallyaccompanied by a distinctive sound:Deep inspirationGlottis closesExpiratory muscles contractIntrapulmonary pressures increaseGlottis opensAir expiration at high pressureSecretion and foreign material excretionVocal cord vibration with tracheobronchial walls, lung parenchyma, and secretions
  • Defense mechanism to clear the airway of foreign material and secretions:Voluntary or involuntaryInvoluntary coughing regulated by the vagal afferent nerves:Voluntary coughing under cortical control allowing for inhibition or voluntary coughBecause of cortical control, placebos can have a profound effect on coughing.Reflex involves respiratory tissue receptor activation of afferent neurons to the central cough center followed by efferent output to the respiratory muscles.Mechanical receptors in larynx, trachea, and carina sense touch and displacement.Chemical receptors in larynx and bronchi are sensitive to gases and fumes.Activated by irritants, mucus, edema, pus, and thermal stimuli
  • Complications of severe coughing:EpistaxisSubconjunctival hemorrhageSyncopePneumothoraxPneumomediastinumEmesisHerniaRectal prolapseIncontinenceSeizuresEncephalitisIntracranial hemorrhageSpinal epidural hemorrhageClubbingPruriginous rash

Etiology

  • Acute (<3 wk):PneumoniaAcute bronchitisSinusitisPertussisTuberculosisUpper respiratory tract infectionCough variant asthmaCOPD exacerbationBronchiectasisPulmonary embolismLeft ventricular failureAirway obstruction (food, pills)GERDAllergiesBronchospasm
  • Subacute (3-8 wk):Postinfectious coughPertussisBronchitisBacterial sinusitisAsthmaGERDPulmonary embolism
  • Chronic (>8 wk):Postnasal dripAsthmaGERDChronic bronchitisTuberculosisBronchiectasisEosinophilic bronchitisACE inhibitor useBronchogenic carcinomaCarcinomatosisSarcoidosisLeft ventricular failureAspiration syndromePsychogenic/habit
  • Most frequent causes:AsthmaViral illnessAcute bronchitisPneumoniaSinusitisGERD
  • Less common causes:TracheobronchomalaciaMediastinal tumorAcyanotic congenital heart diseaseVentricular septal defectPatent ductus arteriosusPulmonary stenosisTetralogy of FallotLodged foreign bodyChronic aspiration of milkEnvironmental exposure
  • Consider:Neonatal historyFeeding historyGrowth and developmental historyAllergiesEczemaSleep disorders
  • Indications for CXR:Suspicion of foreign body ingestionSuspect aspiration

Diagnosis

Signs and Symptoms

  • Sputum production:Frothy (pulmonary edema)MucopurulentSuggestive of bacterial pneumonia or bronchitis but also seen with viral infectionsRust colored (pneumococcal pneumonia)"Currant jelly"Ł (Klebsiella pneumonia)Hemoptysis
  • Post-tussive syncope or emesis (suggests pertussis)
  • Shortness of breath
  • Chest pain
  • Chills/fever
  • Night sweats
  • Wheezing
  • GERD:HeartburnDysphagiaRegurgitationBelchingEarly satiety
  • Malignancy:Weight lossPoor appetiteFatigue

History

  • Duration of cough to classify into acute, subacute, and chronic
  • Description of sputum, if present, including hemoptysis
  • Post-tussive emesis or syncope and paroxysmal cough suggests pertussis.
  • History of GI symptoms pointing to GERD
  • Weight loss and night sweats suggestive of tuberculosis in chronic cough

Physical Exam

  • Vital signs
  • Abnormal breath sounds:Absence or decreased: Reduced airflow vs. overinflationRales (crackles): Popping or rattling when air opens closed alveoli:Rhonchi: Snoring-like sounds when large airways are obstructedWheezes: High-pitched sounds produced by narrowed airwaysStridor: Upper airway obstruction
  • Evidence of respiratory distress:Use of accessory musclesAbdominal breathing

Essential Workup

  • Complete medical history:DurationAssociated symptomsSick contactsSmoking exposureACE inhibitor useHIV/immunocompromised statePotential exposure to tuberculosis
  • EKG:History of cardiac diseaseAssociated chest pain or abnormal vital signsLack of infectious symptoms

Diagnosis Tests & Interpretation

Lab

Order according to presenting signs and symptoms: á

  • WBC count with differential
  • Sputum gram stain, cultures, and sensitivities
  • Acid fast bacilli (AFB) culture
  • CD4 count
  • Pertussis titers
  • d-Dimer
  • Flu swab (for high-risk patients or those to be admitted)

