Cough

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Cough
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Depiction of cough
Pronunciation
Specialty Infectious diseases
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Coughing
The sound of a person coughing.
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A cough is a sudden expulsion of air through the large breathing passages which can help clear them of fluids, irritants, foreign particles and microbes. As a protective reflex, coughing can be repetitive with the cough reflex following three phases: an inhalation, a forced exhalation against a closed glottis, and a violent release of air from the lungs following opening of the glottis, usually accompanied by a distinctive sound. [1]

Contents

Frequent coughing usually indicates the presence of a disease. Many viruses and bacteria benefit, from an evolutionary perspective, by causing the host to cough, which helps to spread the disease to new hosts. Irregular coughing is usually caused by a respiratory tract infection but can also be triggered by choking, smoking, air pollution, [1] asthma, gastroesophageal reflux disease, post-nasal drip, chronic bronchitis, lung tumors, heart failure and medications such as angiotensin-converting-enzyme inhibitors (ACE inhibitors) and beta blockers. [2]

Treatment should target the cause; for example, smoking cessation or discontinuing ACE inhibitors. Cough suppressants such as codeine or dextromethorphan are frequently prescribed, but have been demonstrated to have little effect.[ citation needed ] Other treatment options may target airway inflammation or may promote mucus expectoration. As it is a natural protective reflex, suppressing the cough reflex might have damaging effects, especially if the cough is productive (producing phlegm). [3]

Presentation

Shadowgraph videos of the outer airflow during a cough, comparing unmasked coughing with several methods of covering one's mouth and nose: coughing into a fist, a cupped hand, a tissue, a "coughcatcher" device, a surgical mask, and an N95 mask

Complications

The complications of coughing can be classified as either acute or chronic. Acute complications include cough syncope (fainting spells due to decreased blood flow to the brain when coughs are prolonged and forceful), insomnia, cough-induced vomiting, subconjunctival hemorrhage or "red eye", coughing defecation and in women with a prolapsed uterus, cough urination. Chronic complications are common and include abdominal or pelvic hernias, fatigue fractures of lower ribs and costochondritis. Chronic or violent coughing can contribute to damage to the pelvic floor and a possible cystocele. [4]

Differential diagnosis

A cough in children may be either a normal physiological reflex or due to an underlying cause. [5] In healthy children it may be normal in the absence of any disease to cough ten times a day. [5] The most common cause of an acute or subacute cough is a viral respiratory tract infection. [5] A healthy adult also coughs 18.8 times a day on average, but in the population with respiratory disease the geometric mean frequency is 275 times a day. [6] In adults with a chronic cough, i.e. a cough longer than 8 weeks, more than 90% of cases are due to post-nasal drip, asthma, eosinophilic bronchitis, and gastroesophageal reflux disease. [5] The causes of chronic cough are similar in children with the addition of bacterial bronchitis. [5]

Infections

A cough can be the result of a respiratory tract infection such as the common cold, COVID-19, acute bronchitis, pneumonia, pertussis, or tuberculosis. In the vast majority of cases, acute coughs, i.e. coughs shorter than 3 weeks, are due to the common cold. [7] In people with a normal chest X-ray, tuberculosis is a rare finding. Pertussis is increasingly being recognised as a cause of troublesome coughing in adults.

After a respiratory tract infection has cleared, the person may be left with a postinfectious cough. This typically is a dry, non-productive cough that produces no phlegm. Symptoms may include a tightness in the chest, and a tickle in the throat. This cough may often persist for weeks after an illness. The cause of the cough may be inflammation similar to that observed in repetitive stress disorders such as carpal tunnel syndrome. The repetition of coughing produces inflammation which produces discomfort, which in turn produces more coughing. [8] Postinfectious cough typically does not respond to conventional cough treatments. Medication used for postinfectious coughs may include ipratropium [8] to treat the inflammation, as well as cough suppressants to reduce frequency of the cough until inflammation clears. [9] Inflammation may increase sensitivity to other existing issues such as allergies, and treatment of other causes of coughs (such as use of an air purifier or allergy medicines) may help speed recovery. [10]

Reactive airway disease

When coughing is the only complaint of a person who meets the criteria for asthma (bronchial hyperresponsiveness and reversibility), this is termed cough-variant asthma. Atopic cough and eosinophilic bronchitis are related conditions. Atopic cough occurs in individuals with a family history of atopy (an allergic condition), abundant eosinophils in the sputum, but with normal airway function and responsiveness. Eosinophilic bronchitis is characterized by eosinophils in sputum and in bronchoalveolar lavage fluid without airway hyperresponsiveness or an atopic background. [11] This condition responds to treatment with corticosteroids. Cough can also worsen in an acute exacerbation of chronic obstructive pulmonary disease.

Asthma is a common cause of chronic cough in adults and children. Coughing may be the only symptom the person has from their asthma, or asthma symptoms may also include wheezing, shortness of breath, and a tight feeling in their chest. Depending on how severe the asthma is, it can be treated with bronchodilators (medicine which causes the airways to open up) or inhaled steroids. Treatment of the asthma should make the cough go away.

Chronic bronchitis is defined clinically as a persistent cough that produces sputum (phlegm) and mucus, for at least three months in two consecutive years. Chronic bronchitis is often the cause of "smoker's cough". The tobacco smoke causes inflammation, secretion of mucus into the airway, and difficulty clearing that mucus out of the airways. Coughing helps clear those secretions out. May be treated by quitting smoking. May also be caused by pneumoconiosis and long-term fume inhalation.

