Cough: Defense mechanism and symptoms Flashcards
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
Diagnosis = chronic cough due to asthma, early COPD, GERD
Treatment = inhaled corticosteroid/bronchodilator, PPI
Pathophysiology of cough
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
Cough receptors located where?
1) upper airway
2) tracheobronchial tree
3) lower iarway
what do cough receptors link to?
link to afferents via VAGUS AND SUPERIOR LARYNGEAL NERVES
efferent pathways coordinate what?
intercostal muslces, larynx, diaphragm
types of cough receptors
Types of stimuli
1) rapidly adapting receptors
2) C-fibers
3) slowly adaping receptors
Stimuli =
1) muscus
2) inflamm mediators
people with chronic cough not due to asthma have evidence of ___
changes in cellular level with chronic rhinitis and GERD (not asthma)
airway inflamm and remodeling
–> related to chronic rhinitis and GERD had
1) sub-basement membrane thickening
2) goblet cell hyperplasia
3) more blood vessels
4 phases of efferent pathway
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
Who is at risk for impaired cough?
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
Consequences of impaired cough?
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
Complciations of cough
primary result from?
affect nearly what?
disruption of ?
1) incr in intrathoracic pressure
2) affect nearly every organ system
3) disruption of surgical wounds
define acute cough in adults
key questions to ask
cough < 3 weeks in adults
–> life threatening or antibiotics needed?
Paradigm of acute cough
Life-threatening worries?
1) pneumonia
2) COPD/asthma exacerbation
3) PE
4) heart failure
Non-lifethreatening etiologies of acute cough
infectious?
exacerbation of pre-existing condition?
infectious = URTI, LRTI
exacerbation = asthma, bronchiectasis, UACS (post nasal drip), COPD
environmental vs. occupational cause
URTI or URI
1) Caused by?
2) symptoms
3) what causes irritation causing cough?
4) are antibiotics indicated?
5) treatments
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 (????
LRTI = acute bronchitis
1) caused by
2) symptoms
3) bacterial causes to consider?
4) make sure it’s NOT
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;
what should you consider with underlying COPD?
what should you consider with underlying asthma
what should you consider with underlying bronchiectasis
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)
define Subacute cough in adults
Pertussis
1) causes?
2) mechanism?
3) treatment
4) exacerbations
5) diagnosis
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
post-infectious concerns with subacute cough
1) pneumonia
2) pertussis
3) bronchitis
4) exacerbation of UACS, asthma, GERD
workup for non-postinfectious subacute cough
same as chornic cough
define chronic cough
Top 4 causes in immunocompetent patient with normal CXR
cough > 8 weeks
1) UACS
2) asthma
3) GERD
4) Non asthmatic eosinophilic bronchitis
5) neuropathic cough
UACS
1) mechanism
1) signs (may be absent)
2) consider underlying …
3) treatment
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
Asthma
1) mechanism
2) classic symptoms
3) signs (often absent)
4) diagnosis
5) treatment
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
if cough is only symptom in ashtma patient diagnosis?
cough-variant asthma
Vicious cycle of GERD and cough
1) cough
2) incr abd pressure
2) reflux
4) cough
GERD
1) classic symptoms
2) diagnostic test
3) treatment
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
NAEB
1) define
2) tests
3) treatment
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
Neuropathic cough (chronic cough hypersensitivity syndrome)
1) triggered by
2) throat symptoms
3) caused by
4) treatment
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
ACE-inhibitor therapy
1) names
2) side effects
3) timeline of side effect
1) - end in -pril
2) dry cough
3) 1 week- 6 month after start
cough in children
1) most commonly
2) chronic cough define?
3) other causes
1) viral URTI
2) > 4 weeks
3) asthma, sinus, GERD, chronic tobacco smoke exposure
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!
1st step if not asthma, COPD, not UACS, not bronchitis
—> get CXR
PNA vs. lung cancer
Define idiopathic pulm fibrosis
why do they cough?
physical exam?
scar tissue that irritates cough recpetors
dry crackles on exam
How does subglottic stenosis appear on P-V loop
fixed obstruction box shape on both top and bottom
what should you be worried about in child with localzied wheezing?
foreign body aspiration –> could be aspirating weeks ago –> chronic cough
