cough Flashcards
when would a cough require an urgent referal?
: clinical features of suspected PE (dry and blood in cough), pneumothorax or sepsis (productive cough)
signs of serious illness:
- Resp rate >30
- Tachycardia >130bpm
- Systolic bp <90 or diastolic <60
- Oxygen sats of <92% or central cyanosis – if person has no history of chronic hypercapnia
- Peak expiratory rate of less than 33% of predicted
- Altered level of consciousness
- Use of accessory muscles of resp (esp if becoming exhausted)
- Features of foreign body aspiration – stridor (haemodynamically unstable)
define an acute cough
<3 weeks
define sub-acute cough
3-8weeks
what is chronic cough?
> 8weeks
what can cause an acute cough?
Acute cough causes: URTI, foreign body aspiration. PE, pneumothorax, acute bronchitis, pneumonia, acute asthma, exacerbation of COPD, whooping cough, lung cancer
Non resp causes of acute cough: ACEi, aortic aneurysm, cardiac failure – pulmonary oedema, GORD
what would a sudden acute cough indicate?
aspiration, foreign body, pneumothorax
what is important to cover in cough history taking?
Acute cough history:
- Sudden: aspiration, foreign body, pneumonthorax
- Triggers: asthma?
- When do you cough: asthma? (diurnal)
- Exertion?
- Breathlessness when coughing?
- Phlegm? – productive
- Blood – PE, lung cancer
- Red flag questions – any unintentional weight loss?
- High temp – fever – TB, sepsis
- Any contact with TB?
- Smoker or not? – lung cancer?
- Current of past occupation? – asbestosis
- Any new meds – ACEi
- Travel/ hotels? – TB, legionella pneumonia
- Pets? – psttaci pneumonia
what can cause an acute cough if it is an upper resp tract infection?
Acute causes: sinusitis, rhinitis, pharyngitis, laryngitis
what can foreign body aspiration lead to?
Foreign body aspiration: vary from life threatening and death to non-specific symptoms of cough, wheezing, fever, haemoptysis or dyspnoea
- Large objects may completely occlude the trachea and result in asphyxiation and death
- Small objects may lodge in lower lobar airways and cause wheezing and coughing – atelectasis (partial lobe collapse) , post obstructive pneumonia, bronchiectasis, lung abscess
- Right lower lobe is more likely to have foreign body: right bronchus is wider and steeper
who is most at risk of foreign body aspiration?
- At risk groups: children, >70yrs, stroke patients, dementia, impaired cough reflex – medications, alcohol, drugs
- swallowing impairments
what tests can be find foreign body aspiration?
Investigations- CXR
- Non specific – aspiration has caused atelectasis, pneumonia, air trapping and pneumomediastinum.
- Normal CXR does not rule out foreign body aspiration – CT/ bronchoscopy may needed to confirm
- CT – more sensitive, non-invasive
- Bronchoscopy – flexible for stable
can acute bronchitis lead to a cough?
yes Pneumonia progresses goes lung parenchyma hence shows consolidation
- Infections causing inflammation in bronchial airways, increased mucus production and oedema of bronchus
- Productive cough is hallmark of LRTI
- Pneumonia denotes infection in lung parenchyma resulting in consolidation of affected segment or lobe
what is common in pertussis?
post infectious cough
can be dry or productive
what are the stages of pertussis?
- Three stages: catarrhal ( build of mucus in nose/ throat), paroxysmal (sudden) and convalescent (recovering from illness) and may persist for several months
- Initial symptoms: similar to cold, rhinoorhoea and lacrimination, dry cough followed by episodes of severe coughing – fever may be absent or low grade
if whooping cough occurs in childhood what is patient at risk of in future?
bronchiectasis - widening of bronchi
how might a upper airway cough syndrome present?
