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.
A 40-year-old man presents to the primary care clinic due to a dry cough that started five weeks ago. He initially attributed it to “allergies,” but the cough has not improved. He also experienced a runny nose, nasal congestion, and frequent throat clearing over this same period. He has not experienced itchy or red eyes, a sour taste in the mouth in the morning, or substernal burning. He has no known medical history, takes no medication, and is not aware of any medication or food allergies. Vital signs are within normal limits. On physical examination, he is well-appearing with no rashes and no conjunctival injection or discharge. Tiny amounts of drainage are seen at the posterior oropharynx. The lungs are clear to auscultation. What additional findings would be present on physical examination?
When patients present with subacute or chronic cough and a negative chest x-ray, a thorough history and physical examination are often sufficient to diagnose the cause. Patients with upper airway cough syndrome may have frequent throat clearing, rhinorrhea, nasal congestion, and a cobblestone appearance of the posterior oropharynx. This patient, presenting with a subacute cough (3-8 weeks), rhinorrhea, nasal congestion, and frequent throat clearing, likely has upper airway cough syndrome (UACS; commonly known as “post-nasal drip”). It can be allergic or nonallergic. A cobblestone appearance of the oropharynx would be consistent with this diagnosis. Evaluation of a patient with subacute or chronic requires a thorough history and physical exam, and often chest radiography. A detailed history should include questions about the frequency, quality, and degree of sputum production associated with the cough. For example, patients with bronchiectasis tend to have copious sputum production, whereas patients with UACS may have minimal sputum, and patients with gastroesophageal reflux disease (GERD) have none. Environmental exposures, known allergies, and tobacco use should also be explored. Associated symptoms may also point toward the underlying etiology, such as heartburn (GERD), shortness of breath (asthma or COPD), an abnormal sensation in the throat, or frequent throat clearing (UACS). Physical examination should include examination of the ears, nose, throat, and lungs. Patients with UACS may have a cobblestone appearance of the posterior oropharynx (as seen in the image below). Alternatively, individuals with COPD may have a prolonged expiratory phase, and wheezing can be present in patients with severe GERD or asthma. However, lung sounds are normal in UACS, GERD, and nonasthmatic eosinophilic bronchitis.
What are the 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
- Medication side effects (ACE inhibitors)
What are the two most common causes of chronic cough?
Gastroesophageal reflux disease (GERD) and upper airway cough syndrome (UACS) (postnasal drip) are 2 of the most common causes of chronic cough. Patients with GERD typically have accompanying symptoms of reflux and heartburn following meals. In patients with UACS, accompanying rhinorrhea is expected, and oropharyngeal cobblestoning is often present on examination.
What is the most common cause for non-diseased cough?
ACE inhibitor use. This can occur at ANY time following use (weeks, months, years). Most commonly symptoms arise within 1-2 weeks.
How does ACE inhibitor-induced cough present?
Dry, hacking cough 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 condition describes a chronic nonproductive cough that is typically worse at night and triggered by exercise or forced expiration, and allergen exposure?
Cough-variant asthma. This condition presents with a chronic nonproductive cough that is typically worse at night and triggered by exercise, forced expiration, and allergen exposure. The diagnosis can be challenging as these patients typically lack classic asthma symptoms (eg, wheezing, shortness of breath) and physical examination is often largely unremarkable, even during periods of active symptoms. This is a cough is due to asthma, and although most patients are diagnosed during childhood, this disease can present at any age. Patients typically have intermittent wheezing and shortness of breath; however, a subset of patients instead have a chronic nonproductive cough as the predominant symptom, a condition termed cough-variant asthma. The cough is typically triggered by exercise (especially in cold temperatures) or forced expiration and commonly occurs at night. Accompanying chest tightness is often present. Allergens (eg, dust mites, mold) are also common triggers. Some more exoctic causes are due to work in air conditioning repair that leads to frequent allergen exposure. Wheezing and rhonchi are typically absent on physical examination in patients with cough-variant asthma. The diagnosis is typically made by a combination of clinical presentation and pulmonary function testing that demonstrates inducible airway obstruction (eg, positive methacholine challenge). Treatment is essentially the same as for classic asthma and takes into account symptom severity to determine the appropriate level of initial therapy. In some patients with cough that is refractory to bronchodilators and inhaled corticosteroids, leukotriene receptor antagonists (eg, montelukast) have shown efficacy.
