• Nasal partNasal part
• Oral PartOral Part
• Laryngeal PartLaryngeal Part
Functions of Pharynx:Functions of Pharynx:
Respiratory:Respiratory: Air passes thru the nasal & oral parts.Air passes thru the nasal & oral parts.
Air is further warned & moistenedAir is further warned & moistened
Digestive:Digestive: Food passes thru, oral & laryngeal partsFood passes thru, oral & laryngeal parts
Principles of Anatomy & Physiology, Tortora, 1996, pg 708
Lies in front of pharynx.Lies in front of pharynx.
After puberty, grows larger in the male which explainsAfter puberty, grows larger in the male which explains
the prominence of the ‘the prominence of the ‘Adam’s appleAdam’s apple’ and deeper voice.’ and deeper voice.
Speech consists of manipulation of sound produced
by vocal cords, tongue, cheeks.
• Passage way for air between pharynx & trachea (air
further moistened, filtered, warmed)
• Vocal cords produce sounds of various loudness &
• During swallowing larynx moves upwards
occluding the opening into it from the pharynx
Trachea :Trachea :
12 cm long12 cm long
Diameter 2 .5 cmDiameter 2 .5 cm
Cartilages keep the air passages open, allowing forCartilages keep the air passages open, allowing for
unobstructed passage of airunobstructed passage of air
Sticky mucus lining the membranes filters airSticky mucus lining the membranes filters air
Wave motion of cilia & lining membrane waftWave motion of cilia & lining membrane waft
mucus and adherent particles towards the throat.mucus and adherent particles towards the throat.
Contraction & relaxation of muscles in the wallContraction & relaxation of muscles in the wall
regulate the volume of air entering the lungsregulate the volume of air entering the lungs
Cells (lymphocytes, plasma cells, PMNs, macrophages)Cells (lymphocytes, plasma cells, PMNs, macrophages)
protect against infection and inhaled foreign particles.protect against infection and inhaled foreign particles.
Air warmed (or cooled) and moistenedAir warmed (or cooled) and moistened
Pharyngitis: Inflammation of pharynxInflammation of pharynx
Laryngitis: Inflammation of larynxInflammation of larynx
Tracheitis: Inflammation of tracheaInflammation of trachea
Bronchitis Inflammation of bronchiInflammation of bronchi
Bronchiolitis: Inflammation of bronchioleInflammation of bronchiole
Otitis Medium: Inflammation of middle earInflammation of middle ear
Common cold: Is associated with running nose i.e.Is associated with running nose i.e.
rhinorrhoea, congestion, sneezingrhinorrhoea, congestion, sneezing
It is the inflammation of the nasalIt is the inflammation of the nasal
mucus membranemucus membrane
Cough: It is a protective and physiologicalIt is a protective and physiological
reflexreflex which is responsible forwhich is responsible for
expelling any foreign matterexpelling any foreign matter
entering the respiratory tract.entering the respiratory tract.
Bronchiectasis: Localised, chronic and irreversibleLocalised, chronic and irreversible
dilatation of the bronchi.dilatation of the bronchi.
Pneumonia: Inflammation and consolidation ofInflammation and consolidation of
the lung tissue (parenchyma).the lung tissue (parenchyma).
Empyema: Accumulation of pus in pleural cavity.Accumulation of pus in pleural cavity.
Sinusitis: Inflammation of the mucus membraneInflammation of the mucus membrane
lining the various sinus cavities in thelining the various sinus cavities in the
Tonsillitis: Inflammation of the tonsils.Inflammation of the tonsils.
Lung abscess: Collection of pus in the lungs.Collection of pus in the lungs.
Adenitis: Inflammation of the adenoids.Inflammation of the adenoids.
hollow cavities within thehollow cavities within the
facial bones.facial bones.
•Sinus infections:Sinus infections:
most frequently maxillarymost frequently maxillary
and frontal sinuses.and frontal sinuses.
The presence of chronicThe presence of chronic
productive cough for 3 months,productive cough for 3 months,
In each of 2 successive years.In each of 2 successive years.
In a patient in whom otherIn a patient in whom other
causes of chronic cough havecauses of chronic cough have
been excluded.been excluded.
