Cough Flashcards
(120 cards)
What is the definition of acute, subacute, and chronic cough?
Acute cough: <3 weeks
Subacute cough: 3-8 weeks
Chronic cough: >8 weeks
What is the most common cause of acute cough?
Upper respiratory infection (URI)
What are common causes of subacute cough?
Post-infectious cough, pertussis, or resolving pneumonia.
A 40-year-old man presents to the primary care clinic due to a dry cough that started five weeks ago. He initially attributed it to “allergies,” but the cough has not improved. He also experienced a runny nose, nasal congestion, and frequent throat clearing over this same period. He has not experienced itchy or red eyes, a sour taste in the mouth in the morning, or substernal burning. He has no known medical history, takes no medication, and is not aware of any medication or food allergies. Vital signs are within normal limits. On physical examination, he is well-appearing with no rashes and no conjunctival injection or discharge. Tiny amounts of drainage are seen at the posterior oropharynx. The lungs are clear to auscultation. What additional findings would be present on physical examination?
When patients present with subacute or chronic cough and a negative chest x-ray, a thorough history and physical examination are often sufficient to diagnose the cause. Patients with upper airway cough syndrome may have frequent throat clearing, rhinorrhea, nasal congestion, and a cobblestone appearance of the posterior oropharynx. This patient, presenting with a subacute cough (3-8 weeks), rhinorrhea, nasal congestion, and frequent throat clearing, likely has upper airway cough syndrome (UACS; commonly known as “post-nasal drip”). It can be allergic or nonallergic. A cobblestone appearance of the oropharynx would be consistent with this diagnosis. Evaluation of a patient with subacute or chronic requires a thorough history and physical exam, and often chest radiography. A detailed history should include questions about the frequency, quality, and degree of sputum production associated with the cough. For example, patients with bronchiectasis tend to have copious sputum production, whereas patients with UACS may have minimal sputum, and patients with gastroesophageal reflux disease (GERD) have none. Environmental exposures, known allergies, and tobacco use should also be explored. Associated symptoms may also point toward the underlying etiology, such as heartburn (GERD), shortness of breath (asthma or COPD), an abnormal sensation in the throat, or frequent throat clearing (UACS). Physical examination should include examination of the ears, nose, throat, and lungs. Patients with UACS may have a cobblestone appearance of the posterior oropharynx (as seen in the image below). Alternatively, individuals with COPD may have a prolonged expiratory phase, and wheezing can be present in patients with severe GERD or asthma. However, lung sounds are normal in UACS, GERD, and nonasthmatic eosinophilic bronchitis.
What are the common causes of chronic cough?
- Atypical pneumonia
- Asthma
- GERD
- Postnasal drip (upper airway cough syndrome)
- Non-asthmatic eosinophilic bronchitis
- COPD
- Interstitial lung disease
- Lung cancer
- Bronchiectasis
- Medication side effects (ACE inhibitors)
What are the two most common causes of chronic cough?
Gastroesophageal reflux disease (GERD) and upper airway cough syndrome (UACS) (postnasal drip) are 2 of the most common causes of chronic cough. Patients with GERD typically have accompanying symptoms of reflux and heartburn following meals. In patients with UACS, accompanying rhinorrhea is expected, and oropharyngeal cobblestoning is often present on examination.
What is the most common cause for non-diseased cough?
ACE inhibitor use. This can occur at ANY time following use (weeks, months, years). Most commonly symptoms arise within 1-2 weeks.
How does ACE inhibitor-induced cough present?
Dry, hacking cough of starting an ACE inhibitor. However, this can occurred at any time after use of this medication.
What is the treatment for chronic cough due to ACE inhibitors?
Stop the ACE inhibitor and switch to an ARB.
What condition describes a chronic nonproductive cough that is typically worse at night and triggered by exercise or forced expiration, and allergen exposure?
Cough-variant asthma. This condition presents with a chronic nonproductive cough that is typically worse at night and triggered by exercise, forced expiration, and allergen exposure. The diagnosis can be challenging as these patients typically lack classic asthma symptoms (eg, wheezing, shortness of breath) and physical examination is often largely unremarkable, even during periods of active symptoms. This is a cough is due to asthma, and although most patients are diagnosed during childhood, this disease can present at any age. Patients typically have intermittent wheezing and shortness of breath; however, a subset of patients instead have a chronic nonproductive cough as the predominant symptom, a condition termed cough-variant asthma. The cough is typically triggered by exercise (especially in cold temperatures) or forced expiration and commonly occurs at night. Accompanying chest tightness is often present. Allergens (eg, dust mites, mold) are also common triggers. Some more exoctic causes are due to work in air conditioning repair that leads to frequent allergen exposure. Wheezing and rhonchi are typically absent on physical examination in patients with cough-variant asthma. The diagnosis is typically made by a combination of clinical presentation and pulmonary function testing that demonstrates inducible airway obstruction (eg, positive methacholine challenge). Treatment is essentially the same as for classic asthma and takes into account symptom severity to determine the appropriate level of initial therapy. In some patients with cough that is refractory to bronchodilators and inhaled corticosteroids, leukotriene receptor antagonists (eg, montelukast) have shown efficacy.
