CAUGH

THE ‘SCIENCE’  BEHIND THE COMMON

CAUGH

“Three things cannot be hidden: coughing, poverty, and love.”

Yiddish proverb

Dr. Balahura Ana Maria

Why study it?

Cough – is one of the most common symptom for which patients

seek medical attention

- 30 mil. consultations every year in SUA

Furthermore - 40% of the working time of American

pneumologists is spent for identifying the cause of persistent
cough
Coughing

- sudden expulsion of air from the lungs through the epiglottis at an amazingly fast
speed.
- The body’s mechanism for clearing the breathing passageways of unwanted
Cough mechanism

+
Receptor Cough – reflex act in response to receptor stimulation – URT, LRT,
s pericardium, esophagus, diaphragm, stomach, ear

Afferent
pathway 1. Chemical R→ sensitive to acids, heat and „capsaicin-like”
s compounds (vaniloid type 1 R)
2. Mechanical R → stimulated by touch or position changes
Cough
center
Laryngeal and trachea-bronchial R – respond to both mechanical
and chemical stimulation
Efferent
pathway
s
Cough mechanism
Aferent pathways

+
Receptor
s

Afferent
pathway
s

Cough
center

Efferent
pathway
s

Efferent pathways
Classification

 ACUTE – < 3 weeks

 SUBACUTE – between 3-8 weeks

 CHRONIC – > 8 weeks

 Classification

Etiology Pulmonary Extrapulmonary

ACUTE Lower airways disease Upper airways disease
< 3W - Asthma - Infectious (viral)
- Aspiration - Allergic
- Inhalation of chemical
compounds/smoke Cardiac disease
- Postinfectious - Heart failure with pulmonary
oedema
Lung/pleural disease
- Pneumonia
- Pleurisy
- PE

CHRONI
C
> 8W
 Classification

Etiology Pulmonary Extrapulmonary

ACUTE
< 3W
CHRONI Lower airway disease and lung
C disease
>8w - Chronic bronchitis
- COPD
- Asthma
- Chronic infections
- Sistemic diseases with lung
involvement
- Chronic aspiration
- Bronchiectasis
- Chistic fibrosis
- Bronhomalacia and other rare
tracheobronchial diseases
Upper airway disease
- Post nasal drip syndrome/
Upper airway chronic cough
syndrome
- Chronic rhinitis and sinusitis
- Faringitis and laryngitis
- Vocal cord dysfunction
- Obstructive sleep apnea
GERD – gastroesophageal
reflux disease
Medication – ACEI
Cardiac disease with lung
congestion
Lung cancer
 Acute cough

25 year old woman

Presented for:
- Cough – initially dry then productive
(mucous-purulent sputum)
- Fever – 39 ºC

For 3 days
No past medical history

What is your (easy)diagnosis?

Community acquired pneumonia
Treatment – outpatient, Macrolide (Clarithromycin - 250 mg PO q12hr for 7-14
days)

Example slide
Acute cough
1. Upper and lower airway viral infections

Usually dry cough

Cough can persist for 2-3 weeks
When Mycoplasma pneumoniae or adenoviruses are involved – cough can persist for
up to 8 weeks

Persistence of cough can be due to:

 Post nasal drip
 Post infectious Cough hypersensitivity syndrome
 Post infectious inflammation in the airways
Acute cough
2. Upper and lower airway bacterial
infections

Usually productive cough

When Bordetella pertussis is the cause – it can persist

up to 3 months (whooping cough – severe, paroxysmal
cough attacks) – rare now because of vaccines
Acute cough
3. Upper airway allergic diseases

intermittent or persistent allergic rhinitis in

combination with sinusitis, conjunctivitis, pharyngitis

or laryngitis may be trigger factors for acute cough

Acute cough
4. Intermittent asthma (acute or chronic cough)

 the second cause of persistent cough in adults and the most common cause in children
 Cough is predominantly nocturnal or with effort
FEV1 ↑ with
> 12% and 200 mL

 to prove that cough is due to asthma

 a spirometry with bronchodilator test or a challenge tests

 Asthmatic cough - it improves after a week of treatment with inhaled CS and beta-

agonists.
Acute cough
5. Foreign body aspiration

Imaging plus bronchoscopy are the key

 Acute cough
5. Foreign body aspiration
worsening productive cough

Left pneumonia involving the lingula and posterior basal segment. New cylindrical metallic
structure in the left lower lobe.