Chronic BronchitisChronic Bronchitis
Cough: mucus-like, greenish,Cough: mucus-like, greenish,
or pus-like sputumor pus-like sputum
Fever: chills with shakingFever: chills with shaking
Chest pain: sharp or stabbing,Chest pain: sharp or stabbing,
increased by deep breathing,increased by deep breathing,
increased by coughingincreased by coughing
General discomfort:General discomfort:
uneasiness / ill feelinguneasiness / ill feeling
Pneumonia - SymptomsPneumonia - Symptoms
Chronic cough: largeChronic cough: large
amounts of foul-amounts of foul-
smelling sputumsmelling sputum
Coughing up bloodCoughing up blood
Cough worsened byCough worsened by
lying on one sidelying on one side
Shortness of breathShortness of breath
worsened by exerciseworsened by exercise
Weight loss ,FatigueWeight loss ,Fatigue
Brochiectasis - SymptomsBrochiectasis - Symptoms
Sore throat: accompanied byaccompanied by
fever, headache, swollenfever, headache, swollen
lymph nodes in the neck.lymph nodes in the neck.
Viral Pharyngitis: associatedassociated
with runny nose (rhinorrhea)with runny nose (rhinorrhea)
and postnasal dischargeand postnasal discharge
accompanied by difficultyaccompanied by difficulty
swallowing and difficultyswallowing and difficulty
Pharyngitis - SymptomsPharyngitis - Symptoms
Wheezing, shortness of breath, or difficultyWheezing, shortness of breath, or difficulty
Bluish skin due to lack of oxygen (cyanosis),Bluish skin due to lack of oxygen (cyanosis),
Rapid breathing (tachypnea),Rapid breathing (tachypnea),
Nasal flaring(swelling) in infants,Nasal flaring(swelling) in infants,
Bronchiolitis - SymptomsBronchiolitis - Symptoms
Normal LungNormal Lung BronchiolitisBronchiolitis
What is cough?What is cough?
CoughCough is a protectiveprotective and
physiologicalphysiological reflex aimed
at maintaining an open
Cough involves rapid
expulsion of air at high
velocity from the respiratory
airway which expel irritants
and excessive secretions
from respiratory tract.
Coughing is under voluntaryvoluntary and involuntaryinvoluntary control
and consists of 33 phases.
InspiratoryInspiratory : initiated by taking a deep breathe
PhasePhase and results in maximal dilation of
CompressiveCompressive : closure of the glottis followed by
phasephase contraction of thoracic and abdominal
muscles against a fixed diaphragm.
Expiratory : sudden glottis opening results in
phase the explosive release air.
Cough - PhysiologyCough - Physiology
Classification of Cough:
A cough can be classified by its -
Classification as per the Duration of Cough:
Acute (of sudden onset): Present < 3 weeks,
Subacute: Present between
3 and 8 wks, Chronic: Lasting > 8
Types of CoughTypes of Cough
1. Acute Cough1. Acute Cough
Cough which comes all of a sudden,Cough which comes all of a sudden,
1. Dry cough
2. Productive cough
3. Bronchospastic / Asthmatic cough
Most commonly relates to -Most commonly relates to -
1. Viral – induced lower respiratory tract infections.
2. Post-nasal drip resulting from rhinitis or sinusitis.
3. Throat - clearing secondary to laryngitis or pharyngitis.
Types of CoughTypes of Cough
Cough is present between 3 and 8 weeks.
The most common causes:
Post infectious Cough.
2. Sub-acute Cough:2. Sub-acute Cough:
Cough lasting for more than 3 weeks.Cough lasting for more than 3 weeks.
Most Important Causes :Most Important Causes :
•Post-nasal DripPost-nasal Drip
•Chronic bronchitisChronic bronchitis
•Occupation environmentOccupation environment
•Psychogenic coughPsychogenic cough
(left ventricular failure)(left ventricular failure)
•Lung CancerLung Cancer
•Intestinal lung diseaseIntestinal lung disease
3. Chronic Cough … cont.3. Chronic Cough … cont.
Patient is a smoker
Cough worse at work
Cough after URTI
Facial / tooth pain
Possible DiagnosisPossible Diagnosis
Tobacco induced bronchitis
Chronic Cough: DiagnosisChronic Cough: Diagnosis
Troublesome type of cough,Troublesome type of cough,
Tends to aggravate because of rapid flow ofTends to aggravate because of rapid flow of
air, further irritating the trachea andair, further irritating the trachea and
pharyngeal mucosa.pharyngeal mucosa.
There is no sputum or secretions are too thickThere is no sputum or secretions are too thick
and viscid.and viscid.
4. Dry cough4. Dry cough
Patient spits out a lot of sputum.Patient spits out a lot of sputum.
Secretions may be thick or watery.Secretions may be thick or watery.