What is the first step in evaluating an acute cough?
Assess for instability (ABC evaluation) and determine if urgent intervention (e.g., oxygen, IV fluids, intubation) is required. Once stabilized, perform a chest X-ray. Conditions to consider for patients with a new cough and a normal chest radiograph include gastroesophageal reflux disease, allergies, pulmonary embolism, viral bronchitis, and cough caused by medications such as angiotensin-converting enzyme (ACE) inhibitors. For patients with an abnormal chest radiograph, a dense infiltrate or opacity may indicate bacterial pneumonia, while chronic bronchiectasis changes and new tram-track opacities may indicate a bronchiectasis exacerbation in patients with known bronchiectasis. Patients with signs and symptoms consistent with volume overload may have new onset or exacerbation of congestive heart failure (CHF). Signs of CHF include clinical findings such as peripheral edema and pulmonary crackles and radiographic findings may include pleural effusion, pulmonary edema, Kerley B lines, and an enlarged heart. Patients with CHF often experience orthopnea and paroxysmal dyspnea. While wheezing is often associated with obstructive lung disease, mild wheezing can also be present in CHF exacerbation.
What are the indications for antibiotic use in a patient with COPD experiencing an acute exacerbation?
A cough productive of greenish-yellow sputum, dyspnea, and wheezing with a history of chronic obstructive pulmonary disease (COPD) are suggestive of acute COPD exacerbation. Antibiotics are generally not recommended for management of acute bronchitis in otherwise healthy individuals as most exacerbations are of viral etiology. However, guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend antibiotic therapy for patients who have a COPD exacerbation with any two of the following features: increased sputum purulence, increased sputum volume, or increased dyspnea. Antibiotics are also recommended for those requiring mechanical ventilation (noninvasive or invasive).
A 66-year-old man presents to clinic for evaluation of a persistent cough over the past five months. The cough is intermittent and usually dry, but sometimes productive of a small amount of yellow sputum. He has tried nasal saline rinses, oral famotidine, and oral prednisone without relief. The patient quit smoking three months ago, after smoking one pack per day for 40 years, but the cough remains unchanged. He could previously walk up a flight of stairs without stopping but now must stop halfway up to catch his breath. A recent transthoracic echocardiogram was normal.
Temperature is 37.4 °C (99.3 °F), pulse is 84/min, respiratory rate is 18/min, blood pressure is 133/82 mmg, and oxygen saturation is 95% on room air. On physical examination, he is well-appearing, and the posterior oropharynx is unremarkable. lungs are clear to auscultation bilaterally, but expiration is much longer than inspiration. An in-office chest radiograph is unremarkable. Which of the following treatments would be most appropriate now?
This 66-year-old man with a 40-pack-year smoking history presents with a chronic cough (sometimes with sputum production), dyspnea, and low-normal room air oxygen saturation, raising the concern for chronic obstructive pulmonary disease (COPD). The lack of response to other treatments further supports this concern. Pulmonary function tests are indicated to confirm the diagnosis, and a trial of long-acting bronchodilators would be appropriate treatment.
A chest radiograph can help in the evaluation of subacute or chronic cough. An abnormal chest radiograph is often present in atypical pneumonia, severe bronchiectasis, lung cancer, and interstitial lung disease. While early COPD may present with a normal chest radiograph, advanced COPD will generally have abnormal findings such as hyperinflated lungs. In patients with a normal chest radiograph, it is crucial to review the history and physical thoroughly. If the diagnosis is unclear, further testing with pulmonary function tests (for suspected asthma or COPD) or a sputum analysis (for suspected nonasthmatic eosinophilic bronchitis) may be warranted. In other cases, starting a medication trial can be an appropriate next step. This strategy may be most relevant when gastroesophageal reflux disease (GERD) or upper airway cough syndrome (UACS) are suspected. For patients with subacute or chronic cough and a normal chest radiograph, consider further testing or a medication trial. If asthma or COPD is suspected, pulmonary function tests are appropriate to differentiate the two. Long-acting bronchodilators are recommended for the initial treatment of COPD. If they provide relief of symptoms, that would support a diagnosis of COPD.
What are high-risk features in a patient with acute cough that require immediate intervention?
- Hemoptysis
- Hypoxia
- Tachypnea
- Hypotension
- Altered mental status
- Concern for pulmonary embolism (PE) or pneumonia
What is the most common cause for hemoptysis?
