Chronic cough. Self study materials for medical students.
Download as PPTX, PDF14 likes3,477 views
This document provides an overview of chronic cough, including its definition, physiology, causes, and management. Some key points: - Chronic cough is defined as lasting 8 weeks or longer in adults and 4 weeks in children. It is a common reason for visiting a primary care physician. - Common causes of chronic cough include postnasal drip, asthma, GERD, COPD, and less commonly, bronchiectasis, use of ACE inhibitors, and occult infection. - The cough reflex involves irritation of cough receptors triggering afferent and efferent pathways that lead to forced expulsion of air to clear irritants from the lungs. - Evaluation of chronic cough includes assessing duration
Chronic cough. Self study materials for medical students.
- 1. ProPowerPoint.Ru Chronic cough Dr. Anton Litvin Assistant professor Department of Internal Medicine V. N. Karazin Kharkiv National University Self study materials for students 6th year, Internal Medicine, Pulmonology circle Topic 1. Management of patients with chronic cough syndrome
- 2. ProPowerPoint.Ru Definition Cough (Latin: tussis): 1) is a sudden and often repetitively occurring reflex which helps to clear the large breathing passages from secretions, irritants, foreign particles and microbes; 2) is an expelling of air or solid matter from the lungs abruptly and explosively through the partially closed vocal chords.
- 3. ProPowerPoint.Ru Cough reflex • Cough reflex is the basis of cough as a protective mechanism. • Coughing may be initiated either voluntarily or reflexively. • It has both sensory (afferent) and motor (efferent) components. • Pulmonary irritant receptors (cough receptors) in the epithelium of the respiratory tract are sensitive to both mechanical and chemical stimuli.
- 4. ProPowerPoint.Ru Physiology • Stimulation of the cough receptors by foreign particles (dust, mucus, etc.) produces a cough, which is necessary to remove the foreign material from the respiratory tract before it reaches the lungs. • The anatomical structures that perform afferent component of cough reflex are cough center (in medulla), vagus nerve, irritant receptors (in trachea and larynx).
- 5. ProPowerPoint.Ru Physiology • The efferent neural pathway brings relevant signals back from the cerebral cortex and medulla via the vagus and superior laryngeal nerves to the glottis, external intercostals, diaphragm, and other major inspiratory and expiratory muscles.
- 6. ProPowerPoint.Ru Physiology https://www.youtube.com /watch?v=4Tcfp5Kf2WE
- 7. ProPowerPoint.Ru Cough mechanism • Diaphragm and external intercostal muscles contract, creating a negative pressure around the lung. • Air rushes into the lungs in order to equalise the pressure. • The glottis closes and the vocal cords contract to shut the larynx.
- 8. ProPowerPoint.Ru Cough mechanism • The abdominal muscles contract to accentuate the action of the relaxing diaphragm (to increase the pressure of air within the lungs). • The vocal cords relax and the glottis opens, releasing air at over 100 mph. • The bronchi and non-cartilaginous portions of the trachea collapse to form slits through which the air is forced, which clears out any irritants attached to the respiratory lining.
- 9. ProPowerPoint.Ru Cough phases Irritation Inspiration Compression Expulsion http://web.missouri.edu/~danneckere/pt316/case/pulm/cough-4phases.jpg
- 10. ProPowerPoint.Ru Summary The cough starts with a deep inspiration followed by glottic closure, relaxation of the diaphragm, and muscle contraction against a closed glottis. It is the most frequent symptom of respiratory disease.
