DIFFERENTIAL OF COUGH

DEFINITION:
An explosive expiration that provides a normal protective mechanism for clearing the
tracheobronchial tree of secretions and foreign material which is associated with
characteristic sound.

MECHANISM:

ABOUT 2.5 L of air inspired

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

Abdominal muscles contract forcefully pushing against the diaphragm

Internal intercoastal muscles also contract forcefully

vocal cords and epiglottis suddenly open widely ,air is expelled at velocities ranging from
75 to 100 miles /hr

The shearing forces that develops aid in the elimination of mucus and foreign material

COUGH REFLEX

The cough reflex arc is made up of three main pathways:

1. Sensory Afferent Pathway

The cough reflex arc is initiated by irritation of cough receptors, for example,
mechanoreceptors or chemoreceptors. Irritants are detected by these receptors and they send
sensory information to afferent nerves.

There are three main types of sensory nerve fibres involved in the afferent pathway:

 Rapidly Adapting Stretch Receptors (RARs)

o These are myelinated fibres found mostly in the pharynx and trachea which
rapidly respond to mechanical stimuli, e.g. changes in lung volumes
  Slowly Adapting Stretch Receptors (SARs)

o These are myelinated fibres which respond more slowly to mechanical stimuli
and are involved in the Hering-Breuer reflex

 C-fibres

o These are non-myelinated nerve fibres which respond to mechanical and

chemical stimuli

Sensory information travels from these fibres through the afferent pathway via the vagus
nerve to the medulla oblongata.

2. Central Pathway
Sensory information travels to the nucleus tractus solitarius (NTS) of the medulla. The vagus
nerve then synapses with motor neurones, delivering information to effector muscles which
triggers the cough reflex to occur.

3. Motor Efferent Pathway

Various respiratory muscles contract to allow initiation of the cough reflex.

 The diaphragm contracts to become flattened which increases the thoracic cavity
space
 The laryngeal muscles contract to close the vocal cords
 The external intercostal muscles contract to change the space available in the thoracic
cavity
 Rectus abdominis contracts to depress the rib cage and decrease space in the thoracic
cavity

IMPORTANCE
1) Defense mechanism (physiological natural reflex):

Providing a normal protective mechanism for clearing the tracheobronchial tree free of
secretions and foreign material

2) Complication of its force:

Excessive coughing can be exhausting; can be complicated by vomiting, syncope, muscular

pain or rib fractures; and can aggravate abdominal or inguinal hernias, urinary incontinence
and Uterine prolapse

3) Symptom of disease: Associated with many medical diseases and conditions

 HISTORY
1) Onset and Duration:
Acute: < 3weeks
Subacute: 3-8 weeks
Chronic: > 8 weeks

A. ACUTE COUGH

 UPPER RESPIRATORY TRACT INFECTIONS (URTI)

Viral syndromes
Sinusitis
 LOWER RESPIRATORY TRACT INFECTIONS (LRTI)
• URTI triggering exacerbations of chronic lung disease e.g. Asthma/COPD,
 Fever, chills , purulent sputum, pleuritic chest pain(Bacterial infections)
• Pneumonia, Bronchitis
 Left ventricular heart failure
 Inhalation of bronchial irritant (eg, smoke or fumes)
SUDDEN COUGH
Foreign body aspiration

Red flags in acute cough

Symptoms: -
o Hemoptysis- X ray -abnormal
Normal-HRCT- Endobronchial lesions
o Breathlessness-
o Fever - TB
o Chest Pain - Bouts of cough can cause fracture
o Weight Loss -+ smoking= TB

2) SUBACUTE COUGH
 POST INFECTIOUS: Prior infection irritates all cough receptors
A cough that begins with an acute respiratory tract infection and is not complicated by
pneumonia
 ATYPICAL CAP
Fever without chill,dry cough without sputum
CXR: Interstitial infiltration
Causative organisms: mycoplasma pneumonia
Chlamydia pneumonia
 PERTUSSIS-explosive cough with bouts of severe cough with whooping inspiration

