Cough Flashcards
What is the definition of acute, subacute, and chronic cough?
Acute cough: <3 weeks
Subacute cough: 3-8 weeks
Chronic cough: >8 weeks
What is the most common cause of acute cough?
Upper respiratory infection (URI)
What are common causes of subacute cough?
Post-infectious cough, pertussis, or resolving pneumonia.
What are common causes of chronic cough?
Atypical pneumonia, Asthma, GERD, postnasal drip (upper airway cough syndrome), non-asthmatic eosinophilic bronchitis, COPD, interstitial lung disease, lung cancer, bronchiectasis, or medication side effects (ACE inhibitors).
What is the most common cause for non-diseased cough?
ACE inhibitor use.
How does ACE inhibitor-induced cough present?
Dry, hacking cough within 1-2 weeks (or even 6 months) of starting an ACE inhibitor. However, this can occurred at any time after use of this medication.
What is the treatment for chronic cough due to ACE inhibitors?
Stop the ACE inhibitor and switch to an ARB.
What is the first step in evaluating an acute cough?
Assess for instability (ABC evaluation) and determine if urgent intervention (e.g., oxygen, IV fluids, intubation) is required.
What are high-risk features in a patient with acute cough that require immediate intervention?
Hemoptysis, hypoxia, tachypnea, hypotension, altered mental status, concern for pulmonary embolism (PE) or pneumonia.
What characteristic guides management for hemoptysis?
The volume of blood expectorated. The most common sources for blood are the brachial arteries secondary to airway disease (bronchitis, bronchiectasis, neoplasm, trauma, or iatrogenic), parenchymal disease (infection, autoimmune, connective tissue disease), or vascular (PE or AVM). Less than 500 mL is mild to moderate and above 500 mL or above 100 mL per hour is considered massive. For mild and moderate cases, ensure to work up and treat the underlying cause, but a CT scan can help guide diagnosis and treatment (flexible bronchoscopy can also be performed but this is usually reserved for active bleeding). For Massive blood loss, establish an airway if indicated and manage hemodynamics. These usually require a flexible bronchoscopy with electrical cautery or balloon tamponade. If these measures fail, perform an arteriographic embolization.
What conditions present with an abnormal chest X-ray in acute cough?
Pneumonia, bronchiectasis exacerbation, congestive heart failure (CHF), lung cancer.
What are the classic signs of pneumonia?
Fever, pleuritic chest pain, rales, tachypnea, tachycardia, infiltrates on chest X-ray.
What are signs of aspiration pneumonia?
History of dysphagia (e.g., stroke), altered mental status, right lower lobe infiltrate, foul-smelling sputum.
What is the most common presentation of bronchiectasis exacerbation?
Copious phlegm production, inspiratory wheeze, crackles, and tram-track opacities on chest X-ray.
What is the best diagnostic test for bronchiectasis?
High-resolution CT scan showing bronchial wall thickening and airway dilation.
What features suggest congestive heart failure (CHF) as a cause of acute cough?
Pink frothy sputum, dyspnea on exertion, S3 heart sound, rales, enlarged cardiac silhouette on chest X-ray.
What is the significance of Kerley B lines?
Septal thickening from pulmonary edema.
What are high-risk features for tuberculosis?
Cavitary lung lesion, hilar lymphadenopathy, history of immunocompromised state, travel to endemic regions.
What conditions present with a normal chest X-ray in acute cough?
Acute bronchitis, asthma/COPD exacerbation, pulmonary embolism, GERD.
How does acute bronchitis present?
Nonspecific symptoms.
How does pulmonary embolism (PE) present with acute cough?
Sudden dyspnea, pleuritic chest pain, tachycardia, tachypnea, hemoptysis, unilateral leg swelling.
What is the first step in evaluating chronic cough?
Obtain a chest X-ray to determine if there is an underlying lung pathology.
What test confirms a PE?
CT pulmonary angiogram (CTPA).
What conditions present with an abnormal chest X-ray in chronic cough?
Atypical pneumonia, bronchiectasis, lung cancer, interstitial lung disease.
What are the features associated with atypical pneumonia?
Hx: Slow/progressive onset of MILD symptoms, Fever, Chills, Sore throat, +/- Headache
PE: +/- Scattered rales, wheezes, +/- Rash
CXR: Bilateral patchy infiltrates
What pathogens are responsible for atypical pneumonia?
Mycoplasma, Chlamydia, and Legionella. These can all be diagnosed with history, physical exam, and chest x-ray. However specific test such as cold agglutinin for These can all be diagnosed with history, physical exam, and chest x-ray. However specific tests, such as cold agglutinin for mycoplasma, and urine antigens for both chlamydia and legionella, can help confirm the diagnosis and guide treatment.
What other symptoms can help distinguish the pathogens that cause atypical pneumonia?