- 11. ProPowerPoint.Ru Classification • Duration • Quality • Characteristic • Timing http://img.thesun.co.uk/aidemitlum/archive/00874/cough-280_874576a.jpg
- 12. ProPowerPoint.Ru Duration • Acute (< 3 weeks) • Subacute (3 – 8 weeks) • Chronic (> 8 weeks) http://images.wisegeek.com/man-coughing-in-red-shirt.jpg
- 13. ProPowerPoint.Ru Quality • Dry (non-productive) • Wet (productive) •Laryngitis •Dry pleurisy •Smoking cough •Debut of diseases •Acute viral diseases •Bronchitis •Pneumonia •Tuberculosis •Bronchiectatic disease
- 14. ProPowerPoint.Ru Characteristic • Barking • Whooping • Staccato • Hoarse • Brassy • Rattling • Loose • Moist • Bovine • Wheezy = Croup = Pertussis
- 15. ProPowerPoint.Ru Timing • Morning cough (“wash up cough”) – smokers cough • Day cough • Night cough (“nocturnal cough”) • All day long cough • Spring/Autumn – allergological cough • Winter – asthma, bronchitis, ARD
- 16. ProPowerPoint.Ru Threatening symptoms • Cough with increasing intensity that lasting for week and more • Cough accompanied by hyperthermia above 38 °C during 3 days or more • Cough accompanied by dyspnea and thoracic pain on breathing • Hemoptysis • Cough with dyspnea • Cough, weakness and weight loss
- 17. ProPowerPoint.Ru Threatening symptoms • Excessive sweating, shivering • Sudden attack of severe cough • Severe cough during an hour without any interval • Abundant expectoration of sputum
- 18. ProPowerPoint.Ru Chronic cough • Chronic cough is defined as lasting eight weeks or longer in adults, four weeks in children. http://www.productive-cough.com/wp- content/uploads/2014/11/productive-cough-treatment.jpg
- 19. ProPowerPoint.Ru Epidemiology • A cough is the most common reason for visiting a primary care physician in the United States. • Chronic cough is estimated to occur in up to 40% of the population. • Risk factors include atopy and smoking. Cough may be work-related and a thorough occupation history is very important in assessment.
- 20. ProPowerPoint.Ru Etiology • An exogenous source (smoke, dust, fumes, foreign bodies, patogens) • An endogenous origin (upper airway secretions, gastric contents, patogens)
- 21. ProPowerPoint.Ru These factors result in inflammation, constriction, infiltration, or compression of airways and are associated with cough.
- 22. ProPowerPoint.Ru Common causes • Postnasal drip (38-87%) • Asthma (14-43%) • GERD (10-40%) • COPD (0-12%) • More than one cause (24-72%)
- 23. ProPowerPoint.Ru Post-nasal drip Post-nasal drip (PND) - a drop-by-drop discharge of nasal mucus into the posteriorpharynx caused by rhinitis,chronic sinusitis, or hypersecretion by the nasopharyngeal mucosa. PND Sore throat http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/media/medical/hw/n1820.jpg
- 24. ProPowerPoint.Ru Post-nasal drip • Caused by allergic and infection otolaryngologic diseases • Often accompanied by a feeling of obstruction, an unpleasant taste, and fetid breath • Treatment include the application of drops or sprays of phenylephrine or epHEDrine sulfate to constrict blood vessels and reduce hyperemia, sinusirrigation to improve drainage and use of appropriate antibiotics
- 25. ProPowerPoint.Ru Post-nasal drip • Therapy for allergies may be indicated in some cases, and surgery maybe required if the nasal passages are obstructed by polyps or a deviated septum. http://i.doctorpiter.ru/photos/2012/11/350x650_Xf78ljyq4BLt89YSeqK2.jpg
- 26. ProPowerPoint.Ru Asthma Asthma is a common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction and bronchospasm. http://www.webwhispering.net/wp-content/uploads/2011/01/AsthmaWoman.jpg
- 27. ProPowerPoint.Ru Asthma Common symptoms include wheezing, coughing, chest tightness, and shortness of breath. http://cdn-2.normalbreathing.com/d/asthma-bronchoconstriction-mechanism.jpg
- 28. ProPowerPoint.Ru GERD Gastroesophageal reflux disease (GERD) is a chronic condition in which the lower esophageal sphincter allows gastric acids to reflux into the esophagus, causing heartburn, acidi ndigestion, and possible injury to the esophageal lining. http://www.drugs.com/health-guide/images/205069.jpg
- 29. ProPowerPoint.Ru GERD There are two main mechanisms of cough in GERD: • Micro or macro-aspiration of esophageal contents into the tracheo-bronchial tree. • Acid in the distal esophagus stimulating a vagally mediated esophageal- tracheobronchial cough reflex.
