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Cough
- 1. Dr M Ushashree 1st yr pg Gandhi Medical College
- 2. Introduction Phases of cough Cough reflex Types of cough Evaluation Investigations Treatment complications
- 3. COUGH – it is a sudden and variable expiratory thrust of air from the lungs through the air passages associated with phonation, which momentarily interrupts the physiological pattern of breathing Without an effective cough reflex, there is a risk of retaining airway secretions and aspirated material predisposing to infection， atelectasis， and respiratory compromise
- 6. Cough reflex initiated by chemical/mechanical stimuli This is carried by the afferents which are type c and type 1 fibers and innervate pharynx, larynx ,large airways , terminal bronchiole and lung parenchyma Afferents travel via vagus and superior laryngeal nerve NTS in brain stem is the cough center Efferents travel via vagus, phrenic, spinal motor nerves to the larynx, trachea, bronchi, diaphragm producing cough
- 8. MECHANO RECEPTORS NOCICEPTORS CELL BODIES ARE IN NODOSE GANGLION (ING VAGAL GANGLION CELL BODIES IN JUGULAR GANGLION( SUP VAGAL GANGLION) SENSITIVE TO MECHANICAL DISPLACEMENT NOXIOUS CHEMICAL IRRITANTS LIKE IRRITANT VAPOURS ETC LIMITED CHEMOSENSORY UNMYELINATED C FIBRES ION CHANNELS BELONG TO ASIC FAMILY acid-sensing ion channel ION CHANNELS BELONG TO TRPV1transient receptor potential vanilloid AND TRPA1transient receptor potential cation channel, subfamily A, TWO TYPES RAR AND SAR
- 10. Voluntarily a person is capable of suppressing the reflex cough for some time Cough can also be voluntarily induces (motor and pre motor areas of brain) Neuro transmitters involved in voluntary control of cough are seratonin, gaba, dopamine, nmda(N-methyl-D-aspartate ) etc The central nervous pathways for cough show interactions and plasticity
- 11. ACUTE (<3 WKS) Tracheobronchitis Bronchopneumonia Viral pneumonia Acute-on-chronic bronchitis Pertussis Pulmonary embolism Foreign body aspiration Sudden onset – bronchial asthma ,asthmatic bronchitis , whooping cough, foreign body ,LVF with PE
- 12. SUB ACUTE (3-8 wks ) trachiobronchitis , pertussis , post viral tussive syndrome
- 13. CHRONIC > 8 wks • Upper airway cough syndrome • Asthma • Gastro oesophageal reflux disorder • Post viral cough • Chronic bronchitis • Bronchiectasis, cystic fibrosis • Ace inhibitor induced Cough • Environmental irritants.
- 14. • Infections – Mycoplasma Chlamydia Bordetella • Granulomatous disease – TB , Sarcoidosis. • Neoplasms – Bronchogenic carcinoma,Carcinoid tumor • ILD
- 15. Micro aspirations Zenker’s diverticulum CVS – Disorders of pericardium, CCF, Vasculitis Tourette syndrome Habitual or psychogenic cough. Asymptomatic enlarged tonsils
- 16. Based on expectoration • Dry cough: pleural disorders , diseases of interstitium, mediastinal lesions • Productive cough: suppurative lung disease, airway diseases
- 17. Brassy/Gander cough –metallic sound d/t compression of trachea by intra thoracic space occupying lesions or aortic aneurysms also known as leopards growl Bovine cough –loss of expulsive nature as in a tumour pressing on the recurrent laryngeal nerve Paroxysmal cough – whooping cough , chronic bronchitis, foreign body , bronchial asthma
- 18. Barking cough – involvement of epiglottis , croup( laryngo trachiobronchitis) , hysteria Whooping cough – pertussis Spluttering cough- s/I T-E fistula , cough while swallowing Hacking – heavy smokers, chronic pharyngitis or laryngitis
- 22. IMPAIRED COUGH Decreased expiratory-muscle strength Decreased inspiratory-muscle strength chest wall deformity Impaired glottic closure or tracheostomy Tracheomalacia Central respiratory depression (e.g.， anesthesia， sedation)
- 23. Efforts should be made to identify the cause of cough A cough lasting than more than 3 wks require a detailed evaluation Cough associated with or without sputum is more important than the amount of sputum and the presence or absence of sputum should not be taken as a strict criterion for diagnosis
