Clinical Reasoning-Cough Flashcards
Where are the cough receptors located?
At most of the major branching points of the airway: Larynx, Carina, Right upper lobe bronchus and distal esophagus.
What nerves are responsible for sensing a need to cough and where to they go?
Vagus and superior laryngeal nerves. They go to the cough center in the upper medulla/pons region. They also go to the cerebral cortex where you can consciously control cough.
What nerves are responsible for conducting the impulse to cough?
Vagus, phrenic and spinal motor nerves stimulate the diaphragm. The laryngeal nerve, intercostals and abdominal wall muscles are also stimulated.
What are the four phases of cough?
Inspiratory, compressive, expiratory and relaxation.
What complication exists if you lose your cough reflex?
You are at higher risk for aspiration of oral or gastric contents. This could result in pneumonia or bronchiectasis.
What patients are at risk for loss of cough reflex?
General anesthesia, sedation, intoxication, narcotics, neuromuscular disease (spinal cord injuries) and an inability to close the glottis properly (from stroke).
Why would you look inside someone’s ears when they present with cough?
The auricular branch of the superior laryngeal nerves are in the afferent pathway of the cough reflex.
Why is it important to find the underlying cause of a patient who presents with chronic cough?
Whatever the irritant is, enhances the cough reflex. This causes more coughing, irritation and fibrosis of the tissue and more coughing. The pattern will spiral down until the underlying issue is resolved.
A patient presents with a two week history of cough. What is you differential diagnosis?
This is an acute cough < 3 weeks: URI, LRI, pneumonia, aspiration, chemical exposure or exacerbation of pre-existing condition (COPD, asthma, UACS, bronchiectasis).
A patient presents with a 6 week history of cough. What should you try to figure out at this point in the patient’s cough progression?
Is it residual symptoms from a recovered illness (post-viral syndrome)? Is it pertussis, the 100 day cough? Is it pneumonia or bacterial bronchitis?
A patient presents with a 1 year history of cough. CXR is normal and the patient is immunocompetent. What are the most likely causes of this patient’s cough?
Upper airway cough syndrome, cough variant asthma, GERD, non-asthma eosinophilic bronchitis.
What are key things you should ask the patient in the history to unveil the underlying cause of their cough?
Frequency and timing (day vs. night), exposures (sick kids, allergens), exacerbations (meals, medications), quality (dry, productive, hemoptysis), occupation, workplace exposures, pets, and presence of any other respiratory/esophageal disease.
What is your first clinical distinction when a patient presents coughing up blood?
Epistaxis (bloody nose)/hematemesis (Gastro-esophageal tract) or is it coming from inside the actual lungs.
How do you classify hemoptysis?
Massive vs. non-massive (<200cc blood per day)
When would a tumor in the lung turn the corner from non-massive hemoptysis to massive hemoptysis?
Once it erodes through the bronchial mucosa enough to reach the bronchovascular bundle. This bundle is under systemic pressure and present with massive hemoptysis.
What are the most common causes of hemoptysis?
Bronchitis, lung cancer, pneumonia, Tb, bronchiectasis and heart failure.
A patient coughs up a pink, frothy sputum. What is your diagnosis?
Heart failure.