It is usually the result of an allergic response or RTI.It is usually the result of an allergic response or RTI.
•Productive cough are coughs that produce phlegm, in
contrast to dry coughs.
•Productive cough is associated with tuberculosis,
bacterial pneumonia, and bronchitis .
•The loose productive cough is a sign of chest congestion
or infection due to colds or flu.
5. Productive Cough5. Productive Cough
Associated withAssociated with
Common in asthmaCommon in asthma
patients & chronicpatients & chronic
It frequently wakes upIt frequently wakes up
the patient during thethe patient during the
night or the early hours ofnight or the early hours of
the morning.the morning.
6. Bronchospastic (Asthmatic) Cough6. Bronchospastic (Asthmatic) Cough
Characteristics of Cough Originating at
Various Levels of Respiratory Tract:
Origin Causes Characteristics
PharynxPharynx Post nasal dripPost nasal drip Usually Persistent.Usually Persistent.
LarynxLarynx Laryngitis, tumor,Laryngitis, tumor,
whooping cough, croupwhooping cough, croup
Harsh, barking, painful, persistent,Harsh, barking, painful, persistent,
often associated with strider.often associated with strider.
TracheaTrachea TracheitisTracheitis PainfulPainful
BronchiBronchi Acute Bronchitis andAcute Bronchitis and
Bronchial CarcinomaBronchial Carcinoma
Dry or Productive, , worse in mornings.Dry or Productive, , worse in mornings.
Dry or productive, worse at night.Dry or productive, worse at night.
Persistent often with haemoptysis.Persistent often with haemoptysis.
Pulmonary edemaPulmonary edema
Interstitial FibrosisInterstitial Fibrosis
Productive, often with haemoptysis.Productive, often with haemoptysis.
Initially Dry, Productive later.Initially Dry, Productive later.
Often at night ( may be productive)Often at night ( may be productive)
Dry, irritant and distressing.Dry, irritant and distressing.
Water 95% - secreted by bronchialWater 95% - secreted by bronchial
Glycoproteins - thickGlycoproteins - thick
mucopolysaccharides secreted bymucopolysaccharides secreted by
Goblet cellsGoblet cells
Proteinaceous material is calledProteinaceous material is called
Respiratory Tract Fluids …cont.Respiratory Tract Fluids …cont.
Together - Muco-ciliary blanket
It has two layers:It has two layers:
Sol layer :Sol layer : watery layer in which cilia bathe freelywatery layer in which cilia bathe freely
Gel layer :Gel layer : above the sol layer contains mucusabove the sol layer contains mucus
relatively thicker and stickierrelatively thicker and stickier
Respiratory Tract Fluids …cont.Respiratory Tract Fluids …cont.
The respiratory tract fluid and muco-ciliaryThe respiratory tract fluid and muco-ciliary
Resp. Fluid gradually propelled upwards into theResp. Fluid gradually propelled upwards into the
pharynx where it is swallowed without awareness.pharynx where it is swallowed without awareness.
Respiratory Tract Fluids …cont.Respiratory Tract Fluids …cont.
Respiratory tract fluid - increases duringRespiratory tract fluid - increases during
During RTIs or when lungs are exposed to foreignDuring RTIs or when lungs are exposed to foreign
particles secretion increase in order to:particles secretion increase in order to:
Dilute irritants, if any,Dilute irritants, if any,
Drive away foreign bodies and unwanted particles,Drive away foreign bodies and unwanted particles,
Trap micro-organisms.Trap micro-organisms.
Respiratory Tract FluidsRespiratory Tract Fluids
When respiratory tract is contaminated by –When respiratory tract is contaminated by –
Oropharyngeal cells, bacteria, food particles andOropharyngeal cells, bacteria, food particles and
saliva, … it is called sputum.saliva, … it is called sputum.
What is Sputum?What is Sputum?
⁺Phlegm is a sticky material from patient’s mucous
membranes in the respiratory system.
During Cold it might be yellowish brown.
During an infection, it might be greenish brown.
Normal phlegm is usually clear.
Actions of Anti-Cough PreparationsActions of Anti-Cough Preparations
Mucolysis Mucokinesis Expectoration
Breaking down of
the long, complex,
fibers to facilitate
of the mucous
(mainly, gel layer of
the Respiratory Tract
Driving away of
respiratory tract fluid, done
by liquefying the
secretions so that
particles, bacteria and the
line) material can easily be
Mucokinesis is responsible for removal of secretionsMucokinesis is responsible for removal of secretions
from respiratory tract.from respiratory tract.
