cough M.A.zohalpulmonologist

inflammation, constriction, infiltration, or compression of airways inflammation, constriction, infiltration, or compression of airways

Evaluation full history Duration of cough Duration of cough When it tends to occur When it tends to occur –nights or early morning, after exertion, on exposure to dust, pollen or cold air (asthma), – after meals or on sitting or bending over (GERD), –nocturnal (postnasal drip and asthma) hemoptysis hemoptysis

Evaluation full history Associated symptoms Associated symptoms –Shortness of breath –Wheeze –Throat clearing –Sensation of postnasal drip –Chest pain –Ankle swelling –Orthopnoea/paroxysmal nocturnal dyspnoea –Dyspepsia

Evaluation full history Previous respiratory disease, such as childhood asthma, eczema, or hay fever Previous respiratory disease, such as childhood asthma, eczema, or hay fever History of sinus disease or perennial rhinitis History of sinus disease or perennial rhinitis History of severe respiratory infections, such as whooping cough, that may have caused bronchiectasis History of severe respiratory infections, such as whooping cough, that may have caused bronchiectasis Known cardiac disease or valvular heart disease Known cardiac disease or valvular heart disease

Evaluation full history Drug history ?ACE inhibitor Drug history ?ACE inhibitor Occupation ?workplace irritants Occupation ?workplace irritants Pets/birds Pets/birds Smoker Smoker Use of recreational drugs Use of recreational drugs

Investigations Initially Spirometry Spirometry Methacholine challenge test Methacholine challenge test Serial peak flow recording Serial peak flow recording Induced sputum examination Induced sputum examination

investigation later Consider chest HRCT if any features suggestive of lung cancer or interstitial lung disease, as a small proportion may present with a normal CXR (central tumour) Consider chest HRCT if any features suggestive of lung cancer or interstitial lung disease, as a small proportion may present with a normal CXR (central tumour) Consider ENT examination if predominantly upper respiratory tract disease, resistant to treatment. Consider sinus CT Consider ENT examination if predominantly upper respiratory tract disease, resistant to treatment. Consider sinus CT Consider bronchoscopy if foreign body possible, or history suggestive of malignancy, small carcinoid, endobronchial disease. Perform after CT to help guide bronchoscopist Consider bronchoscopy if foreign body possible, or history suggestive of malignancy, small carcinoid, endobronchial disease. Perform after CT to help guide bronchoscopist Consider esophageal pH monitoring. Consider esophageal pH monitoring.

ACUTE COUGH Common cold Common cold pneumonia, pneumonia, congestive heart failure, congestive heart failure, exacerbation of COPD exacerbation of COPD gastric aspiration gastric aspiration pulmonary embolism. pulmonary embolism.

Chronic cough Asthma Asthma GERD GERD postnasal drip (rhinosinusitis) postnasal drip (rhinosinusitis) chronic bronchitis chronic bronchitis bronchiectasis bronchiectasis

Common cold postnasal drip, postnasal drip, throat-clearing, throat-clearing, irritation of the throat, irritation of the throat, sore throat, sore throat, nasal obstruction, nasal obstruction, nasal discharge nasal discharge

treatment Codeine was ineffective against the acute cough of the common cold Codeine was ineffective against the acute cough of the common cold Dextromethorphan may be Dextromethorphan may be antibiotic therapy unless it persists for more than 10 to 14 days. antibiotic therapy unless it persists for more than 10 to 14 days.