Acute bronchitis.
A 50-year-old woman presents to the urgent care with three days of cough associated with sinus congestion and postnasal drip. She has also had fatigue and myalgias. She does not smoke. Past medical history is unremarkable. Temperature is 36.8 °C (98.2 °F), pulse is 90/min, respiratory rate is 20/min, blood pressure is 126/82 mmHg, and Sp02 is 98% on room air. On physical examination, the patient is well-appearing. There is no jugular venous distention. There are coarse breath sounds in both lung fields which improve after the patient is asked to cough. Faint wheezing is heard in the upper left lobe. There is no peripheral edema. A chest radiograph is obtained and shows no pacifications or effusions. What is the most likely diagnosis?
This patient presenting with new onset cough, postnasal drip, sinus congestion and systemic symptoms (fatigue, myalgias). On physical exam, she is found to have coarse breath sounds which improve with coughing and faint wheezing in the left upper lobes. Together, these suggest acute bronchitis as the etiology of her cough, which is usually managed with supportive care. The evaluation of an acute cough (less than 3 weeks) begins with a thorough history and physical exam. Patients with viral bronchitis can present with an acute cough, coarse breath sounds that clear with coughing, and occasionally wheezing. They typically have other signs and symptoms of a viral upper respiratory illness (congestion, postnasal drip). Chest radiograph can be useful to rule out other conditions when the clinical picture is unclear, but the diagnosis of viral bronchitis can generally be made with history and physical examination alone. Covering factors such as infectious exposures, environmental exposures, smoking history, and medications. Physical exam should focus on assessing for abnormal pulmonary sounds, evidence of volume overload, as well as evaluating for any related systemic signs. While it is not always necessary in a clear viral upper respiratory infection, a chest radiograph can be performed for patients presenting with an acute cough. For patients with new onset cough and sinus tachycardia, hypoxemia, unilateral leg swelling or chest pain, consider pulmonary embolism. Chest radiography will typically be normal in pulmonary embolism, therefore computed tomography of the chest should be performed to confirm the diagnosis. Exacerbation of chronic obstructive pulmonary disease (COPD) should be suspected in patients with known COPD who present with dyspnea, a cough, and a notable change in sputum character and quantity. Acute bronchitis may present with a viral syndrome and coarse breath sounds that clear with coughing. Wheezing is also common in acute bronchitis due to airway inflammation and resultant turbulent air flow. For patients with an abnormal chest radiograph, consider bacterial pneumonia, malignancy, bronchietasis exacerbation and congestive heart failure.
What is the source of hemoptysis the majority of the time?
Brachial arteries.
What characteristic guides management for hemoptysis?
The volume of blood expectorated will influence the initial management of hemoptysis. The most common sources for blood are the brachial arteries secondary to airway disease (bronchitis, bronchiectasis, neoplasm, trauma, or iatrogenic), parenchymal disease (infection, autoimmune, connective tissue disease), or vascular (PE or AVM). Less than 500 mL is mild to moderate and above 500 mL or above 100 mL per hour is considered massive. For mild and moderate cases, ensure to work up and treat the underlying cause, but an XR usually is indicated initially, followed by CT scan, to help guide diagnosis and treatment (flexible bronchoscopy can also be performed but this is usually reserved for active bleeding). For Massive blood loss, establish an airway if indicated and manage hemodynamics. Massive blood loss usually requires a flexible bronchoscopy with electrical cautery or balloon tamponade. If these measures fail, perform an arteriographic embolization.
What are the major pulmonary causes for hemoptysis?
Infectious (TB, Lung abscess, Bacterial pneumonia, Aspergillosis), malignancy, or bronchiectasis. Airway inflammation in acute bronchitis can cause erosion of the superficial vessels, leading to hemoptysis, which is usually scant or small in volume.
What are the major hematological causes for hemoptysis?
PE or coagulopathy
What is the major vascular cause for hemoptysis?
AVMs
What are Systemic diseases causes for hemoptysis?
Granulomatosis with polyangiitis or Goodpasture syndrome
What are the cardiac causes for hemoptysis?
Mitral stenosis or acute pulmonary edema from heart failure.
Given the wide range of underlying causes for hemoptysis, what is the best imaging modality for hemoptysis?
Chest x-ray abnormalities may suggest a variety of specific causes in patients with hemoptysis, including malignancy, focal infection (eg, pulmonary tuberculosis), or heart disease (eg, mitral disease). Plain chest radiograph remains the initial test of choice as it may identify the site and cause of bleeding (eg, cavitary lesion, lung mass, or stigmata of mitral stenosis) in over one-third of patients. In combination with the clinical picture, a chest radiograph may also help direct further management (bronchoscopy versus CT scan).