- 24. Considerations at 1st visit Determine the severity Assess the cause Plan investigation and treatment
- 25. Cough: onset, duration, character, triggers Sputum-volume & character Postural variations Diurnal variations Smoking, occupation Drug history(ACE inhibitors)
- 26. Asthma: wheeze, nocturnal symptoms, atopy GE Reflux ass. Symptoms Rhinitis: PND, sinusitis, throat clearing, nasal congestion chest pains, incontinence, syncope, anxiety, disturbed sleep
- 27. Lobar pneumonia – the cough is initially dry a/w chest pain later becomes productive Chronic bronchitis – productive cough for most days of 3 months for 2 consecutive yrs Bronchiectasis – copious amt of foul smelling sputum more on lying down Gastro esophageal reflux disorder - Nonproductive cough often following meals with or without symptoms of GERD
- 28. Left ventricular failure - Cough intensifies while supine, along with aggravation of dyspnea Angiotensin-converting enzyme (ACE) inhibitors Nonproductive cough, more common in women, may occur at any time , neurokinin 1 receptor polymorphism
- 29. Routine investigations Absolute eosinophil count Pulmonary function tests Sputum gram stain , culture sensitivity , zn stain Chest x ray Ct chest Sinus x ray/CT sinus
- 30. Quality of life questionnaires Leicester cough questionnaire used to assess cough intensity and frequency Measurement of cough reflex- by inhalation of tussive agent like capsaicin Visual analogue scales
- 31. Cough lasting less than 3 wks Usually it is due to viral and bacterial infections of upper respiratory tract Usually the cough resolves within 2 wks Other symptoms that can be associated with cough are post nasal discharge , nasal obstruction, nasal discharge
- 32. Rhinitis associated with common cold may have mucopurulent discharge but it is not an indication of antibiotics unless it persists for more than 10 to 14 days
- 33. Step 1: Identification and Treatment of Obvious Causes Step 2: Focused Testing for and Treatment of Asthma, Gastroesophageal Reflux, and Rhinosinusitis Step 3: Investigations to Rule Out Rarer Causes of Cough Step 4: Management of Idiopathic or Refractory Chronic Cough
- 36. Cough variant Asthma Upper airway cough syndrome Aspiration Habitual cough Foreign body Drugs Angiotensin converting enzyme inhibitors Chronic bronchitis
- 37. Chronic idiopathic cough, narcotic cough suppressants， such as codeine or hydrocodone Dexomethorphan can also be used Benzonatate Case series have reported benefit from off- label use of gabapentin or amitryptyline for chronic idiopathic cough.
- 38. In paediatric age group cough more than 4 wks is considered chronic Most common cause of chronic cough in infants is aspiration and congenital heart defects 2-5 yrs – foreign body inhalation , hyper reactive airways Adolescents – hyper reactive airways, infections
- 40. ANTITUSSIVE AGENT • Morphine • Dihydro- morphinone • Codeine • pholcode ine • Dexomet horphan • noscapin e , • Diphenhydram ine • Benzonatate • Triprolidine
- 41. Depression of medullary centres or associated higher centres. Increased threshold of cough centre
- 42. An opium alkaloid. It is more selective for cough centre. Suppresses cough for about 6 hours. The antitussive action is blocked by naloxone. Cough suppression occur with low doses of opioids than those needed for analgesia.(sub-analgesic dose 15 mg) Abuse liability is low, but present. Adverse Effects •Constipation. •Respiratory depression & drowsiness
- 43. Little/ no analgesic or addicting property. Similar efficacy as antitussive to codeine Is longer acting—–acts for 12 hours or more. Given once or twice daily. Adverse Effects Nausea Drowsiness
- 44. •Depresses cough but has no narcotic, analgesic or dependence inducing properties. •Efficacy same as codeine, specially useful in spasmodic cough. Adverse Effects •Headache & nausea can occur
- 45. raises threshold for cough & depresses cough centre in medulla. It has been found to enhance the analgesic action of morphine & other μ receptors agonists As effective as codeine, does not depress mucociliary function of the airway mucosa.
