Respiratory defense mechanism to clear the airways of large amounts of Inhaled material Mucus/secretions Abnormal substances – edema fluid, pus, blood

1. Intractable and Refractory Cough
Jindal Clinics, Chandigarh

2. What is cough?
1. Respiratory defense
mechanism to clear the
airways of large amounts of
• Inhaled material
• Mucus/secretions
• Abnormal substances –
edema fluid, pus, blood
2. Receptor stimulation –Irritant
3. Warning symptom of an
illness
Cough is a vital protective reflex
preventing aspiration and
enhancing airway clearance.
Pathologically excessive and
protracted cough is a common
and disabling complaint: 5–10%
of the adult population.
When severe: major decrement
in the quality of life, with
comorbidities such as
incontinence, cough syncope and
dysphonia

3. Vigorous Cough: Complications
Intrathoracic pressures: Up to 300 mmHg;
Expiratory velocities: 28000 cm/s or 500 miles/h
Haemodynamic: Sys pr- Up to 140 mmHg
Energy 1 to 25 Joules
Respiratory
Exacerbation of asthma
Lung herniation
Laryngeal oedema
Air leaks, Tracheobron
trauma
Cardiovascular
Hypotension, Arrhythmias
Cath. malfunction
Venous rupture
Genitourinary
Incontinence, inversion
Gastrointestinal
GE reflux, Hernia,
Rupture (spleen)
Neurological
Syncope, seizures
Radiculopathy, Headache
Musculoskeletal
CPK, Rib fracture
• Miscellaneous
Constitutional, life style
changes, self
consciousness, fear, wound
disruption, petechiae,
purpura

4. Classification & Causes of cough
Acute cough: < 3 weeks;
no more than 28 days
• Upper respiratory tract
infections/ allergies
• Pneumonia of any cause
• TB
• Asthma
• CHF
• Pulm Embolism
Chronic cough – Cough that lasts
longer than 8 weeks in adults or 4
weeks in children.
• Common causes:
Asthma,
gastroesophageal reflux
disease, COPD or
bronchitis.
• Less commonly, it can
be a sign of a more
severe condition, such as
ILDs, heart disease.

5. Chronic refractory & intractable cough
Refractory Cough: Cough that persists despite
guideline based treatment- seen in 20-46% of patients
presenting to specialist cough clinics
Intractable Cough: Chronic cough whose aetiology is
not clear in spite of standard investigations
Uncommon and unrecognized causes:
Laryngeal neuropathy
Non-acid GE Reflux

6. Chronic cough or “cough hypersensitivity
syndrome”
The concept of cough hypersensitivity syndrome has been endorsed as an overarching
syndromic diagnosis and can be found concomitant with any of the other above causes
of chronic cough.
Cough is often triggered by changes in temperature, perfumes, aerosols, strong smells,
talking, laughing and singing.
Patients often describe sensations of ‘itch’, ‘irritation’ and ‘unpleasantness’ in the throat
region or even describe it as ‘something physically stuck on the throat’.
Chronic cough has also been described as “cough hypersensitivity syndrome” as many
patients have coughing which is triggered by exposure to low levels of thermal, chemical
or mechanical stimulation

7. Red flags for Chronic cough
Presence of one or more of the following signs/
symptoms
• Difficulty breathing/ shortness of breath.
• Shallow, rapid breathing.
• Wheezing. Chest pain. Fever.
• Coughing up blood or yellow or green phlegm.
• Severe coughing induced vomit.
• Unexplained weight loss.
Red flag may indicate a more serious infection (bronchitis,
pneumonia, TB, another respiratory infection), ILDs,
malignancy, Heart disease, PTE, others

8. Management Principles
• Symptomatic treatment
• Home and SOS remedies
• Identify the underlying cause and manage
accordingly: Chronic cough disappears once
the underlying problem is treated.
• Removal of triggers
• Psychosocial support
• Management of complications
• Maintenance treatment

9. Symptomatic: Anti-cough agents
Anti tussives (cough center suppressants)- for
dry unproductive cough: Inhibit cough reflex by
suppressing cough center in medulla; both centrally
and peripherally acting agents are available
• Pharyngeal demulcents (Soothing agents):
logenges, linctuses, liquorice
• Expectorants (Encourage expectoration): sodium
and potassium citrate, potassium iodide, guaiphensin,
ammonium chloride
• Mucolytics (Liquify thick mucus): bromhexine,
acetylcysteine, carbocisteine, ambroxol.