This document discusses an approach to cough management. It begins by describing cough as both a defense mechanism and a factor in disease spread. It then outlines the most common causes of acute and chronic cough, including postnasal drip syndrome, asthma, and gastroesophageal reflux disease. The document proposes a 6-step empiric treatment algorithm beginning with treating postnasal drip and proceeding through evaluations and treatments for asthma, chest abnormalities, GERD, and less common causes before considering psychogenic cough.
by
Dr. Khairul Hassan Jessy
MD (Chest Diseases)
Associate Professor, Respiratory Medicine
National Institute of Diseases of the Chest and Hospital (NIDCH)
Mohakhali, Dhaka.
What is bronchiolitis and its definition, the age group, signs and symptoms and clinical presentation The clinical practice guidelines, how to diagnosis, clinical criteria, what are the severity degrees and How to assess the severity, what are the investigations that may be needed, Is there any diagnostic test, what is the prognosis
What is the management,
by
Dr. Khairul Hassan Jessy
MD (Chest Diseases)
Associate Professor, Respiratory Medicine
National Institute of Diseases of the Chest and Hospital (NIDCH)
Mohakhali, Dhaka.
What is bronchiolitis and its definition, the age group, signs and symptoms and clinical presentation The clinical practice guidelines, how to diagnosis, clinical criteria, what are the severity degrees and How to assess the severity, what are the investigations that may be needed, Is there any diagnostic test, what is the prognosis
What is the management,
Bronchial Asthma: Definition,Pathophysiology and ManagementMarko Makram
Definition and Pathophysiology of Asthma in addition to classification and recent updates in the management of asthma based on GINA-2019 Guidelines, by Dr. Marco Makram.
These lecture notes were prepared by Dr. Hamdi Turkey- Pulmonologist- Department of internal medicine - Taiz university
Do Not Forget To Visit Our Pages On Facebook on the following Links:
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International Journal of Pharmaceutical Science Invention (IJPSI)inventionjournals
is an international journal intended for professionals and researchers in all fields of Pahrmaceutical Science. IJPSI publishes research articles and reviews within the whole field Pharmacy and Pharmaceutical Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online
Bronchial Asthma: Definition,Pathophysiology and ManagementMarko Makram
Definition and Pathophysiology of Asthma in addition to classification and recent updates in the management of asthma based on GINA-2019 Guidelines, by Dr. Marco Makram.
These lecture notes were prepared by Dr. Hamdi Turkey- Pulmonologist- Department of internal medicine - Taiz university
Do Not Forget To Visit Our Pages On Facebook on the following Links:
https://www.facebook.com/groups/569435236444761/
AND
https://www.facebook.com/groups/690331650977113/
International Journal of Pharmaceutical Science Invention (IJPSI)inventionjournals
is an international journal intended for professionals and researchers in all fields of Pahrmaceutical Science. IJPSI publishes research articles and reviews within the whole field Pharmacy and Pharmaceutical Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online
the scenario given at the start of ppt z nt interstitial lung diseases... its a similar diseases to it.... diagnose it urself to differniate it and hv better command over diffferntial diagnosis.
The Comprehensiveness of Homoeopathy in Bronchial Asthmaijtsrd
The Bronchial Asthma is one of the common chronic disorders of respiratory system. The Individual of all age group can be suffering by this respiratory system disorder. Most often the asthma is disease which is related with the symptoms like difficulty in breathing and cough. Wheezing sound heard while the auscultation of chest. Though the bronchial asthma is critical condition it can be treated with the perfect treatment. The knowledge of respiratory tract disorder like bronchial asthma is Important for community. The people should know what is Bronchial asthma, How it progresses, How to avoid critical attack. 11 On the basis of the concept of persistent airway inflammation, two important principles are there. First, the complaint is chronic, frequently life long second, its severity fluctuates and sometimes there may be prolonged remissions. According to WHO Asthma affected an estimated 262 million people in 2019 worldwide and it caused around 4, 55,000 deaths. The Global Asthma Report 2022, by Global Asthma Network, shows that about 35 million Indian people suffer from asthma in 2022. 11 The bronchial asthma need to be treated by Homoeopathic medicines. Homoeopathic medicines produce similar symptoms after administration of it in the healthy human beings. Some of Homoeopathic medicines can help to relive symptoms of acute attack of asthma. This can also help to prevent the recurrence of asthma. According to Dr. Hahnemann asthma is true chronic disease which is because of Miasm. Sometimes symptoms of asthma may alternate with skin symptoms. 12 Homoeopathic treatment is Important to avoid unnecessary adverse effects of modern medicine. Dr. Jayshree Rathva | Pandya Santosh Kumar Jashvantbhai | Parmar Ketulkumar Dilipbhai "The Comprehensiveness of Homoeopathy in Bronchial Asthma" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-7 | Issue-6 , December 2023, URL: https://www.ijtsrd.com/papers/ijtsrd60153.pdf Paper Url: https://www.ijtsrd.com/medicine/other/60153/the-comprehensiveness-of-homoeopathy-in-bronchial-asthma/dr-jayshree-rathva