- 46. Devoid of addicting actions. Produces less constipation than codeine Antitussive action for 6 hours. it does not act through opioids receptors. Side effects: Dizziness, nausea, drowsiness & ataxia.
- 47. It acts at the CNS level by inhibiting the medullary cough centre In addition to this peripheral effects are related to its antihistamine, antiserotonergic and muscle-relaxant properties it is used in the treatment of cough, bronchospasm and related symptoms
- 48. It has antihistamine with anticholinergic properties Centrally acting with no addicting properties the most common side effect is drowsiness quick acting drug that can clear congestion and stop runny noses in 15– 30 minutes Useful in cough in allergic conditions
- 49. Diphenhydramine is an antihistamine used to relieve symptoms of allergy, hay fever, and the common cold. Commonly present in many cough syrups Drowsiness, dizziness, constipation, stomach upset, blurred vision
- 50. Demulcents. promotes salivation & inhibit impulses from inflamed mucosa Linctus Thick liquid preparation containing sucrose and medicinal substance Throat lozenges:They have lubricating and soothing effect on irritated tissue of throat may contain benzocaine or dextromethorphan.
- 51. selective NOP1 (nociceptin opioid 1) receptor agonist TRPV1 antagonists TRPA1 antagonists Memantine, the non competitive NMDA channel blocker The neurokinin-1 (NK1) receptor has been implicated in the sensitization of synapses in the nTS, and its antagonist (aprepitant) was recently found to reduce cough in patients with lung cancer
- 52. Drugs which render sputum less visous Inhalational: •Acetylcysteine, Oral : •Acetylcysteine, •Bromohexine, •Carbocysteine, •Methylcysteine. Clinical Uses Acute & chronic bronchitis. Bronchial asthma
- 53. Drugs which ↑ bronchial secretions or reduces its viscosity facilitating its removal by coughing Ipecacuanha Ammonium chloride Ammonium bicarbonate. Terepin hydrate Potassium Iodide Guaiphenesin Sodium or Potassium citrate
- 54. RESPIRATORY Pneumothorax Subcutaneous emphysema Pneumomediastinum Pneumoperitoneum Laryngeal damage CARDIOVASCULAR Cardiac dysrhythmias Loss of consciousness or cough syncope Subconjunctival hemorrhage
- 55. CENTRAL NERVOUS SYSTEM Syncope Headaches Cerebral air embolism MUSCULOSKELETAL Intercostal muscle pain Rupture of rectus abdominis muscle Increase in serum creatine phosphokinase Cervical disc prolapse
- 56. CENTRAL NERVOUS SYSTEM Syncope Headaches Cerebral air embolism MUSCULOSKELETAL Intercostal muscle pain Rupture of rectus abdominis muscle Increase in serum creatine phosphokinase Cervical disc prolapse
- 57. GASTROINTESTINAL Esophageal perforation OTHER Social embarrassment Depression Urinary incontinence Disruption of surgical wounds Petechiae Purpura
Editor's Notes
- THE MAIN MECHANISM of clearing the secretions IS MUCO CILIARY CLEARANCE … BUT IN PEOPLE WITH IMPARED MuCo ciliary CLEARANCE COUGH IS ESSENTIAL IN CLEARING THE SECRETIONS cough is effective in causing clearance if there is hypersecretion of mucus