- Mycoplasma is associated with erythema multiforme.
- Chlamydia can be associated with pharyngitis.
- Legionella may have high fever, hyponatremia, GI symptoms, and confusion.
What are the considerations of chronic cough triggered by bronchiectasis?
Increased productive cough.
What findings would be suggestive of lung malignancy?
Concerning constitutional findings with clubbing. A concerning lesion might require a bronchoscopy with biopsy.
What clinical findings would be suggestive of restrictive lung disease?
Shortness of breath with crackles heard on auscultation of the lungs.
What chest x-ray findings are associated with restrictive lung disease?
Reticular or nodular lung opacities lung opacities. The next step would be to order pulmonary function tests (consistent findings would be low DLCO and restrictive lung PFT parameters such as FEV1 > 70%). After the PFT, a high resolution CT scan is used to confirm the diagnosis.
What conditions present with a normal chest X-ray in chronic cough?
GERD, upper airway cough syndrome, asthma, COPD, non-asthmatic eosinophilic bronchitis.
How does GERD cause chronic cough?
Cough worse at night, after meals, with heartburn, epigastric tenderness, and possible halitosis.
What test is used to confirm GERD as a cause of chronic cough?
Empiric trial of a proton pump inhibitor (PPI) for 2 weeks. If there is improvement, the diagnosis of GERD can be made.
What are the findings of non-asthmatic eosinophilic bronchitis?
History of seasonal allergies, sputum eosinophils, normal lung function.
What is the diagnostic test for non-asthmatic eosinophilic bronchitis?
Sputum eosinophil count. if the count is high start the patient on inhaled corticosteroids for two weeks.
What are the classic signs of upper airway cough syndrome (postnasal drip)?
Throat clearing sensation, cobblestone oropharynx, nasal congestion.
What is the first-line treatment for upper airway cough syndrome?
H1 antihistamine and decongestant trial for 2 weeks.
How do asthma and COPD cause chronic cough?
Cough with dyspnea, wheezing, exposure to allergens (asthma) or smoking history (COPD).
How do you distinguish asthma from COPD?
Spirometry with bronchodilator reversibility test (asthma improves, COPD does not).
What are the spirometry findings in asthma?
FEV1/FVC <0.7 with >12% improvement in FEV1 after bronchodilator administration.
What are the spirometry findings in COPD?
FEV1/FVC <0.7 with little to no improvement after bronchodilator administration.
What should be suspected in a patient with chronic cough and hemoptysis?
Lung cancer or tuberculosis.
What findings suggest interstitial lung disease as a cause of chronic cough?
Dyspnea on exertion, fine inspiratory crackles, reticular opacities on chest X-ray, honeycombing on high-resolution CT.
What is the best test for congestive heart failure as a cause of chronic cough?
BNP and transthoracic echocardiogram (TTE).
What is the treatment for asthma or COPD exacerbation?
Oxygen, bronchodilators (SABA), systemic steroids.
How do you confirm an obstructive lung disease diagnosis after exacerbation treatment?
Spirometry (FEV1/FVC ratio assessment).
What test confirms asthma versus COPD?
Bronchodilator reversibility testing (asthma improves, COPD does not).
What is the most common cause of chronic cough in non-smoking adults?
Upper airway cough syndrome (postnasal drip).
What is the most common cause of chronic cough in children?
Asthma.
A pediatric patient is brought to the clinic due to a prolonged cough. The patient developed rhinorrhea 6 weeks ago, followed a week later by a cough with occasional expectoration of whitish sputum; the rhinorrhea resolved at that time. For the past 5 weeks, the patient’s cough has continued without improvement throughout the day and night, occasionally awakening her. Use of a humidifier has not relieved her symptoms. The patient has been afebrile and has had no vomiting, abdominal pain, diarrhea, or sick contacts. She takes no daily medications. Immunizations are up to date. Family history is notable for atopic dermatitis in the mother. Height and weight are tracking at the 25th percentile. Temperature is 36.7 C (98 F) and respirations are 24/min. The patient is awake, alert, and playing. Tympanic membranes are normal. The tonsils are normal. The mucous membranes are moist, and the lips are pink. Heart rate and rhythm are normal. The lungs are clear to auscultation bilaterally; no retractions or use of accessory chest muscles is present. What is the best next step in diagnosis?