Imaging

  • CXR:For immunosuppressed patientAt least 1 of the following in healthy patients with acute cough and sputum production:Heart rate >100 bpmRespiratory rate >24 breaths/minOral body temperature of >38 ░CChest exam findings of focal consolidation, egophony, or fremitusIll appearingChange in chronic coughContinued cough after discontinuation of ACE inhibitor
  • CT of chest:Abnormal CXRAssess for pulmonary embolism

Diagnostic Procedures/Surgery

  • Peak flow
  • Bronchoscopy:For unknown mass on chest radiographHemoptysisSuspected cancer

Differential Diagnosis

See "Etiology."Ł á

Treatment

Initial Stabilization/Therapy

Assess airway, breathing, and circulation. á

Ed Treatment/Procedures

Specific treatment related to cause: á

  • Respiratory infection: Consider antibiotics, antivirals (flu), decongestants, and antitussives.
  • Asthma: Inhaled β2-agonist and steroids
  • GERD: H2-blockers, proton pump inhibitors, and antacids
  • Suspicion of pertussis: Macrolide and 5 days isolation
  • Exacerbation of chronic bronchitis: Inhaled β2-agonist and steroids
  • Malignancy: Supportive care

Medication

  • Antibiotics:Pick appropriate coverage for suspected bacteria.
  • Antivirals:Tamiflu: 75 mg (peds: 30-75 mg PO BID Ś 5 days) PO daily
  • Antitussives:Codeine: 10-20 mg (peds: 1-1.5 mg/kg/d) PO q4-6hDextromethorphan: 10-20 mg (peds: 1 mg/kg/d) PO q6-8hHydrocodone: 5-10 mg (peds: 0.6 mg/kg/d q6-8h) PO q6-8h
  • Bronchodilators:Albuterol: 2.5 mg in 2.5 NS (peds: 0.1-0.15 mg/kg/dose q20min) q20min inhaledIpratropium: 0.5 mg in 3 mL NS (peds: Nebulizer 250-500 ╬╝g/dose q6h) q3h
  • Decongestants:Chlorpheniramine: 4-12 mg (peds: 2 mg PO q4-6h) PO q4-12hPhenylpropanolamine: 25-50 mg (peds: 6.25-12.5 mg PO q4h) PO q4-8h
  • Mucolytics:Guaifenesin: 200-400 mg (peds: 2-5 yr 50-100 mg PO, 6-11 yr 100-200 mg) PO q4h PRN
  • Steroids:Dexamethasone: 2 sprays/nostril BIDMethylprednisolone: 60-125 mg IV (peds: 1-2 mg/kg/dose IV/PO q6h)Prednisone: 40-60 mg (peds: 1-2 mg/kg/d q12h) PO

Follow-Up

Disposition

Admission Criteria

  • Hypoxemia or critical illness
  • Suspected tuberculosis with positive chest radiograph result
  • Immunocompromised with fever
  • Risk of bacteremia or sepsis

Discharge Criteria

  • Oxygenation at baseline for patient
  • Oral medications
  • Safe environment at home

Issues for Referral

Close follow-up by primary care physician for outpatient management á

Follow-Up Recommendations

  • Stop smoking, avoid being around smokers or other harmful substances such as asbestos.
  • Change diet:Avoid coffee, tea, and soda.Avoid eating for at least 4 hr prior to sleeping.
  • Use pillows to keep head elevated at night.
  • Seek care immediately with:Chest painCoughing bloodShortness of breathFainting

Pearls and Pitfalls

  • For patients fitting the clinical profile for cough due to GERD, it is recommended that treatment be initially started in lieu of testing.
  • For patients with a presumed diagnosis of acute bronchitis, routine treatment with antibiotics is not justified and should not be offered.

Additional Reading

  • Irwin áRS. Unexplained cough in the adult. Otolaryngol Clin North Am. 2010;43(1):167-180, xi-xii.
  • Irwin áRS, Baumann áMH, Bolser áDC, et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006;129:1S.
  • Schroeder áK, Fahey áT. Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst Rev. 2004;18(4):CD001831.

Codes

ICD9

  • 306.1 Respiratory malfunction arising from mental factors
  • 786.2 Cough
  • 786.30 Hemoptysis, unspecified

ICD10

  • F45.8 Other somatoform disorders
  • R04.2 Hemoptysis
  • R05 Cough

SNOMED

  • 49727002 Cough (finding)
  • 66857006 Hemoptysis (disorder)
  • 68154008 Chronic cough (finding)
  • 191954008 Psychogenic cough (finding)
  • 11833005 dry cough (finding)
  • 28743005 Productive cough (finding)
  • 300959008 Allergic cough (finding)