- IRRITATION TO Inhaled particles. Mucus Inflammatory exudates in airways and parenchyma. A new growth . A foreign body Bradykinin, substance-P, capsaicin INSPIRATORY which lasts about 200 ms up to 2.5 liters of air are rapidly inspired VIA EXT INTER COASTALS AND DIAPHRAGM intrapleural and intra-alveolar pressures rise rapidly to a range of values that can vary from 40 to 400 cm H2O, which can be used as an index of the intensity of the cough. COMPRESSIVE Dynamic compression the epiglottis closes and the vocal cords shut tightly to entrap the air within the lungs of the airways downstream from the equal pressure point increases velocity, kinetic energy, and turbulence of the air passing through the proximal , Third, the abdominal muscles contract forcefully, pushing against the diaphragm while other expiratory muscles, such as the internal intercostals,also contract forcefully .Consequently, the pressure in the lungs rises rapidly to as much as 100 mm Hg or more EXPIRATORY the vocal cords and the epiglottis suddenly open widely, so that air under this high pressure in the lungs explodes outward. Indeed, sometimes this air is expelled at velocities ranging from 75 to 100 miles per hour
- Reflex coughing is integrated in the medulla oblongata, where the afferent fibers for coughing first relay in or near the nucleus of the tractus solitarius; the motor outputs are in the nucleus retroambigualis, sending motoneurons to the respiratory muscles, and in the nucleus ambiguous, sending motoneurons to the larynx and bronchial tree The most sensitive sites for initiating cough are the larynx and tracheobronchial tree
- RAR RAPID ADAPTING RECEPTORS BENEATH THE EPITHELIUM OF BOTH INTRA AND EXTRA PULM AIRWAYS SENSITIVE TO DEFLATION COLLAPSE BRONCHOSPASM IMPULSES ARE CARRIED BY MYELINATED NURONS 4-18M/SEC … ACTIVATION OF RAR CAUSES REFLEX BRONCHOSPASM AND INCREASES MUCOUS SECRETION VIA PARASYMPATHETIC STIMULATION SAR SLOW ADAPTING RECEPTORS – SENSTIVE TO MECHANICAL FORCES ACTIVITY OF THESE PEAKS DURING INSPIRATION HERING BREURE DEFLATION REFLEX AND INITIATES EXPIRATION WHEN LUNG IS SUFFICIETNLY INFLATED THESE ARE PRESENT IN ALVEOLI AND BRONCHIOLES C FIBRES SENSORS THESE ARE UNMYELINATED FIBRES THEY ARE RELATIVELY INSENSITIVE TO MECHANICAL STIMULI THESE ARE DIRETLY ACTIVATED BY BRADY KININS ACTIVATION OF THESE INCREASES PARA SYMPATHETIC ACTIVITY CHARACTERIZED BY APNEA FOLLOWED BY RAPID SHALLOW BREATHING BRADYCARDIA AND HYPOTENSION
- CENTRAL MECHANISMS EXHIBIT PLASTICITY- that is when the impulses are being carried by the afferents of mechano receptors the neuro transmitters released also stimulate the afferents of nociceptors hence the final response can be a mixed one and is not exclusive
- Cough may fail to clear secretions despite a preserved ability to generate normal expiratory velocities; such failure may be due to either abnormal airway secretions (e.g.， bronchiectasis due to cystic fibrosis) or structural abnormalities of the airways (e.g.， tracheomalacia with inspiratory and expiratory collapse more in expitarion during cough).
- COLOUR OF SPUTUM GREEN/ YELLOW – D/T MYELOPEROXIDASE / VERDOPEROXIDASE S/I PSEUDOMONAS INFECTION , ASTHMA BLACK – PNEMOCONIOSIS (COAL MINERS) RUSTY- PNEMOCOCCAL PNEUMONIA RED CURRENT JELLY – KLEBSIELLA INFECTION PINK FROTHY – PULM EDEMA PRUNE JUICE – BR.CARCINOMA ANCHOVY SAUCE- RUPTURE OF AMOEBIC LIVER ABSCESS IN TO THE BRONCHUS polymorphisms in the neurokinin-2 receptor gene are associated with ACE inhibitor-induιed cough
- Many cigarette smokers have a chronic cough, but a change in the pattern or characteristics of their cough, such as an increase in intensity or an accompanying hemoptysis, should force a smoker to seek medical attention. A chest radiograph is mandatory in this situation.