- > 8weeks and non productive
- Presence of abnormal sensations arising from throat – patients describe as something stuck in throat
cobblestone throat - lighter bumps on throat
trial of empirical therapy - antihistamine and decongestant may help improve after 2 weeks
who is at risk of GORD?
- Risk factors: smokers, alcohol, NSAIDs, diet
GORD is a common cause of cough, what is the management
- Management: smoking cessation, regular exercise, sit up straight, eat small meals throughout the day, chew food slowly, avoid triggers of heartburn (spice, citrus, chocolate, alcohol, coffee), wear loose and comfortable clothing, sleep with head and shoulders propped up, avoid lying down for 3 hrs following a meal
trial PPIs
if lung cancer is suspected, when does someone require an urgent referral (within 2 weeks)?
- CXR within 2 weeks: cough, fatigue, SoB, chest pain, weight loss, appetite loss if 2 and unexplained or 1 unexplained and have smoked
- CXR may show: mediastinal shift, pneumothorax, visible tumour
- CXR in 2 week sif 40> and have 1 of following: persistent or recurrent chest infections, finger clubbing, supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, chest signs consistent of lung cancer
what is a mesothelioma?
– induced by asbestos, long latency periods (20-40yrs), poor prognosis
- Aggressive mesothelioma is aggressive epithelial neoplasm arising from lining of lung
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when does someone require a CXR for suspected mesothelioma?
- CXR for within 2 weeks if cough, fatigue, SoB, chest pain, weight loss, appetite loss in 2 unexplained or 1 unexplained symptom and either smoked or asbestos exposure
what are red flags within a cough?
- Lasts more than 3 weeks
- Systemic symptoms – fever sweats, weight loss (TB, lymphoma, bronchial carnicoma)
- Coughing up blood – TB, bronchial carcinoma
- Associated to dyspnoea – heart failure, COPD, fibrotic lung disease
- Hoarseness – laryngitis
- Peripheral oedema with weight gain
- Smokers aged 45+ with new cough, change in cough or coexisting voice disturbance
- Trouble swallowing
what is haemopytsis?
- Can range from small amount of blood-streaked sputum to massive amounts (life threatening) – due to airway obstruction and haemodynamic instability
what is mild haemoptysis and what might cause it?
- Mild haemoptysis - <30ml over 24hrs – damage to capillaries from excessive coughing (most common)
what is moderate haemoptysis and what can cause it?
- Frank or moderate 30-600ml over 25hrs (TB, PE, lung cancer, bronchiectasis)
what is classed as life threatening haemoptysis and why?
- Anything over 150ml is life threatening as this could flood the conducting airways
why is history taking important in haemoptysis?
History: need to confirm blood is actually from lungs
- Is bleeding from nose eg O2 therapy
- Dental problems
- Any GORD, vomiting, blood mixed with sputum?
what does pink and frothy sputum suggest?
heart failure
what does purulent/ rusty sputum indicate?
bacterial infection
what does white sputum with blood streaks indicate?
possible tumour
what can cause haemoptysis?
- Acute bronchitis
- COPD
- Pneumonia
- Lung cancer – metastasis
- PE
- Infections
neoplasm - bronchiectasis
- cardiac causes
why might an infection lead to haemopytsis?
causing necrosis of bronchial vessels or local mucosal ulceration
why might bronchiectasis lead to haemopytsis?
: recurrent inflammatory destruction and healing leading to bronchopulmonary vascular anatomoses (airway linking to vasculature)
why might a neoplasm lead to haemoptysis?
– increase in bronchial artery supply to supply region of tumour. Haemoptysis from necrosis, mucosal invasion or direct local invasion of blood vessel
what cardiac conditions may lead to haemopytsis?
left ventricular failure, mitral stenosis. Blood streaked sputum is caused by rupture to pulmonary veins/ capillaries
what type of cough is common in CAP?
dry or productive with haemoptysis - reddish/ brown colour
what type of cough is common in HAP?
cough with greenish/ pus-like sputum