The Comprehensiveness of Homoeopathy in Bronchial Asthmaijtsrd
The Bronchial Asthma is one of the common chronic disorders of respiratory system. The Individual of all age group can be suffering by this respiratory system disorder. Most often the asthma is disease which is related with the symptoms like difficulty in breathing and cough. Wheezing sound heard while the auscultation of chest. Though the bronchial asthma is critical condition it can be treated with the perfect treatment. The knowledge of respiratory tract disorder like bronchial asthma is Important for community. The people should know what is Bronchial asthma, How it progresses, How to avoid critical attack. 11 On the basis of the concept of persistent airway inflammation, two important principles are there. First, the complaint is chronic, frequently life long second, its severity fluctuates and sometimes there may be prolonged remissions. According to WHO Asthma affected an estimated 262 million people in 2019 worldwide and it caused around 4, 55,000 deaths. The Global Asthma Report 2022, by Global Asthma Network, shows that about 35 million Indian people suffer from asthma in 2022. 11 The bronchial asthma need to be treated by Homoeopathic medicines. Homoeopathic medicines produce similar symptoms after administration of it in the healthy human beings. Some of Homoeopathic medicines can help to relive symptoms of acute attack of asthma. This can also help to prevent the recurrence of asthma. According to Dr. Hahnemann asthma is true chronic disease which is because of Miasm. Sometimes symptoms of asthma may alternate with skin symptoms. 12 Homoeopathic treatment is Important to avoid unnecessary adverse effects of modern medicine. Dr. Jayshree Rathva | Pandya Santosh Kumar Jashvantbhai | Parmar Ketulkumar Dilipbhai "The Comprehensiveness of Homoeopathy in Bronchial Asthma" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-7 | Issue-6 , December 2023, URL: https://www.ijtsrd.com/papers/ijtsrd60153.pdf Paper Url: https://www.ijtsrd.com/medicine/other/60153/the-comprehensiveness-of-homoeopathy-in-bronchial-asthma/dr-jayshree-rathva
Chronic Obstructive Pulmonary Disease basis of drugs used in treatment and Describe the factors which affect the quality of life of individuals suffering from COPD
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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How to Give Better Lectures: Some Tips for Doctors
1
1. 1
to cough management
Introduction
Cough can be an important
defense mechanism to help clear
excessive secretions and foreign
material from airways. But,
cough can also be an important
factor in the spread of infection.
1. Coughing is more often the
result of an involuntary reflex
response to stimulation of
cough receptors in the
airways.
2. An effective cough depends
on the ability to achieve high
gas flows and intrathoracic
pressures, enhancing the
removal of mucus adhering
to the airway wall. A variety
of protussive treatment
modalities may improve
cough mechanics.
3. It is the complications of
cough that lead patients to
seek medical attention.
4. There are two categories of
cough although they are not
mutually exclusive (Grade II-
2, III-3) and they are:
• Acute, lasting less than 3
weeks, [most frequently
due to the common cold
(Grade III)].and
• Chronic, lasting 3 to 8
weeks or longer [often
simultaneously due to
more than one condition
(Grade II-2, II-3), but can
be the sole clinical
manifestation of asthma
and gastroesophageal
reflux disease (GERD)
(Grade II-2). In the
nonsmoking population,
persistent cough is
reported to occur in 14 to
23 % of adults]. Although
in most patients chronic
cough has a single cause,
in up to one fourth of
patients, multiple
disorders contribute to
the cough.
• The most common
causes of chronic cough
in nonsmokers are
postnasal drip syndrome
(PNDS), asthma, and/or
GERD (Grade II-2, II-3),
whether or not the cough
is described as dry or
productive (Grade II-2).
PNDS, asthma, and/or
GERD are likely to be
causes(s) of chronic
cough in approximately
100% of the nonsmokers
who are not taking
angiotensin-converting
enzyme inhibitor (ACEI)
drugs and who have
normal or nearly normal
chest radiographs
showing no more than
stable inconsequential
scars (Grade II-2).
