Cough: Defense mechanism and symptoms

Question 1

Diagnosis and treatment?

47 y/o Caucasian woman, c/o cough x 3 years.

30 pack-year smoking history, quit in 2001.

Traveled to China caught “bad chest cold”. Recovered, but had “bronchitis” (phlegm, cough) ≥ 8 times/year thereafter.

Coughs day and night.

ROS = mildly hoarse, several sinus infections, no heartburn, regurg, cardiac or neuromuscular

Physicla exam = looks depressed, normal vitals
–Chest CT: mild emphysema
–Sinus CT: normal
–PFTs: consistent with asthma
–Methacholine challenge: positive
–pH probe: couldn’t place– too much coughing
–Esophagram: severe GERD
–Laryngoscopy: interarytenoid erythema, c/w reflux
–PPD: negative

–Chest CT: mild emphysema
–Sinus CT: normal
–PFTs: consistent with asthma
–Methacholine challenge: positive
–pH probe: couldn’t place– too much coughing
–Esophagram: severe GERD
–Laryngoscopy: interarytenoid erythema, c/w reflux
–PPD: negative

Answer 1

Diagnosis = chronic cough due to asthma, early COPD, GERD

Treatment = inhaled corticosteroid/bronchodilator, PPI

Question 2

Pathophysiology of cough

Answer 2

1) Stimulation of cough receptors in upper airway, tracheobronchial tree, lower esophagus
2) link to afferents via VAGUS AND SUPERIOR LARYNGEAL NERVES to cough center in brainstem
3) efferent pathways (purple) coordinate intercostal muscles, larynx, and diaphgram –> cough to expel irritating factor of cough

Question 3

Cough receptors located where?

Answer 3

1) upper airway
2) tracheobronchial tree
3) lower iarway

Question 4

what do cough receptors link to?

Answer 4

link to afferents via VAGUS AND SUPERIOR LARYNGEAL NERVES

Question 5

efferent pathways coordinate what?

Answer 5

intercostal muslces, larynx, diaphragm

Question 6

types of cough receptors

Types of stimuli

Answer 6

1) rapidly adapting receptors
2) C-fibers
3) slowly adaping receptors

Stimuli =

1) muscus
2) inflamm mediators

Question 7

people with chronic cough not due to asthma have evidence of ___

changes in cellular level with chronic rhinitis and GERD (not asthma)

Answer 7

airway inflamm and remodeling

–> related to chronic rhinitis and GERD had

1) sub-basement membrane thickening
2) goblet cell hyperplasia
3) more blood vessels

Question 8

4 phases of efferent pathway

Answer 8

1) inspiratory phase = subglottic closure with incr in intrathoracic pressure, vocal folds open, incr flow rate
2) compressive phase
3) expiratory phase
4) relaxation phase

Question 9

Who is at risk for impaired cough?

Answer 9

1) Interruption of afferent and/or efferent pathways of cough reflex impairs cough
2) Altered sensorium- anesthesia, narcotics, sedatives, alcohol, coma, stroke, seizure, SLEEP
3) Laryngeal/ upper airway disorders = can’t close vocal cords so can’t generate intrathoracic pressure
4) Tracheostomy tube
5) Restrictive and obstructive lung diseases
6) Neuromuscular diseases
7) Supine in hospital bed

Question 10

Consequences of impaired cough?

Answer 10

1) aspiration of oropharyngeal or stomach contents
2) acute airway obstruction
3) pneumonia
4) lung abscess
5) respiratory failure/ARDS
6) bronchiectasis

7) pulm fibrosis = in bottom part of lung and vascular areas because
gravity pulls all down

Question 11

Complciations of cough

primary result from?

affect nearly what?

disruption of ?

Answer 11

1) incr in intrathoracic pressure
2) affect nearly every organ system
3) disruption of surgical wounds

Question 12

define acute cough in adults

key questions to ask

Answer 12

cough < 3 weeks in adults

–> life threatening or antibiotics needed?

Question 13

Paradigm of acute cough

Life-threatening worries?

Answer 13

1) pneumonia
2) COPD/asthma exacerbation
3) PE
4) heart failure

Question 14

Non-lifethreatening etiologies of acute cough

infectious?

exacerbation of pre-existing condition?

Answer 14

infectious = URTI, LRTI

exacerbation = asthma, bronchiectasis, UACS (post nasal drip), COPD

environmental vs. occupational cause

Question 15

URTI or URI

1) Caused by?
2) symptoms
3) what causes irritation causing cough?
4) are antibiotics indicated?
5) treatments

Answer 15

1) viruses (rhinoviruses)
2) nasal congestion, drainage
3) post-nasal drainage irritates larynx; inflamm incr sensitivity of sensory afferents
4) NO
5) decongestants, cough suppressants (????