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. Once stabilized, perform a chest X-ray. Conditions to consider for patients with a new cough and a normal chest radiograph include gastroesophageal reflux disease, allergies, pulmonary embolism, viral bronchitis, and cough caused by medications such as angiotensin-converting enzyme (ACE) inhibitors. For patients with an abnormal chest radiograph, a dense infiltrate or opacity may indicate bacterial pneumonia, while chronic bronchiectasis changes and new tram-track opacities may indicate a bronchiectasis exacerbation in patients with known bronchiectasis. Patients with signs and symptoms consistent with volume overload may have new onset or exacerbation of congestive heart failure (CHF). Signs of CHF include clinical findings such as peripheral edema and pulmonary crackles and radiographic findings may include pleural effusion, pulmonary edema, Kerley B lines, and an enlarged heart. Patients with CHF often experience orthopnea and paroxysmal dyspnea. While wheezing is often associated with obstructive lung disease, mild wheezing can also be present in CHF exacerbation.
What are the indications for antibiotic use in a patient with COPD experiencing an acute exacerbation?
A cough productive of greenish-yellow sputum, dyspnea, and wheezing with a history of chronic obstructive pulmonary disease (COPD) are suggestive of acute COPD exacerbation. Antibiotics are generally not recommended for management of acute bronchitis in otherwise healthy individuals as most exacerbations are of viral etiology. However, guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend antibiotic therapy for patients who have a COPD exacerbation with any two of the following features: increased sputum purulence, increased sputum volume, or increased dyspnea. Antibiotics are also recommended for those requiring mechanical ventilation (noninvasive or invasive).
A 66-year-old man presents to clinic for evaluation of a persistent cough over the past five months. The cough is intermittent and usually dry, but sometimes productive of a small amount of yellow sputum. He has tried nasal saline rinses, oral famotidine, and oral prednisone without relief. The patient quit smoking three months ago, after smoking one pack per day for 40 years, but the cough remains unchanged. He could previously walk up a flight of stairs without stopping but now must stop halfway up to catch his breath. A recent transthoracic echocardiogram was normal.
Temperature is 37.4 °C (99.3 °F), pulse is 84/min, respiratory rate is 18/min, blood pressure is 133/82 mmg, and oxygen saturation is 95% on room air. On physical examination, he is well-appearing, and the posterior oropharynx is unremarkable. lungs are clear to auscultation bilaterally, but expiration is much longer than inspiration. An in-office chest radiograph is unremarkable. Which of the following treatments would be most appropriate now?
This 66-year-old man with a 40-pack-year smoking history presents with a chronic cough (sometimes with sputum production), dyspnea, and low-normal room air oxygen saturation, raising the concern for chronic obstructive pulmonary disease (COPD). The lack of response to other treatments further supports this concern. Pulmonary function tests are indicated to confirm the diagnosis, and a trial of long-acting bronchodilators would be appropriate treatment.
A chest radiograph can help in the evaluation of subacute or chronic cough. An abnormal chest radiograph is often present in atypical pneumonia, severe bronchiectasis, lung cancer, and interstitial lung disease. While early COPD may present with a normal chest radiograph, advanced COPD will generally have abnormal findings such as hyperinflated lungs. In patients with a normal chest radiograph, it is crucial to review the history and physical thoroughly. If the diagnosis is unclear, further testing with pulmonary function tests (for suspected asthma or COPD) or a sputum analysis (for suspected nonasthmatic eosinophilic bronchitis) may be warranted. In other cases, starting a medication trial can be an appropriate next step. This strategy may be most relevant when gastroesophageal reflux disease (GERD) or upper airway cough syndrome (UACS) are suspected. For patients with subacute or chronic cough and a normal chest radiograph, consider further testing or a medication trial. If asthma or COPD is suspected, pulmonary function tests are appropriate to differentiate the two. Long-acting bronchodilators are recommended for the initial treatment of COPD. If they provide relief of symptoms, that would support a diagnosis of COPD.
