This document provides an overview of cough, including its definition, phases, reflex, types, evaluation, investigations, treatment, and complications. It discusses the cough reflex pathway and various receptors involved. It describes acute, subacute and chronic cough and their typical causes. Various types of cough are defined based on their characteristics. A detailed evaluation and focused testing is recommended for cough lasting more than 3 weeks. Common antitussive medications are outlined along with their mechanisms and side effects.
TUBERCULOSIS HAS BEEN EXCLUDED BECAUSE IN INDIA TUBERCULOSIS IS THE MOST COMMON CAUSE OF CHRONIC COUGH AND REST OTHER CAUSES OF CHRONIC COUGHS ARE IGNORED
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3. COUGH – it is a sudden and variable expiratory
thrust of air from the lungs through the air
passages associated with phonation, which
momentarily interrupts the physiological pattern
of breathing
Without an effective cough reflex, there is a risk
of retaining airway secretions and aspirated
material predisposing to infection， atelectasis，
and respiratory compromise
6. Cough reflex initiated by chemical/mechanical
stimuli
This is carried by the afferents which are type c
and type 1 fibers and innervate pharynx, larynx
,large airways , terminal bronchiole and lung
parenchyma
Afferents travel via vagus and superior laryngeal
nerve
NTS in brain stem is the cough center
Efferents travel via vagus, phrenic, spinal motor
nerves to the larynx, trachea, bronchi,
diaphragm producing cough
7.
8. MECHANO RECEPTORS NOCICEPTORS
CELL BODIES ARE IN NODOSE
GANGLION (ING VAGAL
GANGLION
CELL BODIES IN JUGULAR
GANGLION( SUP VAGAL
GANGLION)
SENSITIVE TO MECHANICAL
DISPLACEMENT
NOXIOUS CHEMICAL
IRRITANTS LIKE IRRITANT
VAPOURS ETC
LIMITED CHEMOSENSORY UNMYELINATED C FIBRES
ION CHANNELS BELONG TO
ASIC FAMILY acid-sensing
ion channel
ION CHANNELS BELONG TO
TRPV1transient receptor
potential vanilloid
AND TRPA1transient
receptor potential cation
channel, subfamily A,
TWO TYPES RAR AND SAR
9.
10. Voluntarily a person is capable of
suppressing the reflex cough for some time
Cough can also be voluntarily induces (motor
and pre motor areas of brain)
Neuro transmitters involved in voluntary
control of cough are seratonin, gaba,
dopamine, nmda(N-methyl-D-aspartate ) etc
The central nervous pathways for cough show
interactions and plasticity
11. ACUTE (<3 WKS)
Tracheobronchitis
Bronchopneumonia
Viral pneumonia
Acute-on-chronic bronchitis
Pertussis
Pulmonary embolism
Foreign body aspiration
Sudden onset – bronchial asthma ,asthmatic
bronchitis , whooping cough, foreign body
,LVF with PE
12. SUB ACUTE (3-8 wks )
trachiobronchitis ,
pertussis ,
post viral tussive syndrome
16. Based on expectoration
• Dry cough: pleural disorders , diseases of
interstitium, mediastinal lesions
• Productive cough: suppurative lung disease,
airway diseases
17. Brassy/Gander cough –metallic sound d/t
compression of trachea by intra thoracic
space occupying lesions or aortic aneurysms
also known as leopards growl
Bovine cough –loss of expulsive nature as in a
tumour pressing on the recurrent laryngeal
nerve
Paroxysmal cough – whooping cough ,
chronic bronchitis, foreign body , bronchial
asthma
18. Barking cough – involvement of epiglottis ,
croup( laryngo trachiobronchitis) , hysteria
Whooping cough – pertussis
Spluttering cough- s/I T-E fistula , cough
while swallowing
Hacking – heavy smokers, chronic pharyngitis
or laryngitis
23. Efforts should be made to identify the cause
of cough
A cough lasting than more than 3 wks
require a detailed evaluation
Cough associated with or without sputum is
more important than the amount of sputum
and the presence or absence of sputum
should not be taken as a strict criterion for
diagnosis
24. Considerations at 1st visit
Determine the severity
Assess the cause
Plan investigation and treatment
27. Lobar pneumonia – the cough is initially dry
a/w chest pain later becomes productive
Chronic bronchitis – productive cough for
most days of 3 months for 2 consecutive yrs
Bronchiectasis – copious amt of foul smelling
sputum more on lying down
Gastro esophageal reflux disorder -
Nonproductive cough often following meals
with or without symptoms of GERD
28. Left ventricular failure - Cough intensifies
while supine, along with aggravation of
dyspnea
Angiotensin-converting enzyme (ACE)
inhibitors Nonproductive cough, more
common in women, may occur at any time ,