Question 16

LRTI = acute bronchitis

1) caused by
2) symptoms
3) bacterial causes to consider?
4) make sure it’s NOT

Answer 16

1) usu viral (rhino, adeno, RSV) but can be bacterial
2) cough with or without phlegm (yellow, rusty, green = bacterial)
3) mycoplasma pneumo, chlam pneumo, bordatella = superinfection following viral infection; yellow green sputum
4) pneumonia;

Question 17

what should you consider with underlying COPD?

what should you consider with underlying asthma

what should you consider with underlying bronchiectasis

Answer 17

1) most are actually viral but also can be bacterial infection
2) exposure, viral URTI, viral LRTI
3) bacteiral infection (gram neg rod, staph aureus, antibiotic resistance)

Question 18

define Subacute cough in adults

Pertussis

1) causes?
2) mechanism?
3) treatment
4) exacerbations
5) diagnosis

Answer 18

3-8 weeks

1) B pertussis = contagious
2) airway inflamm, disrupt epithelial integrity, incr cough sensitivity
3) short course macrolide, prevent with vaccination
4) post-tussive vomiting
5) culture, PCR, serologies

Question 19

post-infectious concerns with subacute cough

Answer 19

1) pneumonia
2) pertussis
3) bronchitis
4) exacerbation of UACS, asthma, GERD

Question 20

workup for non-postinfectious subacute cough

Answer 20

same as chornic cough

Question 21

define chronic cough

Top 4 causes in immunocompetent patient with normal CXR

Answer 21

cough > 8 weeks

1) UACS
2) asthma

3) GERD
4) Non asthmatic eosinophilic bronchitis

5) neuropathic cough

Question 22

UACS

1) mechanism
1) signs (may be absent)
2) consider underlying …
3) treatment

Answer 22

1) nose/sinus secretiions stim upper airway cough receptors; incr receptor sensitivity
1) “tickle in throat”, throat clearing, hoarseness, nasal congestion

infalmed nasal mucosa, secretions in posterior oropharynx

2) allergies, chronic sinusitis, overuse of alpha-agonist sprays
3) 1st gen anti-histamine/decogestant x2 weeks

Question 23

Asthma

1) mechanism
2) classic symptoms
3) signs (often absent)
4) diagnosis
5) treatment

Answer 23

1) inflamm mediators, mucus, bronchoconstriction stim cough
2) intermittent wheeze
3) expiratory wheezing
4) spirometry before/after bronchodilatory = partially reversible obstruction

methacholine challenge = positive

5) inhaled corticosteroid + bronchodilator x 8 weeks

Question 24

if cough is only symptom in ashtma patient diagnosis?

Answer 24

cough-variant asthma

Question 25

Vicious cycle of GERD and cough

Answer 25

1) cough
2) incr abd pressure
2) reflux
4) cough

Question 26

GERD

1) classic symptoms
2) diagnostic test
3) treatment

Answer 26

1) heartburn, sour taste in mouth
2) 24 hr esophageal pH probe

esophagram

3) gastric acid suppression with PPI (omeprazole) x2 months

diet and lifestyle modification

Question 27

NAEB

1) define
2) tests
3) treatment

Answer 27

1) eosinophilic airway inflamm WITHOUT variable airflow obstruction or hyperresponsiveness
2) spirometry = normal

methacholine = normal; rules out asthma

induced sputum = > 3% eos

3) inhaled corticosteroid x 4 weeks

Question 28

Neuropathic cough (chronic cough hypersensitivity syndrome)

1) triggered by
2) throat symptoms
3) caused by
4) treatment

Answer 28

1) triggered by low level stim (change temp, breath, laugh)
2) need to clear throat, globus sensation, tickle
3) post-viral vagal neuropathy

chronic irritation/inflamm (PND, GERD)

environ pollutants

4) manage irritants

amitryptyline, gabapentin

Question 29

ACE-inhibitor therapy

1) names
2) side effects
3) timeline of side effect

Answer 29

1) - end in -pril
2) dry cough
3) 1 week- 6 month after start

Question 30

cough in children

1) most commonly
2) chronic cough define?
3) other causes

Answer 30

1) viral URTI
2) > 4 weeks
3) asthma, sinus, GERD, chronic tobacco smoke exposure

Question 31

A 67 y/o man, life-long non-smoker, complains of 12 weeks of non-productive cough. He’s had a couple of “colds” this winter. He has no current nasal or sinus symptoms, rarely has heartburn, and never wheezes. He’s on no meds. Vitals and physical exam are normal. Your next step would be:

A) Prescribe a 1st generation antihistamine/ decongestant!

B) Prescribe an inhaled corticosteroid for asthma!

C) Order an induced sputum to look for eosinophils!

D) Order a chest x-ray!

E) All of the above!

Answer 31

1st step if not asthma, COPD, not UACS, not bronchitis
—> get CXR
PNA vs. lung cancer

Question 32

Define idiopathic pulm fibrosis

why do they cough?

physical exam?

Answer 32

scar tissue that irritates cough recpetors

dry crackles on exam

Question 33

How does subglottic stenosis appear on P-V loop

Answer 33

fixed obstruction box shape on both top and bottom

Question 34

what should you be worried about in child with localzied wheezing?

Answer 34

foreign body aspiration –> could be aspirating weeks ago –> chronic cough