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 is the most common cause for hemoptysis?
Acute bronchitis.
A 50-year-old woman presents to the urgent care with three days of cough associated with sinus congestion and postnasal drip. She has also had fatigue and myalgias. She does not smoke. Past medical history is unremarkable. Temperature is 36.8 °C (98.2 °F), pulse is 90/min, respiratory rate is 20/min, blood pressure is 126/82 mmHg, and Sp02 is 98% on room air. On physical examination, the patient is well-appearing. There is no jugular venous distention. There are coarse breath sounds in both lung fields which improve after the patient is asked to cough. Faint wheezing is heard in the upper left lobe. There is no peripheral edema. A chest radiograph is obtained and shows no pacifications or effusions. What is the most likely diagnosis?
This patient presenting with new onset cough, postnasal drip, sinus congestion and systemic symptoms (fatigue, myalgias). On physical exam, she is found to have coarse breath sounds which improve with coughing and faint wheezing in the left upper lobes. Together, these suggest acute bronchitis as the etiology of her cough, which is usually managed with supportive care. The evaluation of an acute cough (less than 3 weeks) begins with a thorough history and physical exam. Patients with viral bronchitis can present with an acute cough, coarse breath sounds that clear with coughing, and occasionally wheezing. They typically have other signs and symptoms of a viral upper respiratory illness (congestion, postnasal drip). Chest radiograph can be useful to rule out other conditions when the clinical picture is unclear, but the diagnosis of viral bronchitis can generally be made with history and physical examination alone. Covering factors such as infectious exposures, environmental exposures, smoking history, and medications. Physical exam should focus on assessing for abnormal pulmonary sounds, evidence of volume overload, as well as evaluating for any related systemic signs. While it is not always necessary in a clear viral upper respiratory infection, a chest radiograph can be performed for patients presenting with an acute cough. For patients with new onset cough and sinus tachycardia, hypoxemia, unilateral leg swelling or chest pain, consider pulmonary embolism. Chest radiography will typically be normal in pulmonary embolism, therefore computed tomography of the chest should be performed to confirm the diagnosis. Exacerbation of chronic obstructive pulmonary disease (COPD) should be suspected in patients with known COPD who present with dyspnea, a cough, and a notable change in sputum character and quantity. Acute bronchitis may present with a viral syndrome and coarse breath sounds that clear with coughing. Wheezing is also common in acute bronchitis due to airway inflammation and resultant turbulent air flow. For patients with an abnormal chest radiograph, consider bacterial pneumonia, malignancy, bronchietasis exacerbation and congestive heart failure.
What is the source of hemoptysis the majority of the time?
Brachial arteries.
What characteristic guides management for hemoptysis?
The volume of blood expectorated will influence the initial management of hemoptysis. 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 an XR usually is indicated initially, followed by CT scan, to 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. Massive blood loss usually requires a flexible bronchoscopy with electrical cautery or balloon tamponade. If these measures fail, perform an arteriographic embolization.
What are the major pulmonary causes for hemoptysis?
Infectious (TB, Lung abscess, Bacterial pneumonia, Aspergillosis), malignancy, or bronchiectasis. Airway inflammation in acute bronchitis can cause erosion of the superficial vessels, leading to hemoptysis, which is usually scant or small in volume.
What are the major hematological causes for hemoptysis?
PE or coagulopathy
What is the major vascular cause for hemoptysis?
AVMs
What are Systemic diseases causes for hemoptysis?
Granulomatosis with polyangiitis or Goodpasture syndrome
What are the cardiac causes for hemoptysis?
Mitral stenosis or acute pulmonary edema from heart failure.
Given the wide range of underlying causes for hemoptysis, what is the best imaging modality for hemoptysis?
Chest x-ray abnormalities may suggest a variety of specific causes in patients with hemoptysis, including malignancy, focal infection (eg, pulmonary tuberculosis), or heart disease (eg, mitral disease). Plain chest radiograph remains the initial test of choice as it may identify the site and cause of bleeding (eg, cavitary lesion, lung mass, or stigmata of mitral stenosis) in over one-third of patients. In combination with the clinical picture, a chest radiograph may also help direct further management (bronchoscopy versus CT scan).
