The document discusses the approach to cough and its management. It defines cough and describes the cough reflex mechanism. Cough can be initiated voluntarily or involuntarily and involves both afferent and efferent pathways. Cough receptors are located in various areas including the pharynx, sinuses, stomach and ears. The cause of cough can be extra-pulmonary. A careful history regarding onset, character, production, timing and associated symptoms is important to narrow the diagnosis. Acute, recurrent and chronic cough have different etiologies depending on the patient's age. Proper diagnosis involves considering clinical features, sputum examination and treatment response.

1. APPROACH TO COUGH
BY : Dr. Mahesh Yadav

2. Cough is an explosive
expiration that provides a
normal protective
mechanism for clearing
the tracheobronchial tree
of secretions and foreign
material.
DEFINITION

3. The bronchi and trachea
are so sensitive to light
touch that excessive
amounts of foreign
matter or other causes of
irritation initiates the
cough reflex.

4. Coughing may be initiated
either voluntarily or
reflexively
As a defensive reflex it has
both afferent and efferent
pathways

5. The afferent limb includes receptors
within the sensory distribution of the
trigeminal, glossopharyngeal,
superior laryngeal, and vagus nerves.
The efferent limb includes the
recurrent laryngeal nerve and the
spinal nerves.

6. COUGH RECEPTORS RECIDES IN
PHARYNX, PARANASAL SINUSES,
STOMACH AND EXTRA-AUDITORY
CANAL
CAUSE OF COUGH MAY BE
EXTRAPULMONARY.

7. Mechanism
About 2.5L of air is
inspired
Epiglottis closes,
vocal cords shut
tightly to entrap the
air within the lung

8. Abdominal muscles contract
forcefully, pushing against
the diaphragm
Internal intercosatal muscles also
contract forcefully
Pressure in the lungs rises to
100mmHg or more. Markedly
positive intrathoracic pressure
causes narrowing of the trachea.

9. Vocal cords and epiglottis
suddenly open widely .
The large pressure differential
between the airways and the
atmosphere coupled with tracheal
narrowing produces rapid flow
rates through the trachea.
Air is expelled at velocities ranging
from 75 to 100 miles/hr.

10. The shearing forces that develop aid in the
elimination of mucus and foreign materials
Cough is therefore PROTECTIVE

12. MECHANISM OF COUGH
• How Do We Cough_ - The Mechanism of
Coughing - Cough Reflex Animation - Learn
Human Body.mp4

13. Thus..
• Fromthe mechanism..
• Presence of significant COUGH- irritation of cough receptors..

14. HOW WE
NARROW
OUR
DIAGNOSIS
WHILE
APPROACH
ING
?????
STILL
THINKING
MAY BE
NEXT
SLIDES
WILL
HELP

15. ASK THESE
QUESTION
ONSET
PRODUCTIVE ?
CHARACTER
AND
TIMING
VARIATION

16. D/D
• Onset- sudden onset after choking episode-
foreign body, recurrent- atopic type, chronic- TB,
bronchiectasis
• Productive- older children with early morning
severe expectoration- Bronchiectasis, non-
productive and only when awake- habitual
• Character- Barking- croup, spasmodic- atopic type
• Variation- nocturnal and early morning- atopic
type, lying down- GERD

17. ETIOLOGY

18. ACUTE
•1.INFANT
•2.TODDLERS
•3.CHILDREN
•4.ADOLESCENT
RECURRENT
•1.INFANT
•2.TODDLERS
•3.CHILDREN
•4.ADOLESCENT
CHRONIC
>3WEEKS
•1.INFANT
•2.TODDLERS
•3.CHILDREN
•4.ADOLESCENT

19. ACUTE
• INFECTION
• ASPIRATION
• FOREIGN BODY
RECURRENT
• REACTIVE AIRWAYS
• CF
• GERD
• ANATOMIC ABNORMALITY
• PASSIVE SMOKING
CHRONIC
• REACTIVE AIRWAYS
• CF
• ASPIRATIONS
• PERTUSSIS
• ANATOMIC ABNORMALITY
• PASSIVE SMOKING

20. ACUTE • INFECTION
RECURRENT
• REACTIVE AIRWAYS
• CF
• GERD
• PASSIVE SMOKING
CHRONIC
• Tuberculosis/ Bronchiectasis
• REACTIVE AIRWAYS
• CF
• GERD
• PERTUSSIS, MYCOPLASMA
• PSYCHOGENIC
• ANATOMIC ABNORMALITY
• PASSIVE SMOKING

21. CAUTION
• Pneumonia- involves parenchyma
• Cough receptors may not be involved in the
early stages
• Hence cough may be a late feature of lobar
pneumonia- Fever with tachypnea +/-
retractions is diagnostic of pneumonia

22. Productive cough: significant amount of sputum;
Blood- hemoptysis; smell- putrid smell- lung
abscess
Color of sputum- no bearing on the diagnosis
Large amounts:-
a)regular coughing up-bronchiectasis
b)Single occasion-lung abscess,empyema
c)Pink frothy-Pulmonary edema

23. PURULENT SPUTUM

24. RUSTY SPUTUM

25. BLOODY SPUTUM

26. VARIATION
SEASONAL
DIURNAL
NO
VARIATION
POSTURAL

27. 1.Diurnal variation
Cough which gets worse in night and
early morning :- Asthma
2.Postural variation
Bronchiectasis, Lung abscess
Lying down- postnasal drip, GERD,
cardiac cause- pulmonary congestion
3.Seasonal variation
Asthma, C/c bronchitis

28. Aggravating & Relieving factors
Cold,smoke,dust,exertion: asthma
Cough and choking on swallowing of
liquids: Neuromuscular disorders-
affects swallowing
Solids- Oesophageal motility problems
Otogenic cough: impacted wax or
foreign body in external auditory
meatus- subsides with removal of
cause

29. Associated symptoms
Fever: Pneumonia, lung abscess- clubbing also+
Chest pain: Pneumonia with pleuritis
Pleuritic chest pain: lateral part of chest with
associated splinting- increases on deep inspiration/
cough- Pleurisy, pleural effusion, bronchiectasis
Frequent hawking of throat, Nasal discharge, snoring,
tickling sensation in throat- Post nasal drip
Cough with associated dyspnea on exertion/
palpitations- Cardiac cause

30. Stridor: FB, Laryngeal nerve
involvement
Hoarseness of voice: Laryngeal
nerve involvement
Heart burn, regurgitation: GERD

31. NOT TO FORGET TO NOTE

32. .Laryngeal inflammation:-cough, hoarseness of voice,stridor
.FB:-cough,stridor,history
.WHOOP SOUND-pertussis
• ALL DAY NEVER DURING SLEEP-habit cough

33. INFANT WITH WHOOPING COUGH
• My Movie.wmv

34. BABY WITH CROUP STRIDOR BARKING COUGH
• My Movie 2.wmv

35. .Post nasal drip;-nasal discharge…
mucoid or mucopurulent,tickle in
throat
.GERD:-cough,heart burns,
regurgitation

36. 6.Tuberculosis:-cough
(dry…purulent
…blood streaks in
sputum),
anorexia,LOW,
night sweats,
evening rise of
temperature

37. • APPROACH TO
TUBERCULOSIS

41. APPROACH TO FOREIGN BODY

43. APPROACH IN CHILD