This patient has chronic cough, which is defined as daily cough lasting >4 weeks in children (>8 weeks in adults). Initial evaluation includes a thorough history and physical examination to look for a specific underlying cause and guide management. For example, a history of choking preceding symptom onset may suggest an aspirated foreign body, and poor growth may suggest a chronic illness (eg, cystic fibrosis [CF]). In the absence of specific findings, the first step in evaluation is spirometry. This simple pulmonary function test can assess for asthma, a common cause of chronic cough in children. Although asthma may be associated with other findings (eg, wheezing, dyspnea, history of atopy), it can present with cough alone and a normal examination, as in this case. Spirometry can be performed in a cooperative child (generally age >6) and, in asthma, it shows an obstructive pattern (due to bronchial inflammation and smooth muscle contraction) that is reversible with a bronchodilator (eg, albuterol). Symptom improvement following a 2-week trial of a short-acting beta agonist and inhaled corticosteroid is confirmatory. This trial can be conducted empirically (ie, without spirometry) in children unable to perform spirometry. If spirometry is unrevealing or an empiric bronchodilator trial fails, then chest x-ray is performed to evaluate for abnormalities such as foreign body aspiration (eg, unilateral hyperinflation). CT scan of the chest may be considered if x-ray is nondiagnostic but is not preferred for initial imaging due to radiation exposure.
What is bronchiectasis?
Permanent abnormal dilation and destruction of bronchial walls due to chronic inflammation and impaired mucous clearance.
What is the underlying mechanism of bronchiectasis?
Chronic inflammation leads to destruction of the elastic and muscular components of the bronchial wall, causing airway dilation, mucus accumulation, and recurrent infections.
What are the major risk factors for bronchiectasis?
Recurrent infections, airway obstruction, immunodeficiency, allergic bronchopulmonary aspergillosis (ABPA), cystic fibrosis, primary ciliary dyskinesia, and autoimmune diseases like rheumatoid arthritis and lupus.
What is the most common cause of bronchiectasis worldwide?
Tuberculosis.
What is the most common cause of bronchiectasis in the United States?
Cystic fibrosis.
What are the key clinical findings of bronchiectasis?
Chronic cough with large amounts of mucopurulent sputum, dyspnea, hemoptysis, and halitosis.
What is a distinguishing feature of the sputum in bronchiectasis?
Copious, foul-smelling, mucopurulent sputum that can be described as ‘cups of sputum’.
What are the common lung sounds heard in bronchiectasis?
Coarse crackles, wheezing, and rhonchi.
What is the imaging modality of choice for diagnosing bronchiectasis?
High-resolution CT (HRCT) scan.
What characteristic findings are seen on HRCT in bronchiectasis?
Bronchial dilation, thickened bronchial walls, lack of bronchial tapering, and ‘signet ring sign’.
What is a common chest X-ray finding in bronchiectasis?
Linear opacities, especially in the right middle lobe.
What is right middle lobe syndrome?
Recurrent or persistent collapse of the right middle lobe due to chronic inflammation and impaired clearance, often seen in bronchiectasis or infection.
What pulmonary function test (PFT) pattern is seen in bronchiectasis?
Obstructive lung disease pattern with decreased FEV1/FVC ratio.
What are the key components of the workup for bronchiectasis?
Identify the underlying cause, including CF testing, sputum culture, Ig quantification for immunodeficiency, and workup for atypical infections (e.g., TB, Pseudomonas).
What bacteria commonly colonize the lungs in bronchiectasis?
Pseudomonas aeruginosa, Staphylococcus aureus, Haemophilus influenzae, and non-tuberculous mycobacteria (e.g., MAC).
What is the first-line treatment for acute exacerbations of bronchiectasis?
Empiric antibiotics, tailored based on sputum culture results.
What antibiotics are commonly used for bronchiectasis exacerbations?
Amoxicillin-clavulanate or fluoroquinolones, with broader coverage for Pseudomonas and MRSA when indicated.
What additional treatment is needed if a bronchiectasis patient has asthma or ABPA?
Oral glucocorticoids and bronchodilators.
What is the primary long-term management strategy for bronchiectasis?
Chest physiotherapy and mucus-clearing techniques (postural drainage, vibration, and airway clearance devices).
When is azithromycin used for bronchiectasis?
If exacerbations occur ≥2 times per year, as it has anti-inflammatory and antimicrobial properties.
What is the role of inhaled bronchodilators in bronchiectasis?
Used in patients with coexisting obstructive lung disease, such as asthma or COPD.
What are the major complications of bronchiectasis?
Recurrent infections, massive hemoptysis, respiratory failure, and pulmonary hypertension.
What pathogen is most concerning in cystic fibrosis-associated bronchiectasis?
Pseudomonas aeruginosa, as it is associated with worse outcomes and faster lung function decline.
How does bronchiectasis differ from COPD?
Both have chronic cough and obstruction, but bronchiectasis has copious purulent sputum, recurrent infections, and radiologic evidence of bronchial dilation.
Why is tuberculosis the most common cause of bronchiectasis worldwide?
TB leads to chronic lung damage, fibrosis, and secondary bacterial colonization.
What is the role of surgical intervention in bronchiectasis?
Lung resection is reserved for localized disease with recurrent infections despite medical therapy.