A 26-year-old man with asthma presents with recurrent episodes of fever, wheezing, and productive cough with brownish mucus. CT scan shows central bronchiectasis and fleeting infiltrates. What is the most likely diagnosis?
Allergic bronchopulmonary aspergillosis (ABPA). This is a hypersensitivity reaction to Aspergillus in patients with asthma or cystic fibrosis. It is characterized by recurrent asthma exacerbations, transient pulmonary infiltrates, central bronchiectasis, and elevated IgE levels.
What are the key diagnostic features of allergic bronchopulmonary aspergillosis (ABPA)?
ABPA is diagnosed based on:
- Clinical history (asthma or cystic fibrosis)
- Imaging (central bronchiectasis, fleeting infiltrates)
- Laboratory findings (elevated IgE >417 IU/mL, eosinophilia, Aspergillus-specific IgE, positive Aspergillus skin test).
Is a biopsy needed for allergic bronchopulmonary aspergillosis (ABPA)?
Biopsy is not typically required for diagnosing allergic bronchopulmonary aspergillosis, however, it is required for invasive aspergillosis. Histologically, these organisms produce 45 degree (acute angle) septate hyphae.
What is the first-line treatment for allergic bronchopulmonary aspergillosis (ABPA)?
Glucocorticoids (e.g., prednisone) are the mainstay of treatment to reduce airway inflammation. Antifungal therapy with itraconazole is added to decrease Aspergillus burden and reduce recurrence.
What is the pathophysiology of allergic bronchopulmonary aspergillosis (ABPA)?
ABPA is caused by an exaggerated IgG- and IgE-mediated hypersensitivity response to Aspergillus colonization of the airways, leading to recurrent inflammation, airway damage, and bronchiectasis.
A patient with asthma presents with recurrent episodes of hemoptysis and bronchiectasis. How can you differentiate ABPA from cystic fibrosis?
ABPA occurs in patients with preexisting asthma and is characterized by elevated IgE and eosinophilia. Cystic fibrosis presents at a younger age with persistent respiratory infections, pancreatic insufficiency, and defective chloride transport (CFTR mutation).
What is the first-line treatment for ABPA?
Once ABPA is confirmed, oral glucocorticoids arefirst-line therapy, followed by Itraconazole or Voriconazole (Antifungal Therapy).
A patient with asthma is diagnosed with ABPA and started on corticosteroids. What additional tests should be considered for monitoring?
Serial measurement of total serum IgE levels can help assess treatment response. Persistent eosinophilia and elevated IgE suggest ongoing disease activity.
Why is itraconazole used in the treatment of ABPA?
Itraconazole is used as adjunct therapy to decrease Aspergillus burden, reducing the frequency of exacerbations and the need for long-term corticosteroids. It works by inhibiting ergosterol synthesis in fungal cell membranes.
How does allergic bronchopulmonary aspergillosis (ABPA) appear on high-resolution CT imaging?
CT findings include central bronchiectasis (dilation of proximal bronchi) and transient, patchy infiltrates in different lung regions, often shifting between episodes. These are called fleeting infiltrates on lung imaging (eg, transient infiltrates in different parts of the lungs).
What genetic disorder is associated with a higher risk of developing ABPA?
Cystic fibrosis (CF) predisposes to ABPA due to defective mucociliary clearance, which promotes fungal colonization and persistent airway inflammation.
What is the most common group of people who have invasive pulmonary aspergillosis (IPA)?
Immunodeficiency like AIDs and neutropenia.
What is the first step in diagnosing invasive pulmonary aspergillosis (IPA)?
Obtain a chest CT scan to look for characteristic findings such as nodular infiltrates, the halo sign (early), or the air crescent sign (late).
What are the key imaging findings on chest CT suggestive of IPA?
Halo Sign – Nodular infiltrate surrounded by ground-glass opacity (early sign of angioinvasion). 2. Air Crescent Sign – Cavitary lesion with necrosis (later stage of IPA). 3. Multiple Nodules – Often seen in neutropenic patients.”
What noninvasive laboratory tests are useful in invasive pulmonary aspergillosis diagnosis?