She stated that 5 months prior to the admission, she was abusing cocaine and
during an altercation with law enforcement she attempted to ingest a vial of
cocaine

Example slide
Acute cough
6. Acute intoxications with inhalatory toxic substances

- may be followed by acute lesional pulmonary edema,

interstitial pneumonia or bronchiolitis (always follow the

patient for more than 6 h)

- there is a free range of 6-48 hours without cough, after

which it becomes persistent.

- SABA (salbutamol) for bronhospasm

- immediate administration of inhaled/iv corticosteroids

can be indicated (u/l airway inflammation)

Acute cough
7. Pleural disease

Pleurisy
- can start with irritable dry cough followed by chest
pain and dyspnea

Pneumothorax
Acute cough
8. CV causes
Woman, 24 y

On a Friday night…

• Fever 39.6 *C
3-4 days • Cough +/- minimal sputum production
• Malaise
 Woman, 24 y – medical history

Former smoker
Former smoker (2
(2 months)
months)

Contry side
Contry side
She is
She is getting
getting married…
married…
Medical history

1 an 7 Sapt 3 Sapt

Now

Spontaneous
abortion
Car accident Severe Week 7 of
Antibiotics – disgravidia pregnancy
candidiasis orala, Weight loss
esophageal, genital
Clinical exam

General
• Pale, sweaty skin, lingual whitish deposits
• T 38.4 ° C
• Tattoo on the back
• BMI 19 kg / m2

Pulmonary
• RR 22/min
• MV present bilateral, crackles in the right subclavicular space
• O2 Sat 95% in aa

Cardiac
• HR 95/min
• BP 90/60 mmHg

Abdomen
• Normal exam
 Biologic

Analysis Value
Hb 9 g/dL ↓
Anemia

HEM 25.8 pg↓

Analysis Value
VEM 80.5 fL ↓
Total prot 6.2 g/dL↓
Sideremia 2 μmol/L↓
AST 23 U/L
Trombocit 212*10³/μL
es ALT 29 U/L
Inflamation

Leucocites 5.5 *10³/μL Bil T 0.36 mg/dL

Fibrinoge 414 mg/dL ↑ Creatinine 0.59 mg/dL
n
Na 140 mmol/L
ESR 20 mm/h↑
K 4.28 mmol/L
Chest X ray
 TB?
TB?
Pneumonia /Abcess?
Pneumonia /Abcess?
Excavated cancer?
Excavated cancer?
Excavated
Excavated
mediastinal mass?
mediastinal mass?

…In a
…In a young
young lady
lady
apparently with
apparently with no
no
RF/abortion?
RF/abortion?
Formatiune cavitara
6.6/6.2/7.1 cm
Segm apico-posterior LSD
Apex  AP dreapta, respecta
posterior scizura oblica
Inglobeaza bronhia segmentara
posterioara

Adenopatii mediastinale 1.4/1.7 cm

 Severe
recurrent
candidiasis

Imunosupression ??
Cause?
Day 4

Ac HIV +
(Negativ VHB, VHC,
VDRL)

Haemoculteres–
RHODOCOCCUS
EQUI

URSL ABCESS
Chronic cough

The most frequent

cause of chronic
cough
Chronic cough
1. Upper airway coughing syndrome (former post
nasal drip syndrome)

Definition: chronic cough related to upper airway

abnormalities

- .
Chronic cough
1. Upper airway coughing syndrome (former post
nasal drip syndrome)
- presence of abnormal sensations arising from the throat

(e.g., patients may describe something stuck in the throat)

is central to the diagnosis.

- mechanisms of cough:

- drainage of secretions from the nose or paranasal sinuses into

the pharynx

- or the direct inflammation/irritation of cough receptors in the

upper airway.
 Chronic cough
1. Upper airway coughing syndrome (former post
nasal drip syndrome)

• sensation of something draining into the throat

• a need to clear the throat
Clinical • a tickle in the throat
presentation
• nasal congestion, or a nasal discharge.
• sometimes - hoarseness.