If defectiveIf defective::
Mucus retention occurs resulting in …Mucus retention occurs resulting in …
Impairment in the distribution of inspired air,Impairment in the distribution of inspired air,
Worsening of gas exchange at alveoli,Worsening of gas exchange at alveoli,
Development of bronhcietasis and atelectasis,Development of bronhcietasis and atelectasis,
Reduction in the ability of the lung to resistReduction in the ability of the lung to resist
How Important is Mucokinesis?How Important is Mucokinesis?
Drugs which suppress cough centre situated in theDrugs which suppress cough centre situated in the
(Latin(Latin tussistussis = Cough).= Cough).
There are two types of these drugs :There are two types of these drugs :
In addition to cough suppressing
action, they have properties like -
Powerful analgesia ,
Anti-tussives (Narcotics)Anti-tussives (Narcotics)
NOT the drugs of first choice because of addiction properties.NOT the drugs of first choice because of addiction properties.
Nausea, vomiting, constipation, skin rashes, drowsiness,Nausea, vomiting, constipation, skin rashes, drowsiness,
addiction, confusion, headache, palpitation,addiction, confusion, headache, palpitation,
convulsions, sweating, vertigo, shockconvulsions, sweating, vertigo, shock
RarelyRarely : Respiratory failure and coma, leading to death: Respiratory failure and coma, leading to death
Reduce ciliary motility of respiratory tract.Reduce ciliary motility of respiratory tract.
Interact withInteract with alcohol, antipsychotics, anti-depressants,alcohol, antipsychotics, anti-depressants,
anti-histaminics and anti-cholinergics.anti-histaminics and anti-cholinergics.
Contra-indicatedContra-indicated in respiratory, liver, cerebral diseasesin respiratory, liver, cerebral diseases
and endocrine disorders.and endocrine disorders.
Anti-tussives (Narcotics) – Side EffectsAnti-tussives (Narcotics) – Side Effects
These are a group ofThese are a group of centrally actingcentrally acting anti-tussivesanti-tussives
withoutwithout thethe narcoticnarcotic properties which include –properties which include –
Noscapine andNoscapine and
Dextromethorphan .Dextromethorphan .
Non- Narcotic Anti- TussiveNon- Narcotic Anti- Tussive
Class Drug Name Action
AntihistaminesAntihistamines Cetirizine, Levocetrizine, Diphenhydramine,Cetirizine, Levocetrizine, Diphenhydramine,
Chlorpheniramine maleate (CPM)Chlorpheniramine maleate (CPM)
Block effects of histamine inBlock effects of histamine in
allergic cough.allergic cough.
Codeine, Pholcodeine,Codeine, Pholcodeine,
Noscapine, DextromethorphanNoscapine, Dextromethorphan
To suppress the cough reflex.To suppress the cough reflex.
(Soothing Agents)(Soothing Agents)
Lozenges, cough drops, linctuses containing syrup.Lozenges, cough drops, linctuses containing syrup.
(glycerin, liquorice), and(glycerin, liquorice), and
mentholmenthol (local action)(local action)
To sooth the respiratoryTo sooth the respiratory
ExpectorantsExpectorants Reflexly acting - Ammonium chloride (local action),Reflexly acting - Ammonium chloride (local action),
Potassium chloride.Potassium chloride.
Directly- Guaiphenesin (local action), Sodium andDirectly- Guaiphenesin (local action), Sodium and
Potassium citrate, Potassium iodide.Potassium citrate, Potassium iodide.
To increase mucus clearance.To increase mucus clearance.
MucolyticsMucolytics Bromhexine (local action), CarbocisteineBromhexine (local action), Carbocisteine to liquefy the respiratoryto liquefy the respiratory
secretions for easysecretions for easy
DecongestantDecongestant Ephedrine,Ephedrine, phenylephrinephenylephrine, and topical drugs like, and topical drugs like
oxymetazoline, xylometazoline are widely used asoxymetazoline, xylometazoline are widely used as
decongestants. Phenylephrine HCL a syntheticdecongestants. Phenylephrine HCL a synthetic
sympathomimetic agent,sympathomimetic agent,
Sympathomimetic agents are aSympathomimetic agents are a
vasoconstrictor and pressorvasoconstrictor and pressor
drug chemically related todrug chemically related to
epinephrine and ephedrine.epinephrine and ephedrine.
Drug Therapy of CoughDrug Therapy of Cough
Blocks H1 histamine receptor and thus inhibits theBlocks H1 histamine receptor and thus inhibits the
actions of histamine.actions of histamine.