Serum Beta-D-Glucan Test – Supports fungal infection but is not Aspergillus-specific.
When should a bronchoalveolar lavage (BAL) be performed?
Perform BAL when imaging suggests IPA but serum biomarkers are inconclusive, or in immunocompromised patients where a sample is needed for culture and galactomannan testing.
What role does sputum or bronchoalveolar lavage culture play in diagnosing invasive pulmonary aspergillosis?
A positive Aspergillus culture from bronchoalveolar lavage supports the diagnosis, but culture alone does not confirm invasive disease (as it may represent colonization).
When is a biopsy required in the diagnosis of invasive pulmonary aspergillosis?
A biopsy is required if CT findings and noninvasive tests (serum galactomannan, BAL) are inconclusive, but clinical suspicion remains high.
What are the options for obtaining a lung tissue biopsy in suspected invasive pulmonary aspergillosis?
- Transbronchial biopsy (via bronchoscopy) – For centrally located lesions.
- CT-guided percutaneous lung biopsy – For peripheral nodules.
- Surgical lung biopsy (VATS or open biopsy) – For cases where less invasive methods are non-diagnostic.
What are the key histopathological findings of invasive pulmonary aspergillosis?
- Septate hyphae with acute-angle branching invading lung tissue.
- Angioinvasion (vascular invasion leading to infarction and necrosis).
- Granuloma formation in chronic cases.
What is the final step in confirming a diagnosis of invasive pulmonary aspergillosis?
Histopathological confirmation of fungal invasion into lung tissue, along with microbiologic evidence (culture or PCR), is required for definitive diagnosis.
What is the overall stepwise approach to diagnosing invasive pulmonary aspergillosis?
- Chest CT to identify characteristic findings (halo sign, air crescent sign, nodules).
- Serum biomarkers (galactomannan, beta-D-glucan) and BAL if needed.
- BAL culture and galactomannan test if CT is suspicious.
- Lung biopsy (transbronchial, CT-guided, or surgical) if noninvasive tests are inconclusive.
- Histopathologic confirmation of fungal invasion in lung tissue.
What is the first-line treatment for invasive pulmonary aspergillosis (IPA)?
Voriconazole is the first-line antifungal treatment for IPA due to its high efficacy and better survival rates compared to amphotericin B.
What conditions present with an abnormal chest X-ray in acute cough?
ABPA, Pneumonia, bronchiectasis exacerbation, congestive heart failure (CHF), lung cancer.
What are the major clinical signs of cough caused by a viral pathogen?
Nasal congestion, mildly productive cough, and myalgia are consistent with a viral upper respiratory infection
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.
A 71-year-old woman presents to the emergency department due to increasing shortness of breath over the past eight hours. Over the past several months, she has had a persistent dry cough and unintentional weight loss of 10 lbs (4.5 kg). Initially, she demonstrates increased work of breathing but is not in respiratory distress. A chest radiograph is performed in the emergency department and shows a large perihilar mass. The patient subsequently becomes more short of breath and vomits more than one cup of bright red blood. A nasal cannula is placed, and oxygen is administered. Temperature is 36.3 °C (97.3 °F), pulse is 120/min, respiratory rate is 35/min, blood pressure is 100/64 mmHg, and oxygen saturation is 90% on 6 liters nasal cannula oxygen. On examination, the patient is in respiratory distress with intercostal retractions. There are bibasilar crackles and rhonchi in both lungs. An 18-gauge peripheral intravenous line is placed. What is the best next step in management?