• drainage in posterior pharynx

• throat clearing;
Plus symptoms or • nasal discharge;
evidence of
• cobblestone appearance of the oropharyngeal mucosa;
• mucus in the oropharynx
 Chronic cough
1. Upper airway coughing syndrome (former post
nasal drip syndrome)

The guidelines recommend:

Treatment
physical
symptoms examination
findings Treat the cause (the specific rhinitis/
The diagnosis of
UACS-induced
cough sinusitis)
radiographic response to
findings specific therapy Or empiric combo: Antihistamine /

nasal decongestant therapy (with a

first-generation antihistamine)
Chronic cough
2. Gastro-esophageal reflux
 Stimulation of the R located in the U/L airways by gastric acid content
or by microspiration of the aerosolized gastric juice
 Cough – in the mornings or after significant quantitative meals,
 Along with heartburn or regurgitation

 Diagnosis:
 Clinical history
 Monitoring esophageal pH
 Treatment
 PPI treatment is recommended
 Resistant case / esophagitis - surgical treatment
Chronic cough
Laryngeal-pharyngeal reflux
 Typical clinical manifestations:
 Dysphonia

 chronic cough,

 Dysphagia

 "knot in the throat".

 occurs due to dysfunction

of the superior esophageal sphincter

Chronic cough
3. Treatment with enzyme conversion inhibitors

Cough

 Caused by bradykinin accumulation and C-irritant fibers stimulation

 occurs between 1 week and 6 months after starting treatment

 improves 1-4 days after discontinuation

 discontinuation of IEC treatment + its replacement with an Ag II

receptor blocker
Chronic cough

4. Asthma and other respiratory diseases with

eosinophilia
- dry cough that exacerbates especially during asthma crises / in the late
night and can be associated with wheezing and dyspnea
Chronic cough
5. Non-asthmatic eosinophilic bronchitis
Described 1989 – the cause of 10-30% of chronic cough
Main features:
 ↑ no. of eosinophils in sputum
 airway inflammation
 no bronchial hyperreactivity
 It responds favorably to inhaled CS treatment – however it is associated with
an increased risk for developing bronchial asthma

 Diagnosis: bronchial mucosa biopsy (eosinophilic infiltration and basal

membrane thickening without infiltration with mast cells)
 Chronic cough
6. Cancer
Cough is a frequent symptom – can be chronic, can be dry/with sputum

Look for the red flags!!

Chronic cough
7. Chronic bronchitis / COPD

8. Bronchiectasis
Chronic cough
8. Bronchiectasis
Chronic cough
9. Pulmonary Tuberculosis
Chronic cough

10. Diffuse pulmonary diseases or systemic diseases

with pulmonary involvement

 idiopathic pulmonary fibrosis

 systemic diseases: Sjogren's syndrome, disseminated lupus

erythematosus, rheumatoid arthritis, scleroderma, vasculitis

Chronic cough
11. Other causes we should think of…

RARE VERY RARE

Inhalants UA compressive lessions

OSA - arterio-venous malformations

Psychogenic cough - retro-tracheal tumors

Vocal cords Traheobronhomalacia

dysfunction Tracheal diverticles

Irritations of external auditory canal

(foreign bodies, cerumen plug)

 Acute cough algorithm for the management of adult
patients

Routinely follow up with patient in 4-6 weeks

Chronic cough algorithm for the management of adult
patients
Complications of cough

Skeletal and muscle compl.

Costal fractures (5-7 th costal arch)
Chest pain – muscle strain
Muscle rupures – rectus abdominis

Cardiovascular:
hTA
Presyncope
Subconjuctival hemorrhage
Nasal hemorrhages
Brady-tahyarrhithmias
Complications of cough
Respiratory compl.

Pneumotorax

Subcoutaneous emphysema

Laringeal trauma
Complications of cough

Neurological

Sincope

Head ache

Stroke due to vertebral artery dissection

Gastro-intestinal

Inghinal hernia

Spleen rupture

Genito-urinary

Ureteral reflux

Urinary incontinence
 Cough treatment

Can be treated either as a symptom (non-specific therapy - antitussives)

or with specific treatment (antibiotics, …)
Antitussives - mechanism
Central Opioid Less addicting Codeine
Drugs Dihydrocodeine
Potent addicting Morphine
Drugs
 Non- Opioid Dextromethorpha Frequent
Addicting derivatives n Tussin,
Anti-tussives Noscapine Robitussin
Non Opioids Antihistamine
Chlorpheniramine
Diphenhydramine
Oxeladyne Paxeladine
Periphera Pharyngeal Cough syrop, drops, glycerine, liquorice
l Demulcent
 Steam With menthol
inhalation
Cough treatment
iminate the irritative effect of sputum

Expectorants Ammonium chloride

Sodium or Potassium citrate
Codeina +
Mucolytics Guaiacofosfat
Inhalationa de potasiu
Acetylcysteine
l Tyloxapol

Oral Acetylcysteine
Bromohexine
Carbocysteine
Methylcysteine
ACUTE - Cough treatment

 Acute viral cough is almost invariably benign and prescribed treatment can be

regarded as unnecessary.