5. PNDS, either singly or in
combination with other
conditions, is the single most
common cause of chronic
cough for which patients seek
medical attention (Grade II-Approach
Foreword
There has been a rapidly
increasing volume of
research undertaken in
the field of acute and
chronic cough at both
basic scientific and
clinical levels. All this
leads the clinicians to
handle cough not only as
a defensive symptom
but also to treat it as a
disturbance. However,
no approach is going to
ensure the successful
management of cough
unless the approach is
scientific and sturctured.
Here is an approach to
assist the clinicians in
that direction.
Dr. B. K. Iyer
Consulting editor
Shelys Pharmaceuticals
2. 2
2). The symptoms and signs
of PNDS are nonspecific
(Grade II-2); therefore, a
definitive diagnosis of
PNDS-induced cough
cannot be made from history
and physical examination
alone. An approach to cough
management bearing in minf
the therapy for PNDS is a
crucial step in cough
management. The
combination of a first-generation
antihistamine
and a decongestant is
considered to be the most
consistently effective sole
form of therapy in treating
most patients with PNDS-induced
cough not due to
sinusitis (Grade II-2). Newer
generation, relatively
nonsedating antihistamines
are not as effective as first-generation
antihistamines in
treating PNDS secondary to
nonallergic conditions.
6. Asthma is a common cause
of chronic cough. A
diagnosis of cough-variant
asthma is suggested by the
presence of airway hyper-responsiveness,
and
confirmed only when the
cough resolves with asthma
medications.
7. GERD can cause cough by
aspiration, but it most likely
causes chronic cough in
patients with normal
radiographs by a vagally
mediated reflex mechanism
(Grade II, II-2). When
GERD is the cause of
chronic cough, GI symptoms
are often absent (Grade II-2).
When 24-h esophageal pH
monitoring cannot be done
for the precise diagnosis, an
empiric trial of antireflux
medication is appropriate
when GERD is suspected as
a cause of cough. Treatment
should also include diet and
lifestyle changes in addition
to drugs. Cough due to
GERD has been reported to
resolve with medical therapy
in 70 to 100% of patients;
mean time to recovery may
take as long as 169 to 179
days (Grade II-2).
8. Cough is a principal feature
of chronic bronchitis (CB)
and its treatment should
chiefly be directed to
reduction of sputum
production and airway
inflammation (eg, by
smoking cessation and
removal of environmental
irritants) (Grade II-2).
Ipratropium can decrease
sputum production and
cough (Grade I). Nonspecific
cough suppressants should
be avoided, and mucolytics
are of uncertain benefit.
Although the effectiveness of
systemic corticosteroids and
antibiotics on cough have not
been specifically studied,
they are likely to be helpful
in decreasing cough during
exacerbations of COPD
(Grade III).
9. Bronchiectasis is a cause of
chronic cough in a relatively
small number of patients; the
diagnosis is established by
clinical history, chest
radiograph, high-resolution
CT scan of the thorax, and
cough disappearance with
specific approaches
including physiotherapy,
drugs to stimulate
mucociliary clearance, and
systemic antibiotics (Grade
II-2).
10. Postinfectious cough is a
diagnosis of exclusion; it
should be considered when
a patient complains only of
cough after a respiratory tract
infection and has a normal
chest radiograph.
Postinfectious cough
ultimately resolves over time
but can be controlled by
cough preparations and
maybe, antibacterials, if
needed. Another important
aspect to bear in mind is
eosinophilic bronchitis
developing due to allergy, in
which case therapy has to be
more clearly specific. It
would make sense to note
that worm infestation gives
rise to eosinophilia which in
turn gives rise to cough.
11. Coughs that develop for the
first time and last for months
in susceptible groups are
suggestive of bronchogenic
carcinoma. Present or prior
cigarette smoking or
occupational exposures
increase the risk.
12. Cough due to ACEIs is a
class effect of these drugs
and is not dose-related. The
cough is typically
nonproductive and is
associated with an irritating,
tickling, or scratchy
sensation in the throat. ACEI
3. 3
induced cough may appear
hours to weeks or months
after ACEI is started (Grade
II). Cough due to ACEIs will
disappear or substantially
improve within 4 weeks of
discontinuing the drug
(Grade I). Definitive
treatment of ACEI-induced
cough is discontinuation of
the drug.
13. Habit cough and
psychogenic cough are
diagnoses of exclusion
(Grade III).
14. Chronic interstitial lung
disease is an uncommon
cause of cough. However,
the most common causes of
chronic cough should be
investigated before
antitussives are prescribed
(Grade III).