Prevents allergic manifestations of cough.Prevents allergic manifestations of cough.
Well absorbed from GIT and penetrates the CNS.Well absorbed from GIT and penetrates the CNS.
Side EffectsSide Effects: drowsiness, nausea and vomiting.: drowsiness, nausea and vomiting.
Antihistamine, antagonises the actions of histamine at
the receptor sites.
Reduces allergic reactions produced due to histamine
in the respiratory tract.
Drowsiness and anticholinergic side effects are
1.1. Phenylephrine … cont.Phenylephrine … cont.
Powerful Vasoconstrictor Cardiac Safety
Blood Vessels: Cutaneous, limb,
Coronary blood flow increased
Pulmonary Blood vessels constricted
In nasal mucosa:
Very minimal effects on β-receptors
Stimulate α-receptors in the Blood
vessels, which constricts & stop
Complete lack of action on heart
Very potent decongestant,Very potent decongestant,
Constricts (shrinks) blood vessels (veins and arteries),Constricts (shrinks) blood vessels (veins and arteries),
Constriction leads to drainage of supplied areas,Constriction leads to drainage of supplied areas,
Decreases congestion & swelling of mucus membrane,Decreases congestion & swelling of mucus membrane,
Site of action: Nose & Sinuses.Site of action: Nose & Sinuses.
Phenylephrine in RTI :Phenylephrine in RTI :
•Opens airwaysOpens airways
•Decreases amount of fluid in RTDecreases amount of fluid in RT
•Make easier to breathMake easier to breath
Phenylephrine- Place in TherapyPhenylephrine- Place in Therapy
Histamine in Nature Present in:
Venom and stings
Synthesized by bacteria and certain fungi
3. Chlorpheniramine Maleate (CPM)3. Chlorpheniramine Maleate (CPM)
1. Cells: Mast cells, Basophils, Neurons, Cells in the
2. Tissues: Skin, Lung, Gastrointestinal tract.
CPM: Synthesis and Metabolism
N – methylimidazole acetic acid
histamine methyl transferase
H-1:H-1: GI & bronchial SM contraction.GI & bronchial SM contraction.
H-2:H-2: Cardiac stimulation, Gastric secretion.Cardiac stimulation, Gastric secretion.
H-1 & H-2:H-1 & H-2: Dilation of arterioles and veins.Dilation of arterioles and veins.
H-3:H-3: Mainly in the CNS,Mainly in the CNS,
Preterminal and autoreceptors,Preterminal and autoreceptors,
Not considered further.Not considered further.
1. Block H-1 receptors competitively.
2. Reduce local response to intradermal histamine.
3. Antagonize the vasoconstrictor, and to a lesser extent,
the vasodilator effects of histamine.
4. Antagonize histamine-induced bronchospasm.
5. Inhibit GI smooth muscle contractions.
Developed in France pre-WWII
Penetrate the CNS and generally have CNS effects
Significant anticholinergic effects
CPM: Sedative action, available OTC.
Diphenhydramine:highly sedating, available OTC.
Hydroxyzine: used frequently for urticaria.
Promethazine (Phenergan):anti-motion sickness activity
used by NASA for space motion sickness
Less sedating - less CNS penetration.
Almost no anticholinergic effects.
Produce cardiac toxicity: Removed from the market
(Terfenadine , Astemizole).
Loratidine – no apparent cardiac toxicity
Fexofenadine - active metabolite of Terfenadine,
safer than parent compound
Cetirizine, Levocetrizine – Used for Non-sedative
Soothing action, produces cooling sensation andSoothing action, produces cooling sensation and
has a mild anesthetic action.has a mild anesthetic action.
Action: Stimulation of the mucous membranes cold
Produce a cooling effect when inhaled or come in
contact with mucous membrane
Use: Relieve sore throat, or nasal congestion, headache,
cold, or sore throat. Products that commonly contain
menthol include toothpaste, cough syrups, lip balm,
mouthwash, gum, and cigarettes.
Menthol in Cough Syrups often soothe and cool
sore throats by relieving inflammation.
It can also help clear stuffy sinus passages and break
up chest congestion.
This usually helps a person to cough less and breathe
The combination of menthol in cough syrup is often
an easy treatment that can be given to a person of
almost any age.
Cough with sputum
Difficult to cough
out sputumSore throat
Nose & Throat
Red & swollen
Sinuses & Throat Pain
Difficult to cough out
Nose & Throat
Red & swollen mucus