- 30. ProPowerPoint.Ru COPD • Chronic obstructive pulmonary disease (COPD) is the set of progressive lung diseases that characterized by irreversible airway obstruction. http://pngimg.com/upload/cigarette_PNG4763.png
- 31. ProPowerPoint.Ru COPD COPD includes: • Chronic Bronchitis is characterized by –Chronic inflammation and excess mucus production –Presence of chronic productive cough • Emphysema is characterized by –Damage to the small, sac-like units of the lung that deliver oxygen into the lung and remove the carbon dioxide –Chronic cough
- 33. ProPowerPoint.Ru COPD Causes: • Smoking • Occupational exposures • Air pollution • Genetics
- 34. ProPowerPoint.Ru Less common causes • Bronchiectasis • Use of ACE inhibitors • Post-infectious • Lung Cancer • Occult congestive heart failure • Interstitial Pulmonary Fibrosis • Occult infection • Foreign body
- 35. ProPowerPoint.Ru Less common causes • Problems with: – Auditory canal – Larynx – Diaphragm – Pleura – Pericardium – Esophagus • Psychogenic (habitual cough)
- 36. ProPowerPoint.Ru Bronchiectasis Bronchiectasis is a disease in which there is permanent enlargement (widening, dilatation) of parts of the airways of the lung. Symptoms typically include a chronic cough with sputum production.
- 38. ProPowerPoint.Ru Use of ACE inhibitors • Angiotensin-converting-enzyme inhibitors (ACE inhibitors) are a group of medicaments used primarily for the treatment of arterial hypertension and congestive heart failure. • Frequently prescribed ACE inhibitors include perindopril, captopril, enalapril, lisinopril, and ramipril. http://shop.farmvet.com/c.1220551/images/item-pics/enalapril-Maleate-lg.jpg
- 39. ProPowerPoint.Ru Use of ACE inhibitors • ACE inhibitors cause a nonproductive cough in 5 to 20% of patients. • The cough is usually dry and hacking. • This effect is not dose related, and the cough may begin 1 week to 6 months after therapy is initiated. http://www.rxvietnamstore.com/product_images/v/519/CAPTOPRIL_25mg__71878_zoom.jpg
- 40. ProPowerPoint.Ru Use of ACE inhibitors • The cough should spontaneously resolve a few days to several weeks after the ACE inhibitor is discontinued. • A 4 week trial of withdrawal is usually sufficient to determine whether the medication caused the cough. http://www.dhgpharma.com.vn/dhg/images/stories/virtuemart/product/perindopril_4_4f4e2e9f2b942.jpg
- 41. ProPowerPoint.Ru Psychogenic cough • Psychogenic cough ("habit cough" or "tic cough") is a persistent cough due to a tic or to psychological causes. • May be the cause in the absence of a physical problem. • Common in children, women, hypochondriacs. • Characterized by a small, harsh tinny type sound, and becomes persistent for weeks to months.
- 42. ProPowerPoint.Ru Psychogenic cough • Can reach severe frequency, even a cough every 2–3 seconds. • These patients do not cough during sleep, are not awakened by cough, and generally do not cough during enjoyable distractions. • Any other pathologic cough will not totally stop at night. • A habitual cough is a diagnosis of exclusion.
- 44. ProPowerPoint.Ru Complications Acute: • Cough syncope • Insomnia • Womiting • Pneumothorax, pneumomediastinum, subcutaneous emphysema • Subconjunctival hemorrhage (red eye) • Coughing defecation and urination
- 45. ProPowerPoint.Ru Complications Chronic: • Abdominal or pelvic hernias • Fatigue fractures of lower ribs • Costochondritis
- 46. ProPowerPoint.Ru Complications That’s a nasty cough you’ve got there! https://c1.staticflickr.com/1/3/4573720_b681299daf.jpg
- 47. ProPowerPoint.Ru Red Flags • Massive sputum production (bronchiectasis). • Systemic symptoms - fever, sweats, weight loss (tuberculosis, lymphoma, bronchial carcinoma). • Haemoptysis (tuberculosis, bronchial carcinoma). • Significant dyspnoea (heart failure, COPD, fibrotic lung disease).