15. In children, asthma, URTI &
LRTI, and GERD are the
most common causes of
acute and chronic cough.
Less common causes of
cough in children are
congenital anomalies,
aspiration and environmental
exposures. The approach to
managing chronic cough in
children is similar to the
approach in adults (Grade
III). A chest radiograph
should be obtained in nearly
all children with chronic
cough to rule out lower
respiratory tract and cardiac
pathology (Grade III). The
recommended diagnostic
approach to cough in
children is history, physical
examination, and
determination of a most
likely etiology (Grade III).
16. Pharmacologic treatment of
cough is either:
• (a) antitussive, to
prevent, control, or
eliminate cough, or
• (b) protussive, to make
cough more effective.
Antitussives
Antitussive therapy is indicated
when cough serves no useful
function such as clearing the
airways. Specific antitussive
therapy is directed at the etiology
or mechanism causing cough (eg.
cigarette smoking, postnasal
drip). Nonspecific antitussive
therapy is directed at the
symptom rather than the etiology
or mechanism. Because of the
high probability of being able to
determine the causes of cough
and prescribe specific treatment
that can be successful, there is a
limited role for nonspecific
antitussive treatment (Grade II-
2, II-3). It is indicated (Grade III)
when specific therapy has not
had a chance to work or will not
work (eg. inoperable lung
cancer).
Protussives
Protussive therapy is indicated
when cough performs a useful
function and needs to be
encouraged (eg. in
bronchiectasis, CF). Hypertonic
saline in CF appears promising.
An Empiric Treatment
Algorithm
STEP ONE
For first 1 week, adopt empiric
treatment for postnasal drip using
an older-generation
antihistamine-decongestant
combination. If bacterial
infection is identified, the patient
should be treated with an empiric
trial of antibiotics such as
amoxicillin-clavulanate
potassium or azithromycin, or a
second- or third-generation oral
cephalosporin. When all of these
measures fail, the patient may
require aspiration or irrigation of
the sinuses.
STEP TWO
Patients who continue to cough
despite the treatments in step 1
should be evaluated for asthma.
Physicians should bear in mind
that patients with asthma may
present with only a chronic, non
productive cough termed
“cough-variant asthma.”
Objective evaluation by
spirometry must be done. A
reduced peak expiratory flow rate
and a reduced ratio of forced
expiratory volume in one second
(FEV1) to forced vital capacity
(FVC) is diagnostic of
obstructive lung disease.
Following bronchodilator
therapy, an increase of at least 15
percent in the FEV1 may be
expected in the patient with
asthma. Patients diagnosed with
asthma should be treated
prophylactically with inhaled
cromolyn sodium, and with beta-agonist
and/or steroid inhalers
and oral corticosteroids, as
required.
STEP THREE
Chest and sinus radiographs
should be performed at this stage,
if they are not already done. Any
clinically significant abnormality
4. should be evaluated and treated.
STEP FOUR
Patients in whom a diagnosis has
not been reached by this time and
who remain symptomatic should
be given an empiric gastric-acid
suppression test, along with
antireflux measures for treatment
of possible GERD. Patients who
respond to this empiric therapy
should receive aggressive
therapy with a proton-pump
inhibitor for at least 8 weeks.
STEP FIVE
Patients who still continue to
cough at this stage should receive
bronchoscopic examination. If
this procedure does not produce
a diagnosis, a repeat course of
antiasthmatic therapy with a beta
agonist and steroids should be
tried.
STEP SIX
If cough still persists, the
physician should institute a
careful search for less common
causes but it would be unusual
for cough to be the only
presenting symptom in patients
with serious underlying disease.
Patients with lung cancer,
4
interstitial lung disease, chronic
lung infections or aneurysm
could be expected to be identified
by chest radiographs &/or
bronchoscopy. A CT scan of the
chest would be appropriate in
these patients, and lymph-node
biopsy may be necessary in
diagnosing sarcoidosis or
bronchogenic carcinoma. In the
absence of clinical signs of
congestive heart failure, two-dimensional
echocardiography
may aid in diagnosis.
Any child who coughs and has a
history of recurrent pneumonia
and/or failure to thrive should
have a sweat chloride test for
cystic fibrosis. Finally,
immunosuppression caused by
HIV infection and opportunistic
chest infection must be
suspected.
If all of this evaluation and
treatment fails, a careful history
should be repeated, with
emphasis on occupational or
home exposure to an airway
irritant. If no pathology can be
found, psychogenic cough must
be considered.
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