Rhinosinusitis (PND) throat-clearing throat-clearing nasal quality to the voice nasal quality to the voice cobblestoning" appearance cobblestoning" appearance presence of allergy to pollens presence of allergy to pollens

Treatment PND corticosteroid drops corticosteroid drops short course of oral steroids short course of oral steroids anticholinergic spray anticholinergic spray decongestant vasoconstrictor sprays decongestant vasoconstrictor sprays Antibiotic therapy Antibiotic therapy

Asthma Often nocturnal Often nocturnal reversible airflow limitation reversible airflow limitation bronchial hyperresponsiveness bronchial hyperresponsiveness do not usually have an enhanced cough reflex do not usually have an enhanced cough reflex Cough as the only presenting symptom of asthma has been reported in up to 57% of patients Cough as the only presenting symptom of asthma has been reported in up to 57% of patients

GE reflux laryngeal symptoms laryngeal symptoms –dysphonia –hoarseness –sore throat –posterior vocal cord & laryngeal inflammation esophageal dysmotility ( heartburn, water brash, and oral regurgitation ) esophageal dysmotility ( heartburn, water brash, and oral regurgitation )

Treatment GERD avoiding caffeine, avoiding caffeine, wearing loose fitting clothes, wearing loose fitting clothes, sleeping with an empty stomach sleeping with an empty stomach sleeping propped up sleeping propped up High dose omeprazole High dose omeprazole H2 receptor blockers H2 receptor blockers pro-kinetics like metoclopramide pro-kinetics like metoclopramide

ACE inhibitor cough a tickly irritating sensation in the throat a tickly irritating sensation in the throat It may appear within a few hours of taking the drug or may become apparent only after weeks or even months It may appear within a few hours of taking the drug or may become apparent only after weeks or even months The cough disappears within days or weeks following withdrawal of the drug The cough disappears within days or weeks following withdrawal of the drug

POSTINFECTIOUS COUGH viral in nature viral in nature take weeks or months to resolve spontaneously, although most settle within 8 weeks. take weeks or months to resolve spontaneously, although most settle within 8 weeks.

pathogenesis persistent damage to the cough receptors or persistent airway inflammation induced initially by the virus persistent damage to the cough receptors or persistent airway inflammation induced initially by the virus Irritants may penetrate more readily through the damaged epithelium Irritants may penetrate more readily through the damaged epithelium heightened cough reflex heightened cough reflex

Pathogenesis (continue) Impaired mucociliary clearance Impaired mucociliary clearance Mucus hypersecretion Inflammation in upper airway such as rhinitis & sinusitis Mucus hypersecretion Inflammation in upper airway such as rhinitis & sinusitis Gastro esophageal reflux Gastro esophageal reflux

Associated laryngospasm can occur, which is a sudden hoarseness, with associated stridulous inspiratory efforts and a sensation of being unable to breathe. Associated laryngospasm can occur, which is a sudden hoarseness, with associated stridulous inspiratory efforts and a sensation of being unable to breathe.

Other condition bronchogenic carcinoma bronchogenic carcinoma metastatic carcinoma metastatic carcinoma sarcoidosis sarcoidosis chronic aspiration chronic aspiration interstitial lung disease interstitial lung disease left ventricular failure left ventricular failure Psychogenic or habit cough Psychogenic or habit cough Mediastinal tumor Mediastinal tumor

Other causes of cough in children congenital abnormalities (e.g., vascular rings, tracheobronchomalacia, pulmonary sequestration) congenital abnormalities (e.g., vascular rings, tracheobronchomalacia, pulmonary sequestration) mediastinal tumors mediastinal tumors foreign bodies in the airway or esophagus foreign bodies in the airway or esophagus aspiration aspiration heart disease. heart disease.

Complication of cough Hoarseness Hoarseness Tearing of muscle fiber Tearing of muscle fiber Rib fracture Rib fracture Headache &back pain Headache &back pain Inguinal hernia & incontinence Inguinal hernia & incontinence

codeine the methylether of morphine the methylether of morphine centrally acting antitussive drug centrally acting antitussive drug ineffective against acute cough of the common cold ineffective against acute cough of the common cold Drowsiness Drowsiness physical dependence physical dependence

Dextromethorphan non-narcotic antitussive, non-narcotic antitussive, a synthetic derivative of morphine a synthetic derivative of morphine no analgesic or sedative properties no analgesic or sedative properties