APPROACH TO COUGH

BY : Dr. Mahesh Yadav

Cough is an explosive expiration that provides a normal protective mechanism for clearing the tracheobronchial tree of secretions and foreign material.

DEFINITION

The bronchi and trachea are so sensitive to light touch that excessive amounts of foreign matter or other causes of irritation initiates the cough reflex.

Coughing may be initiated either voluntarily or reflexively

As a defensive reflex it has both afferent and efferent pathways

The afferent limb includes receptors within the sensory distribution of the trigeminal, glossopharyngeal, superior laryngeal, and vagus nerves.

The efferent limb includes the recurrent laryngeal nerve and the spinal nerves.

COUGH RECEPTORS RECIDES IN PHARYNX, PARANASAL SINUSES, STOMACH AND EXTRA-AUDITORY CANAL

CAUSE OF COUGH MAY BE EXTRAPULMONARY.

MechanismAbout 2.5L of air is inspired

Epiglottis closes, vocal cords shut tightly to entrap the air within the lung

Abdominal muscles contract forcefully, pushing against the diaphragm

Internal intercosatal muscles also contract forcefully

Pressure in the lungs rises to 100mmHg or more. Markedly positive intrathoracic pressure causes narrowing of the trachea.

Vocal cords and epiglottis suddenly open widely .

Air is expelled at velocities ranging from 75 to 100 miles/hr.

The shearing forces that develop aid in the elimination of mucus and foreign materials

Cough is therefore PROTECTIVE

http://www.google.co.in/imgres?q=cough+reflex&hl=en&sa=G&biw=1366&bih=533&gbv=2&tbm=isch&tbnid=_4q9eXqs-JzBwM:&imgrefurl=http://drsaravananr.blogspot.com/2008/01/what-is-it-about-your-cough.html&docid=A5-KB-5YqOTOJM&w=400&h=239&ei=2UsuTvW1J436swOLloH-Dw&zoom=1

MECHANISM OF COUGH

• How Do We Cough_ - The Mechanism of Coughing - Cough Reflex Animation - Learn Human Body.mp4

Thus..• From the mechanism..

• Presence of significant COUGH- irritation of cough receptors..

HOW WE NARROW OUR DIAGNOSIS WHILE APPROACHING

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STILL THINKING

MAY BE NEXT SLIDES WILL HELP

ASK THESE QUESTION

ONSET

PRODUCTIVE ?

CHARACTER AND TIMING

VARIATION

D/D

• Onset- sudden onset after choking episode- foreign body, recurrent- atopic type, chronic- TB, bronchiectasis

• Productive- older children with early morning severe expectoration- Bronchiectasis, non-productive and only when awake- habitual

• Character- Barking- croup, spasmodic- atopic type• Variation- nocturnal and early morning- atopic

type, lying down- GERD

ETIOLOGY

ACUTE

•1.INFANT •2.TODDLERS•3.CHILDREN•4.ADOLESCENT

RECURRENT

•1.INFANT•2.TODDLERS•3.CHILDREN•4.ADOLESCENT

CHRONIC >3WEEK

S

•1.INFANT•2.TODDLERS•3.CHILDREN•4.ADOLESCENT

ACUTE

•INFECTION•ASPIRATION•FOREIGN BODY

RECURRENT

•REACTIVE AIRWAYS•CF•GERD•ANATOMIC ABNORMALITY•PASSIVE SMOKING

CHRONIC

•REACTIVE AIRWAYS•CF•ASPIRATIONS•PERTUSSIS•ANATOMIC ABNORMALITY•PASSIVE SMOKING

ACUTE

•INFECTION

RECURRENT

•REACTIVE AIRWAYS•CF•GERD•PASSIVE SMOKING

CHRONIC

•Tuberculosis/ Bronchiectasis•REACTIVE AIRWAYS•CF•GERD•PERTUSSIS, MYCOPLASMA•PSYCHOGENIC•ANATOMIC ABNORMALITY •PASSIVE SMOKING

CAUTION• Pneumonia- involves

parenchyma• Cough receptors may not be

involved in the early stages

• Hence cough may be a late feature of lobar pneumonia- Fever with tachypnea +/- retractions is diagnostic of pneumonia

SPUTUM Productive cough: significant amount of

sputum; Blood- hemoptysis; smell- putrid smell- lung abscess

Color of sputum- no bearing on the diagnosis

Large amounts:-a)regular coughing up-bronchiectasis b)Single occasion-lung abscess,empyema

c)Pink frothy-Pulmonary edema

PURULENT SPUTUM

RUSTY SPUTUM

BLOODY SPUTUM

VARIATION

SEASONAL

DIURNAL

NO VARIATION

POSTURAL

1.Diurnal variationCough which gets worse in night and

early morning :- Asthma

2.Postural variation Bronchiectasis, Lung abscessLying down- postnasal drip, GERD,

cardiac cause- pulmonary congestion

3.Seasonal variationAsthma, C/c bronchitis

Aggravating & Relieving factorsCold,smoke,dust,exertion: asthma Cough and choking on swallowing of

liquids: Neuromuscular disorders- affects swallowing

Solids- Oesophageal motility problems Otogenic cough: impacted wax or

foreign body in external auditory meatus- subsides with removal of cause

Associated symptoms Fever: Pneumonia, lung abscess- clubbing also+ Chest pain: Pneumonia with pleuritis

Pleuritic chest pain: lateral part of chest with associated splinting- increases on deep inspiration/ cough- Pleurisy, pleural effusion, bronchiectasis

Frequent hawking of throat, Nasal discharge, snoring, tickling sensation in throat- Post nasal drip

Cough with associated dyspnea on exertion/ palpitations- Cardiac cause

Stridor: FB, Laryngeal nerve involvement

Hoarseness of voice: Laryngeal nerve involvement

Heart burn, regurgitation: GERD

NOT TO FORGET TO NOTE

.Laryngeal inflammation:-cough, hoarseness of voice,stridor

.FB:-cough,stridor,history

.WHOOP SOUND-pertussis• ALL DAY NEVER DURING SLEEP-habit cough

INFANT WITH WHOOPING COUGH

• My Movie.wmv

BABY WITH CROUP STRIDOR BARKING COUGH

• My Movie 2.wmv

.Post nasal drip;-nasal discharge… mucoid or mucopurulent,tickle in throat

.GERD:-cough,heart burns, regurgitation

6.Tuberculosis:-cough (dry…purulent …blood streaks in sputum), anorexia,LOW, night sweats, evening rise of temperature

•APPROACH TO TUBERCULOSIS

APPROACH TO FOREIGN BODY

APPROACH IN CHILD