This 71-year-old woman who presents with a chronic dry cough, unintentional weight loss, and shortness of breath likely has lung cancer, based on the large perihilar mass seen on chest x-ray. Hemoptysis is a common symptom of lung cancer, and in severe cases, erosion and invasion of bronchopulmonary vessels can cause significant bleeding. Following an episode of large-volume hemoptysis, this patient develops respiratory decompensation and should undergo endotracheal intubation to secure the airway and prevent respiratory failure. Subacute cough refers to a cough lasting 3-8 weeks, and chronic cough refers to a cough lasting more than 8 weeks. While some causes (e.g., upper airway cough syndrome) do not require acute management, certain conditions, such as advanced chronic obstructive pulmonary disease, can present with respiratory compromise requiring emergent management. For patients with subacute or chronic cough who present emergently, a focused ABCDE (airway, breathing, circulation, disability, exposure) assessment should be performed. Patients with a pulmonary cause of subacute or chronic cough may exhibit signs of respiratory distress, including tachypnea, hypoxia, and increased work of breathing. In these cases, endotracheal intubation and mechanical ventilation may be necessary to prevent impending respiratory failure. Once the patient is stabilized, additional diagnostics and treatment can be directed at the underlying cause. In this patient’s case, additional management options could include computed tomography imaging of the chest, bronchoscopy, and/or bronchial artery embolization.
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.
A 65-year-old man with a 40-pack-year smoking history presents to the primary care clinic with an 8-month history of progressively worsening shortness of breath, chronic productive cough, and wheezing. His past medical history is significant for hypertension. Temperature is 36.6°C (98.2°F), blood pressure is 109/72 mmHg, pulse is 98/min, respiratory rate is 22/min, and oxygen saturation is 90% on room air. On physical examination, he has diminished breath sounds and bilateral expiratory wheezing. Laboratory findings are unremarkable. Pulmonary function tests reveal an FEV,/FVC ratio of 0.55 with minimal reversibility after bronchodilator administration. What is most likely to decrease mortality in this patient?
This patient with a 40-pack-year smoking history presents with an 8-month history of worsening dyspnea, cough, wheezing, hypoxia, and bilateral expiratory wheezing. These findings along with an FEV/FVC ratio < 0.7 with minimal reversibility after bronchodilator administration are mostly consistent with the diagnosis of COPD. Smoking cessation has shown to be the most effective intervention for reducing the risk of developing COPD, slowing its progression, and decreasing morbidity and mortality associated with the disease. Other interventions that have been shown to decrease mortality in COPD patients include lung reduction surgery, pulmonary rehabilitation, triple combination therapy (LAMA + LABA + ICS) in patients with a history of severe and/or frequent exacerbations, long-term oxygen therapy for patients with hypoxemia resting PaO2 ≤ 55 mmHg or < 60 mmHg with cor pulmonale or secondary polycythemia), and NIPPV for patients with hypercapnia. In addition to recommending smoking cessation, a stepwise comprehensive management plan should be initiated for patients with COPD which should include pharmacotherapy to control symptoms and reduce the frequency of exacerbations, influenza and pneumococcal vaccinations, and other lifestyle modifications (e.g. increase in physical activity). Treatment is typically based on the GOLD classification. For patients with less severe symptoms and low exacerbation risk (Group A), single-agent long-acting bronchodilator therapy is recommended. For patients with more severe symptoms and low exacerbation risk (Group B), dual long-acting bronchodilator therapy is recommended. For patients with high exacerbation risk, regardless of symptoms (Group E, replacing previous Groups C and D categories), dual long-acting bronchodilator therapy is recommended.
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.
When would you consider using a bronchoscopy to evaluate bronchiectasis?
Chronic daily production of copious, thick mucus with chest imaging showing localized left upper lobe airway dilation and wall thickening consistent with focal bronchiectasis. Patients can have recurring episodes of mucopurulent sputum, typically necessitating extended courses of antibiotic treatment. Bronchiectasis is characterized by permanent airway dilation owing to an underlying bronchial insult coupled with impaired respiratory secretion clearance. Focal bronchiectasis (eg, involvement of a single lobe or segment) usually indicates airway blockage from conditions like malignancy or foreign body proximally. Mucus becomes trapped behind the obstruction, leading to bacterial overgrowth and an inflammatory response that damages the bronchial wall, producing permanent dilation. Patients may develop post-obstructive pneumonia (due to mucus impaction) and/or repeated bronchiectasis exacerbation (due to acute superinfection or worsening of inflammation). Chest CT scanning may sometimes reveal the obstructing lesions; however, endobronchial masses and radiolucent foreign bodies may not be visualized. Therefore, direct airway examination with bronchoscopy is the test of choice to evaluate focal bronchiectasis. It also allows for diagnostic sampling or therapeutic removal of obstructing lesions.
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.