- 48. ProPowerPoint.Ru Diagnostics • Detailed history • Physical examination • Laboratory tests • Chest radiography • Pulmonary function testing • Gross and microscopic examination of sputum • High-resolution computed tomography (HRCT) • Fiberoptic bronchoscopy
- 51. ProPowerPoint.Ru Medicines These groups of drugs are used for symptomatic cough care: • Antitussives • Expectorants • Mucolytics
- 52. ProPowerPoint.Ru Antitussives • Antitussives are agents that suppress cough by depressing the cough center in the medulla oblongata or the cough receptors in the throat, trachea, or lungs.
- 53. ProPowerPoint.Ru Antitussives There are 3 groups of antitussives: 1. Centrally acting antitussives: • narcotics (Codeine, Hydrocodone) • non-narcotics (Dextromethorphan, Sinecod) 2. Locally acting agents (throat lozenges, cough drops, syrups) may suppress cough by increasing the flow of saliva and by containing demulcents or local anesthetics to decrease irritation of pharyngeal mucosa (Libexin, Linkus). 3. Combined (Tussin DM = Dextromethorphan + Guaifenesin)
- 54. ProPowerPoint.Ru Antitussives The only indication is a dry, hacking, non-productive cough that interferes with rest and sleep. It occurs: • Laryngitis • Tumors of airways • Pleuritis • Debut of ARD • COPD http://www.ve.all.biz/img/ve/catalog/7573.jpeg
- 55. ProPowerPoint.Ru Antitussives. Precautions. It is not desirable to suppress a productive cough due to a risk of mucus congestion. So you shouldn’t use them: • Acute bronchitis • Pneumonia • Cystic fibrosis • Etc. https://www.ubuy.com.kw/images/productImages/3659/3659-242012154550.jpg
- 56. ProPowerPoint.Ru Expectorants • Expectorants increase the amount or hydration of secretions, resulting in more yet clearer secretions and as a byproduct lubricating the irritated respiratory tract. http://ingalin.ru/wp-content/uploads/2014/01/grudnoj-sbor-dlya-detej.jpg
- 57. ProPowerPoint.Ru Expectorants • Guaifenesin is the most commonly used expectorant. It is available alone and as an ingredient in many combination cough and cold remedies. • Other expectorants (hot beverages, potassium iodide) stimulate production of watery mucus. https://www.medicinep.com/wp-content/uploads/2011/12/guaifenesin.jpg
- 58. ProPowerPoint.Ru Mucolytics • Mucolytics dissolve thick mucus by dissolving various chemical bonds within secretions and is usually used to help relieve respiratory difficulties. • Ambroxol and Acetylcysteine (Mucomyst, ACC) are the only agents recommended for use as mucolytics. https://cdn-img.aponeo.de/06197481-acc-akut-600-brausetabletten-b1.jpg
- 59. ProPowerPoint.Ru Expectorants & Mucolyeics • Both expextorants and mucolytics help to liquefy respiratory secretions and allow for their easier removal. • Sometimes they are united in one group of drugs – mucokinetics.
- 61. ProPowerPoint.Ru Summary • These drugs may relieve symptoms but do not cure the disorder causing the symptoms.
- 62. ProPowerPoint.Ru Summary • The patient should avoid eating and drinking for approximately 30 minutes after taking cough syrups. • Food or fluid removes the medication from the throat.
- 63. ProPowerPoint.Ru Summary • Don’t try to cure the chronic cough. Try to find and cure the reason of the cough!!!