 Acute viral cough can be distressing and cause significant morbidity.

 Patients report benefit from various over-the-counter preparations

but there is little evidence of a specific pharmacological effect.

 The simplest and cheapest advice may be to provide a ‘‘home remedy’’

such as honey and lemon.

 Opiate antitussives have a significant adverse side effect profile and are not

recommended.
CHRONIC- Cough treatment

 Treat the underlying disease

 NO disease? - Idiopathic cough (only tertiare / specialist care

diagnosis) – treat the symptom

 THE COUGHING UP OF
BLOOD IS TERMED
Hemoptysis HEMOPTYSIS
Bronchial arteries

The lungs have a dual blood supply from the pulmonary arteries and
the bronchial arteries.
The latter arise as a rule from the aorta and are the source of 90%
of the cases of haemoptysis.
Hemoptysis - Mechanism

Vascular rupture - rare

• Pulmonary arteriovenous malformation
• cancer that eroded the walls of an artery
• more rarely in the case of tuberculosis -pseudoaneurysm Rasmunssen near a cavern

Blood extravasated from the lung capillaries in the alveoli

• Mechanism in - acute pulmonary edema, partial in acute infectious processes.
• Alterations of the basal alveolar membrane by immunological processes (Goodpasture) -
leads to increased permeability ana blood extravasation

Changes in capillary circulation with hyper-vasculature.

• Inflammatory or infectious acute processes (pneumonia, abscess, tuberculosis)
• In sequelae processes (bronchial dilation - bronchiectasis)
• aspergillomas.
Hemoptysis – Clinical presentation

Is it really haemoptisys?

Or hematemesis?

Or (ENT exam needed)

- epistaxis, gingival hg,
- ENT cancer
- Pharyngeal-laryngeal varices
Hemoptysis – Clinical presentation

Is it really haemoptisys?

Or hematemesis?

Or (ENT exam needed)

- epistaxis, gingival hg,
- ENT cancer
- Pharyngeal-laryngeal varices

There can be prodromal signs:

- retrosternal heat
- restlessness
- tingling in the throat
- faintness
Hemoptysis – Severity classification

Very severe/massive: leading to death in a few minutes by blood swallowing and

asphyxia by flooding the airways

Massive, abundant - over 500ml. + signs of acute anemia (palpitations,

tachycardia, tiredness or haemorrhagic shock).
NB: The same clinical significance = repeated hemoptysis in which blood loss is
equal to or greater than 500ml / 24h or whose in which flow rate is over 150ml /
hour

Moderate: 300-400ml. It can be a therapeutic emergency because of the risk of

repeating itself with an unpredictable severity

Small: blood tinges sputum / a few blood clots.

Hemoptysis – Causes
Hemoptysis – Causes

Most frequent:

- Bronchiectasis

- Infections

- Tuberculosis

- Cancer

~ depend on age, risk factors

 Algorithm for
diagnosing non-massive
hemoptysis
Treatment of non-massive (mild-moderate) hemoptysis

Conservative treatment of the

underlying pathology Optimization of the
(e.g., treatment of the infection or coagulation status, particularly
anti-inflammatory measures). during anticoagulation treatment

Small studies of hemoptysis of

varying etiology or in cystic
fibrosis have shown that
hemoptysis can be controlled by
antifibrinolytic treatment with
tranexamic acid.
Treatment of massive hemoptysis

Intubation rapidely, +/-

Selective intubation of Place the pts on the
Protect the airway one lung in order to involved side in order
and prevent protect
asphyxiation to protect the
it from spillage of uninvolved lung.
blood from the other.

Bronchoscopy should Bronchoscopic lavage with iced

be performed promptly placement of a balloon saline, or the
in order to identify the catheter to isolate the application of topical
source involved segment epinephrine

angiographic Surgery – high

embolization. mortality