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COUGH

ETIOLOGY

Acute cough, which is defined as duration <21 days, is usually related to respiratory infection, aspiration, or inhalation of respiratory irritants. Subacute cough (present for 3–8 weeks) is often related to persistent inflammation from a tracheobronchitis episode. Chronic cough (>8 weeks in duration) can be caused by many pulmonary and cardiac diseases. Chronic bronchitis related to cigarette smoking is a common cause. If the chest radiograph and physical examination are unremarkable, other common causes of chronic cough include cough-variant asthma, gastroesophageal reflux disease (GERD), postnasal drip related to sinus disease, and medications including angiotensin-converting enzyme (ACE) inhibitors. Irritation of tympanic membranes and chronic eosinophilic bronchitis also can cause chronic cough with a normal chest radiograph. Ineffective cough can predispose to serious respiratory infections due to difficulty clearing lower respiratory secretions; abnormal airway secretions (e.g., due to bronchiectasis) or tracheomalacia can contribute. Weakness or pain limiting abdominal and intercostal muscle use also can lead to ineffective cough.

CLINICAL ASSESSMENT

Key historic issues include triggers for onset of cough, determinants of increased or decreased cough, and sputum production. Symptoms of nasopharyngeal disease should be assessed, including postnasal drip, sneezing, and rhinorrhea. GERD may be suggested by heartburn, hoarseness, and frequent eructation. Cough-variant asthma is suggested by noting the relationship of cough onset to asthmatic triggers. Usage of ACE inhibitors, but not angiotensin receptor blockers, can cause cough long after treatment is initiated.

On physical examination, signs of cardiopulmonary diseases should be assessed, including adventitious lung sounds and digital clubbing. Examination of the nasal passages, posterior pharyngeal wall, auditory canals, and tympanic membranes should be performed.

Laboratory evaluation should include chest radiography. Spirometry with bronchodilator testing can assess for reversible airflow obstruction. With normal spirometry, methacholine challenge testing can be used to assess for asthma. Sputum should be sent for routine bacterial and possibly mycobacterial cultures. Sputum cytology can reveal malignant cells in lung cancer and eosinophils in eosinophilic bronchitis. Esophageal pH probes can be used to assess for GERD. Chest CT should be considered in pts with normal chest radiographs who fail to improve with treatment. Evaluation of hemoptysis is discussed below.

TREATMENT Chronic Cough

In pts with chronic cough and a normal chest x-ray, empiric treatment is directed at the most likely cause based on the history and physical examination. If treatment directed at one empiric cause fails, empiric treatment of an alternative etiology can be considered. Postnasal drip treatment may include antihistamines, nasal corticosteroids, and/or antibiotics. GERD can be treated with antacids, type 2 histamine blockers, or proton pump inhibitors. Cough-variant asthma is treated with inhaled glucocorticoids and as-needed inhaled beta agonists. Pts on ACE inhibitors should be given a 1-month trial of discontinuing this medication. Chronic eosinophilic bronchitis often improves with inhaled glucocorticoid treatment. Symptomatic treatment of cough can include narcotics such as codeine; however, somnolence, constipation, and addiction can result. Dextromethorphan and benzonatate have fewer side effects but reduced efficacy.

HEMOPTYSIS

ETIOLOGY

Hemoptysis, expectoration of blood from the respiratory tract, ...

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