Editor's Notes
- #3: http://en.wikipedia.org/wiki/Cough http://www.collinsdictionary.com/dictionary/english/coughing
- #4: http://en.wikipedia.org/wiki/Cough_reflex
- #5: http://en.wikipedia.org/wiki/Cough_reflex#Physiology
- #6: http://en.wikipedia.org/wiki/Cough_reflex#Physiology
- #8: http://en.wikipedia.org/wiki/Cough_reflex#Physiology
- #9: http://en.wikipedia.org/wiki/Cough_reflex#Physiology
- #10: http://web.missouri.edu/~danneckere/pt316/case/pulm/cough-4phases.jpg
- #11: https://books.google.com.ua/books?id=L7pW3yGjj7kC&printsec=frontcover#v=onepage&q&f=false Api Textbook of Medicine edited by Yash Pal Munjal, Surendra K. Sharma, M.D. Ph.D., A. K. Agarwal, M. D., Pritam Gupta, M.D. page 25
- #17: intranet.tdmu.edu.ua/data/kafedra/theacher/klinpharm/meretskaiv/English/Lectures/Clinical%2520Pharmacy/PHARMACEUTICAL/5%2520year/Ph_%2520guidelines%2520%2520breathingCOUGH.ppt+&cd=1&hl=en&ct=clnk&gl=ua
- #18: intranet.tdmu.edu.ua/data/kafedra/theacher/klinpharm/meretskaiv/English/Lectures/Clinical%2520Pharmacy/PHARMACEUTICAL/5%2520year/Ph_%2520guidelines%2520%2520breathingCOUGH.ppt+&cd=1&hl=en&ct=clnk&gl=ua
- #20: Goldsobel AB, Chipps BE (March 2010). "Cough in the pediatric population". J. Pediatr. 156 (3): 352–358.e1 http://www.cdc.gov/nchs/data/series/sr_10/sr10_260.pdf
- #23: http://image.slidesharecdn.com/cough-140901031949-phpapp02/95/cough-6-638.jpg?cb=1409559647
- #24: http://www.webmd.com/allergies/postnasal-drip http://en.wikipedia.org/wiki/Post-nasal_drip
- #25: http://www.webmd.com/allergies/postnasal-drip http://en.wikipedia.org/wiki/Post-nasal_drip
- #26: http://www.webmd.com/allergies/postnasal-drip http://en.wikipedia.org/wiki/Post-nasal_drip
- #27: http://en.wikipedia.org/wiki/Asthma
- #29: http://dictionary.reference.com/browse/gastroesophageal+reflux
- #30: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3740808/
- #31: http://www.aafp.org/afp/2006/0215/p669.html
- #33: http://www.earthtimes.org/newsimage/tai-chi-therapy-copd_29812.jpg
- #35: http://www.merckmanuals.com/professional/pulmonary_disorders/symptoms_of_pulmonary_disorders/cough_in_adults.html
- #36: http://www.merckmanuals.com/professional/pulmonary_disorders/symptoms_of_pulmonary_disorders/cough_in_adults.html
- #37: http://medical-dictionary.thefreedictionary.com/Bronchiectasis
- #39: http://en.wikipedia.org/wiki/ACE_inhibitor
- #40: http://hyper.ahajournals.org/content/51/6/1465.full
- #41: http://hyper.ahajournals.org/content/51/6/1465.full
- #42: http://www.ncbi.nlm.nih.gov/pubmed/16428707 http://en.wikipedia.org/wiki/Habit_cough
- #43: http://en.wikipedia.org/wiki/Habit_cough
- #44: http://i.dailymail.co.uk/i/pix/2013/10/02/article-0-1870C3F100000578-315_634x635.jpg
- #45: http://journal.publications.chestnet.org/pdfaccess.ashx?ResourceID=2118451&PDFSource=13 http://www.patient.co.uk/doctor/chronic-persistent-cough-in-adults
- #46: http://journal.publications.chestnet.org/pdfaccess.ashx?ResourceID=2118451&PDFSource=13 http://www.patient.co.uk/doctor/chronic-persistent-cough-in-adults
- #47: https://c1.staticflickr.com/1/3/4573720_b681299daf.jpg
- #48: http://www.patient.co.uk/doctor/chronic-persistent-cough-in-adults
- #52: http://www.rmj.ru/articles_5817.htm
- #53: http://www.drugs.com/drug-class/antitussives.html
- #54: http://kashelb.com/lekarstva-ot-kashlya/38-preparaty-ot-kashlya
- #55: http://kashelb.com/lekarstva-ot-kashlya/38-preparaty-ot-kashlya
- #61: http://cdn.someecards.com/someecards/usercards/1342056317524_5416634.png