**Not complicated = normal lung exam normal chest X-ray

Resolve without treatment
• Cause: PND or tracheobronchitis
• Indication for CXR: with automated biopsy needle (ABN) lung exam
-Sinusitis
- Asthma
3) CHRONIC COUGH
 SMOKER (Abnormal Chest X-ray):
1.COPD: dyspnoea, cough, sputum production
• Chronic Bronchitis, Emphysema, bronchiectasis
• CA Lung- large centre airways have more cough receptors, tumour in that
area provoke cough, cough persists after cessation of smoking
 NON-SMOKER (Normal Chest X-ray):
1. Drug (ACEI- Angiotensin Converting Enzyme Inhibitor- Captopril, Captopril,
Cilazapril, Enalapril, Fosinopril, Imidapril, Lisinopril, Moexipril, Perindopril,
Quinapril, and Ramipril)
• Occurs in 10 % patients who are on ACEI s
• These inhibits endogenous breakdown of bradykinin and substance P compounds that
can stimulate cough receptors
• Develops after 6 months on medication -enquiry about heart failure , HTN and
diabetes
• ACEI can be replaced by ARBS
2. UACS (UPPER AIRWAY COUGH SYNDROME)
PND-Post Nasal Drip
3.Asthma-Cough Variant Asthma (without dyspnoea and wheezing seen in (Allergic
rhinitis-atopy, skin allergy)
 • Broncho provocation test- Methacholine challenge test (also known as
bronchoprovocation test) is performed to evaluate how "reactive" or "responsive" your
lungs are. It can help your doctor evaluate symptoms suggestive of asthma, such as
cough, chest tightness and shortness of breath, and help diagnose whether or not you
have asthma.
4. GERD - Gastroesophageal regurgitation disease
• Common cause of chronic cough which occur at night while lying flat and in obese
patients with nocturnal cough
• Those experience sore throat and morning hoarseness

 NON-ASTHMATIC EOSINOPHILIC BRONCHITIS

• Characterised by non-productive chronic cough with a history of Atopy
• It is different from Asthma by lacking the airway hyperreactivity
• Methacholine challenge test will be normal
• Biopsy of bronchial mucosa can confirm the diagnosis which shows
plethora of eosinophils
 INTERTITIAL LUNG DISEASE
•

2) Character:
Bovine with Hoarseness: Left recurrent laryngeal nerve palsy causing left vocal cord
paralysis due to CA Lung

Barking with Hoarsness and Stridor: Acute Epiglottitis, Laryngitis, CA Larynx

Wheezy: COPD, Asthma

ADDED SOUNDS

3) Timing and associated features:

 Nocturnal : Asthma, CHF
Early Morning: Bronchiectasis, Chronic Bronchitis, Asthma
Recumbent : Postnasal drip (PND), CHF, Gastroesophageal reflux disease (GERD)
Change position (Standing): Bronchiectasis
4) With or without sputum:
Dry cough-without sputum: Causes of dry cough (Asthma, Viral infection of
respiratory system, Interstitial Lung Disease)
Productive cough - with sputum:
Causes of productive cough (Respiratory Infections, COPD, Bronchiectasis)
With or without blood: HYes / No – sputum
If yes, ask about


o Frequency of sputum (How frequent?)

 Cough continuously productive of purulent sputum is suggestive of
chronic bronchitis and bronchiectasis.


o Quantity of sputum (How much?)

o

o Appearance of sputum
 Is the sputum clear or discoloured?
 Is there any blood in the sputum
Hemoptysis with blood-TB, Pulmonary oedema, good Pasteur’s syndrome

COMPLICATIONS
CARDIOVASCULAR
 Arterial hypotension
 Loss of consciousness
 Rupture of subconjunctival, nasal and anal veins
 Dislodgement/malfunctioning of intravascular catheters
 Bradyarrhythmia’s, tachyarrhythmias
NEUROLOGICAL
 Cough syncope
 Headache
 Cerebral air embolism
 CSF rhinorrhea
 Acute cervical radiculopathy
 Malfunctioning ventriculoatrial shunts
 Seizures
 Stroke due to vertebral artery dissection

GASTROINTESTINAL
 Gastroesophageal reflux events
 Hydrothorax in peritoneal dialysis
 Malfunction of gastrostomy button
 Splenic rupture
 Inguinal hernia
GENITOURINARY
 Urinary incontinence
 Inversion of bladder through urethra

MUSCULOSKELETAL
From asymptomatic elevations of serum creatine phosphokinase to rupture of rectus
abdomens muscles Rib fractures