1. Cough and
Dr.Bilal Natiq Nuaman
Lecturer at Ibn-Sina Medical College
C.A.B.M. ,F.I.B.M.S. ,D.I.M. ,M.B.Ch.B.
‘A Cough is a forced expulsive
manoeuvre, usually against a closed
glottis and which is associated with a
Cough is the single most common respiratory
complaint for which patients seek care
4. Importance of Cough
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 .
5. 3-Symptom of disease (associated with many
medical diseases and conditions)
6. to others by air dropletstransmit infections-4
Diseases that are commonly spread by coughing or sneezing
• Bacterial Meningitis
• Common cold
• Strep throat
• Whooping cough
7. 5-Impaired Cough in a person
(due to Altered conscious level-
anesthesia, narcotics, sedatives, alcohol, coma, stroke, se
izure, SLEEP,and Neuromuscular diseases)
increase the risk for retained airway secretions and aspirated
material, predisposing to infection, atelectasis, and respiratory
1-Onset and Duration :
Acute : < 3weeks
Subacute :3-8 weeks
Chronic : > 8 weeks
Bovine with Hoarsness---- 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
9. 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 w/out 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 ,
5-With or w/out Blood :
Hemoptysis -------- With blood
11. 2-Amount of Sputum
How much sputum is coughed up each day ? Is it a small
(a teaspoonful) or large (a teacupful) amount?
Bronchiectasis-------- large amount of purulent sputum to be
coughed up mainly in morning on changing posture with a long
Rupture of a lung abscess ------ Sudden production of large
amounts of purulent sputum on a single occasion .
Pulmonary Oedema ------ Large volumes of watery sputum with a
pink tinge in an acutely dyspnic patient .
12. 3-Colour of Sputum
Clear Sputum ------- COPD if there is no active infection.
Yellow Sputum ------Acute lower respiratory tract
infection(neutrophils) , and Asthma (eosinophils)
Green Sputum(purulent) ------- COPD ,Bronchiectasis (dead
Rusty Sputum ------ Pneumococcal Pneumonia
Black Sputum -------- Coal Dust Inhalation
4-Foul Smelling ------- Anaerobic bacterial infection
, Bronchiectasis , Lung Abscess and Empyema .
1. Chronic Bronchitis :
defined clinically as Productive cough (cough with sputum
expectoration ) in a chronic smoker for at least 3 months
a year during a period of 2 consecutive years with
exclusion of other causes of productive cough .
2. Emphysema :
defined pathologically as an abnormal permanent
enlargement of air spaces distal to the terminal
bronchioles, accompanied by the destruction of alveolar
walls without obvious fibrosis.
18. Cough alone as a manifestation of asthma in the absence of
wheezing, shortness of breath, and chest tightness is referred
to as "cough-variant asthma
• Gold standard History (Episodic symptoms with specific
aggravating factors, Family history)
• Reversibility testing(Change in PFT before and after
• PEF monitoring(morning dipping of PEF serials)
• Bronchoprovocation test (if normal pulmonary function
The best way to confirm asthma as a cause of cough is to
demonstrate improvement in the cough with appropriate
therapy for asthma
19. • Post Nasal Drip refers to that sensation of having
excess secretions (either thick or thin) drip down the
back of your throat. Usually sinusitis, colds, allergies and
other upper respiratory disorders are followed by post
• Clinical Presentation:
• Dripping sensation , Tickle in the throat , Nasal
congestion , Mucus in oropharynx , Cobblestone
appearence of oropharynx
20. • Gastroesophageal reflux disease (GERD) refers to
acid reflux, or backward flow, of stomach acid and other
contents into the esophagus. If stomach acid moves backward
up the esophagus, reflexes result in spasm of the airways that
can cause shortness of breath and coughing. In some
individuals, no sensation of heartburn is felt and their only
symptom may be cough.
• 24-hour esophageal pH probe (best)
• OGD – Esophagogastrodudenoscope
Therapeutic trial: gastric acid suppression with proton pump
inhibitor (e.g. omeprazole) for ≥ 2 months, combined with diet and
21. ACE-Inhibitors and Chronic Cough
Onset: one week to six months
Bradykinin increase because it is Usually metabolized by
Treatment: switch to Angiotensin II Receptor Blockers (ARBs)
• Coughing up blood, irrespective of the amount, is an alarming
symptom and patients nearly always seek medical advice. A
history should be taken to establish that it is true haemoptysis
and not haematemesis, or gum or nose bleeding.
• Haemoptysis must always be assumed to have a serious cause
until this is excluded .
• A history of repeated small haemoptysis is highly suggestive of
• Fever, night sweats and weight loss suggest tuberculosis.
Pneumococcal pneumonia often causes 'rusty'-coloured
sputum but can cause frank haemoptysis, as can all
suppurative pneumonic infections including lung abscess.
Bronchiectasis can cause catastrophic bronchial
haemorrhage,, pulmonary thromboembolism is a common
cause of haemoptysis and should always be considered.
23. • Physical examination may reveal additional clues.
• Finger clubbing suggests bronchial carcinoma or
• other signs of malignancy, such as cachexia, hepatomegaly
and lymphadenopathy, should also be sought.
• Fever, pleural rub or signs of consolidation occur in pneumonia
or pulmonary infarction; a minority of patients with pulmonary
infarction also have unilateral leg swelling or pain suggestive of
deep venous thrombosis.
• Rashes, haematuria and digital infarcts suggest an underlying
systemic disease such as a vasculitis, which may be associated
24. • In the vast majority of cases the haemoptysis itself is not life-
threatening and a logical sequence of investigations should be
followed: chest X-ray, which may give evidence of a localised
lesion including pulmonary infarction, tumour (malignant or
benign), pneumonia, mycetoma or tuberculosis
• full blood count and clotting screen
• bronchoscopy after acute bleeding has settled, which may
reveal a central bronchial carcinoma (not visible on the chest X-
ray) and permit biopsy and tissue diagnosis
• CTPA, which may reveal underlying pulmonary thromboembolic
disease or alternative causes of haemoptysis not seen on the
chest X-ray (e.g. pulmonary arteriovenous malformation or
small or hidden tumours).
• Massive Hemoptysis:
• It is coughing of about 600ml blood/24 h