- 1st gen ant hist and decongestants are preferred in pnd with ac coiugh
- ACE INHIBITOR-INDUCED COUGH OCCURS IN 5-30% OF PATIENTS TAKING THESE AGENTS AND IS NOT DOSE DEPENDENT ACE METABO LIZES BRADYKININ AND OTHER TACHYKININS， SUCH AS SUBSTANCE P. THE MECH ANISM OF ACE INHIBITOR-ASSOCIATED COUGH MAY INVOLVE SENSITIZATION OF SENSORY NERVE ENDINGS DUE TO ACCUMULATION OF BRADYKININ polymorphisms in the neurokinin-2 receptor gene are associated with ACE inhibitor-induιed cough UACS, ASTHMA, GERD ,CHR BRONCHITIS, BRONCHIECTASIS Uacs CHRO.BACTERIAL RHINO SINUSITIS ALLERGIC RHINI VASOMOTOR RHINITIS THERAPY FOR POSTNASAI DRAINAGE DEPENDS ON THE PRESUMED ETIOLOGY (INFECTION， AILERGY， OR VASOMOTOR RHINITIS) AND MAY INCLUDE SYSTEMIC ANTIHISTAMIN邸; ANTIBIOTICS; NASAL SALINE IRRI GATION; AND NASAL PUMP SPRAYS WITH GLUCOCORTICOIDS， ANTIHISTAMINES， OR ANTICHOLINERGICS. ANTACIDS， HISTAMINE TYPE 2 (H2) RECEPTOR ANTAGONIST COUGH MAY BE THE ONLY SYMPTOM IN 7- 57% PATIENTS (DEPENDS ON STUDY)– “COUGH-VARIANT ASTHMA PROTON-PUMP INHIBITORS ARE USED TO NEUTRAIIZE OR DECREASE THE PRODUCTION OF GASTRIC ACID IN GASTROESOPHAGEAL REFLUX DISEASE; DIETARY CHANGES， ELEVATION OF THE HEAD AND TORSO DURING SLEEP， AND MEDICATIONS TO IMPROVE GASTRIC EMPTYING ARE ADDITIONAL THERAPEUTIC MEASURES
- Treatment of chronic cough in a patient with a normal chest radiograph is often empirical and is targeted at the most likely cause(s) of cough as determined by history， physical examination， and possibly pulmonary-function testing Patients who fa过 to respond to treatment targeting the common causes of chronic cough or who have had these causes excluded by appropriate diagnostic testing should undergo chest CT. Diseases causing cough that may be missed on chest x-ray include tumors， early interstitial lung disease， bronchiectasis， and atypical mycobacterial pulmonary infection
- ONCE SERIOUS UNDERLYING CARDIOPULMONARY PATHOLOGY HAS BEEN EXCLUDED， AN ATTEMPT AT COUGH SUPPRESSION IS APPROPRIATE. Mucosal biopsies taken from a group of nonasthmatic patients with idiopathic cough showed increased mast cell numbers and features of airway wall remodeling express the neuropeptide, calcitonin gene-related peptide (CGRP), and the calcium channel, TRPV1, in the airway epithelium of chronic coughers that could contribute to the increased cough reflex Triggers such as lying down, eating, singing, talking, laughing, and taking a deep breath (through mechanoreceptors); changes in ambient temperature (through thermoactivation); aerosols, scents, odors, and cigarette smoke (through chemoactivation) are common.1
- Immediate, while still in upper airway Cough associated with progressive evidence of asphyxiation Later, when lodged in lower airway Nonproductive cough, persistent, associated with localizing wheeze According to American academy of paediatrics there is no efficacy of antitussives in children and they are potentially harmful And the cough d/t ac viral infections are treated by fluid and humidity as it is self limiting
- Persistent intractable cough due to terminal incurable disease Opiates (morphine or diamorphine) Local anesthetic aerosol
- STIMULATE SECRETORY CELLS OF RESP TRACT DIRECTLY & PRODUCES DEMULCENT EFFECT BY DECREASING IRRITATION AND VISCOSITY OF MUCOUS. •SINCE THESE DRUGS STIMULATE SECRETION MORE FLUID GET PRODUCED IN RESP TRACT AND SPUTUM IS DILUTED, THERE BY HELPING IN EASY REMOVAL OF SPUTUM IPECACUANHA: •USED AS EXPECTORANT IN SMALL DOSES & EMETIC IN LARGE DOSES. •IT LIQUEFIES THICK SECRETIONS AND RELIEVE THE IRRITATED MUCOSA. •IT ALSO IRRITATES THE GASTRIC MUCOSA AND ENHANCES THE EXPULSION OF SECRETION. •IT IS MAINLY USED FOR EMESIS IN ACCIDENTAL POISONING GUAFENECIN FOR SYMPTOMATIC RELIEF OF DRY, NON PRODUCTIVE COUGH IN THE PRESENCE OF MUCUS IN RESPIRATORY TRACT