neurokinin 1 receptor polymorphism
29. Routine investigations
Absolute eosinophil count
Pulmonary function tests
Sputum gram stain , culture sensitivity , zn
stain
Chest x ray
Ct chest
Sinus x ray/CT sinus
30. Quality of life questionnaires
Leicester cough questionnaire used to assess
cough intensity and frequency
Measurement of cough reflex- by inhalation
of tussive agent like capsaicin
Visual analogue scales
31. Cough lasting less than 3 wks
Usually it is due to viral and bacterial
infections of upper respiratory tract
Usually the cough resolves within 2 wks
Other symptoms that can be associated
with cough are post nasal discharge ,
nasal obstruction, nasal discharge
32. Rhinitis associated with common cold
may have mucopurulent discharge but it
is not an indication of antibiotics unless it
persists for more than 10 to 14 days
33. Step 1: Identification and Treatment of
Obvious Causes
Step 2: Focused Testing for and Treatment of
Asthma, Gastroesophageal Reflux, and
Rhinosinusitis
Step 3: Investigations to Rule Out Rarer
Causes of Cough
Step 4: Management of Idiopathic or
Refractory Chronic Cough
37. Chronic idiopathic cough,
narcotic cough suppressants， such as
codeine or hydrocodone
Dexomethorphan can also be used
Benzonatate
Case series have reported benefit from off-
label use of gabapentin or amitryptyline for
chronic idiopathic cough.
38. In paediatric age group cough more than 4
wks is considered chronic
Most common cause of chronic cough in
infants is aspiration and congenital heart
defects
2-5 yrs – foreign body inhalation , hyper
reactive airways
Adolescents – hyper reactive airways,
infections
39.
40. ANTITUSSIVE AGENT
• Morphine
• Dihydro-
morphinone
• Codeine
• pholcode
ine
• Dexomet
horphan
• noscapin
e
,
• Diphenhydram
ine
• Benzonatate
• Triprolidine
41. Depression of medullary centres or
associated higher centres.
Increased threshold of cough centre
42. An opium alkaloid.
It is more selective for cough centre.
Suppresses cough for about 6 hours.
The antitussive action is blocked by
naloxone.
Cough suppression occur with low doses of
opioids than those needed for
analgesia.(sub-analgesic dose 15 mg)
Abuse liability is low, but present.
Adverse Effects
•Constipation.
•Respiratory depression & drowsiness
43. Little/ no analgesic or addicting
property.
Similar efficacy as antitussive to
codeine
Is longer acting—–acts for 12 hours
or more.
Given once or twice daily.
Adverse Effects
Nausea
Drowsiness
44. •Depresses cough but has no
narcotic, analgesic or dependence
inducing properties.
•Efficacy same as codeine, specially
useful in spasmodic cough.
Adverse Effects
•Headache & nausea can occur
45. raises threshold for cough & depresses
cough centre in medulla.
It has been found to enhance the
analgesic action of morphine & other μ
receptors agonists
As effective as codeine, does not depress
mucociliary function of the airway
mucosa.
46. Devoid of addicting actions.
Produces less constipation than codeine
Antitussive action for 6 hours.
it does not act through opioids
receptors.
Side effects:
Dizziness, nausea, drowsiness & ataxia.
47. It acts at the CNS level by inhibiting the
medullary cough centre
In addition to this peripheral effects are
related to its antihistamine,
antiserotonergic and muscle-relaxant
properties
it is used in the treatment of cough,
bronchospasm and related symptoms
48. It has antihistamine with anticholinergic
properties
Centrally acting with no addicting
properties
the most common side effect is
drowsiness
quick acting drug that can clear
congestion and stop runny noses in 15–
30 minutes
Useful in cough in allergic conditions
49. Diphenhydramine is an antihistamine
used to relieve symptoms of allergy,
hay fever, and the common cold.
Commonly present in many cough
syrups
Drowsiness, dizziness, constipation,
stomach upset, blurred vision
50. Demulcents. promotes salivation & inhibit
impulses from inflamed mucosa
Linctus Thick liquid preparation
containing sucrose and medicinal
substance
Throat lozenges:They have lubricating
and soothing effect on irritated tissue of
throat may contain benzocaine or
dextromethorphan.
51. selective NOP1 (nociceptin opioid 1) receptor
agonist
TRPV1 antagonists
TRPA1 antagonists
Memantine, the non competitive NMDA
channel blocker
The neurokinin-1 (NK1) receptor has been
implicated in the sensitization of synapses in
the nTS, and its antagonist (aprepitant) was
recently found to reduce cough in patients
with lung cancer
