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.
- 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:
- Epistaxis
- Subconjunctival hemorrhage
- Syncope
- Pneumothorax
- Pneumomediastinum
- Emesis
- Hernia
- Rectal prolapse
- Incontinence
- Seizures
- Encephalitis
- Intracranial hemorrhage
- Spinal epidural hemorrhage
- Clubbing
- Pruriginous rash
Etiology
- Acute (<3 wk):
- Pneumonia
- Acute bronchitis
- Sinusitis
- Pertussis
- Tuberculosis
- Upper respiratory tract infection
- Cough variant asthma
- COPD exacerbation
- Bronchiectasis
- Pulmonary embolism
- Left ventricular failure
- Airway obstruction (food, pills)
- GERD
- Allergies
- Bronchospasm
- Subacute (3-8 wk):
- Postinfectious cough
- Pertussis
- Bronchitis
- Bacterial sinusitis
- Asthma
- GERD
- Pulmonary embolism
- Chronic (>8 wk):
- Postnasal drip
- Asthma
- GERD
- Chronic bronchitis
- Tuberculosis
- Bronchiectasis
- Eosinophilic bronchitis
- ACE inhibitor use
- Bronchogenic carcinoma
- Carcinomatosis
- Sarcoidosis
- Left ventricular failure
- Aspiration syndrome
- Psychogenic/habit
- Most frequent causes:
- Asthma
- Viral illness
- Acute bronchitis
- Pneumonia
- Sinusitis
- GERD
- Less common causes:
- Tracheobronchomalacia
- Mediastinal tumor
- Acyanotic congenital heart disease
- Ventricular septal defect
- Patent ductus arteriosus
- Pulmonary stenosis
- Tetralogy of Fallot
- Lodged foreign body
- Chronic aspiration of milk
- Environmental exposure
- Consider:
- Neonatal history
- Feeding history
- Growth and developmental history
- Allergies
- Eczema
- Sleep disorders
- Indications for CXR:
- Suspicion of foreign body ingestion
- Suspect aspiration
Diagnosis
Signs and Symptoms
- 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
- Post-tussive syncope or emesis (suggests pertussis)
- Shortness of breath
- Chest pain
- Chills/fever
- Night sweats
- Wheezing
- GERD:
- Heartburn
- Dysphagia
- Regurgitation
- Belching
- Early satiety
- Malignancy:
- Weight loss
- Poor appetite
- Fatigue
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. 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
- Evidence of respiratory distress:
- Use of accessory muscles
- Abdominal breathing
Essential Workup
- Complete medical history:
- Duration
- Associated symptoms
- Sick contacts
- Smoking exposure
- ACE inhibitor use
- HIV/immunocompromised state
- Potential exposure to tuberculosis
- EKG:
- History of cardiac disease
- Associated chest pain or abnormal vital signs
- Lack 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 patient
- At least 1 of the following in healthy patients with acute cough and sputum production:
- Heart rate >100 bpm
- Respiratory rate >24 breaths/min
- Oral body temperature of >38 ░C
- Chest exam findings of focal consolidation, egophony, or fremitus
- Ill appearing
- Change in chronic cough
- Continued cough after discontinuation of ACE inhibitor
- CT of chest:
- Abnormal CXR
- Assess for pulmonary embolism
Diagnostic Procedures/Surgery
- Peak flow
- Bronchoscopy:
- For unknown mass on chest radiograph
- Hemoptysis
- Suspected 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 q4-6h
- 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
- Bronchodilators:
- Albuterol: 2.5 mg in 2.5 NS (peds: 0.1-0.15 mg/kg/dose q20min) q20min inhaled
- Ipratropium: 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 q4-12h
- Phenylpropanolamine: 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 BID
- Methylprednisolone: 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 pain
- Coughing blood
- Shortness of breath
- Fainting
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)