Gastroesophageal reflux

In people with unexplained cough, gastroesophageal reflux disease should be considered. [5] This occurs when acidic contents of the stomach come back up into the esophagus. Symptoms usually associated with GERD include heartburn, sour taste in the mouth, or a feeling of acid reflux in the chest, although, more than half of the people with cough from GERD do not have any other symptoms. An esophageal pH monitor can confirm the diagnosis of GERD. Sometimes GERD can complicate respiratory ailments related to cough, such as asthma or bronchitis. The treatment involves anti-acid medications and lifestyle changes with surgery indicated in cases not manageable with conservative measures.

Air pollution

Coughing may be caused by air pollution including tobacco smoke, particulate matter, irritant gases, and dampness in a home. [5] The human health effects of poor air quality are far reaching, but principally affect the body's respiratory system and the cardiovascular system. Individual reactions to air pollutants depend on the type of pollutant a person is exposed to, the degree of exposure, the individual's health status and genetics. People who exercise outdoors on hot, smoggy days, for example, increase their exposure to pollutants in the air.

Foreign body

A foreign body can sometimes be suspected, for example if the cough started suddenly when the patient was eating. Rarely, sutures left behind inside the airway branches can cause coughing. A cough can be triggered by dryness from mouth breathing or recurrent aspiration of food into the windpipe in people with swallowing difficulties. [12] [13]

Drug-induced cough

Drugs used for treatments other than coughs, such as ACE inhibitors which are often used to treat high blood pressure, can sometimes cause cough as a side effect, and stopping their use will stop the cough. [14] Beta blockers similarly cause cough as an adverse event. [2]

Tic cough

A tic cough, previously called a habit cough, is one that responds to behavioral or psychiatric therapy after organic causes have been excluded. Absence of the cough during sleep is common, but not diagnostic. A tic cough is thought to be more common in children than in adults. [15] A similar disorder is the somatic cough syndrome previously called the psychogenic cough.

Neurogenic cough

Some cases of chronic cough may be attributed to a sensory neuropathic disorder. [16] Treatment for neurogenic cough may include the use of certain neuralgia medications. Coughing may occur in tic disorders such as Tourette syndrome, although it should be distinguished from throat-clearing in this disorder.

Other

Cough may also be caused by conditions affecting the lung tissue such as bronchiectasis, cystic fibrosis, interstitial lung diseases and sarcoidosis. Coughing can also be triggered by benign or malignant lung tumors or mediastinal masses. Through irritation of the nerve, diseases of the external auditory canal (wax, for example) can also cause cough. Cardiovascular diseases associated with cough are heart failure, pulmonary infarction and aortic aneurysm. Nocturnal cough is associated with heart failure, as the heart does not compensate for the increased volume shift to the pulmonary circulation, in turn causing pulmonary edema and resultant cough. [17] Other causes of nocturnal cough include asthma, post-nasal drip and gastroesophageal reflux disease (GERD). [18] Another cause of cough occurring preferentially in supine position is recurrent aspiration. [17]

Given its irritant nature to mammal tissues, capsaicin is widely used to determine the cough threshold and as a tussive stimulant in clinical research of cough suppressants. Capsaicin is what makes chili peppers spicy, and might explain why workers in factories with these fruits can develop a cough.

Coughing may also be used for social reasons, and as such is not always involuntary. A voluntary cough, often written as "ahem", can be used to attract attention or express displeasure, as a form of nonverbal, paralingual metacommunication. [19] [20]

Airway clearance

Coughing, and huffing are important ways of removing mucus as sputum in many conditions such as cystic fibrosis, and chronic bronchitis.

Pathophysiology

Coughing is viewed as a public health issue. CoughsAndSneezesSpreadDiseases.jpg
Coughing is viewed as a public health issue.

A cough is a protective reflex in healthy individuals which is influenced by psychological factors. [5] The cough reflex is initiated by stimulation of two different classes of afferent nerves, namely the myelinated rapidly adapting receptors, and nonmyelinated C-fibers with endings in the lung. [21]

Diagnostic approach

The type of cough may help in the diagnosis. For instance, an inspiratory "whooping" sound on coughing almost doubles the likelihood that the illness is pertussis.

Blood may occur in small amounts with severe cough of many causes, but larger amounts suggests bronchitis, bronchiectasis, tuberculosis, or primary lung cancer. [22]

Further workup may include labs, x-rays, and spirometry. [5]

Classification

A cough can be classified by its duration, character, quality, and timing. [5] The duration can be either acute (of sudden onset) if it is present less than three weeks, subacute if it is present between three or eight weeks, and chronic when lasting longer than eight weeks. [5] A cough can be non-productive (dry) or productive (when phlegm is produced that may be coughed up as sputum). It may occur only at night (then called nocturnal cough), during both night and day, or just during the day. [5]

A number of characteristic coughs exist. While these have not been found to be diagnostically useful in adults, they are of use in children. [5] A barky cough is part of the common presentation of croup. [23] A staccato cough has been classically described with neonatal chlamydial pneumonia. [24]

Treatment

The treatment of a cough in children is based on the underlying cause. In children half of cases go away without treatment in 10 days and 90% in 25 days. [25]

According to the American Academy of Pediatrics the use of cough medicine to relieve cough symptoms is supported by little evidence and thus not recommended for treating cough symptoms in children. [5] There is tentative evidence that the use of honey is better than no treatment or diphenhydramine in decreasing coughing. [26] It does not alleviate coughing to the same extent as dextromethorphan but it shortens the cough duration better than placebo and salbutamol. [26] A trial of antibiotics or inhaled corticosteroids may be tried in children with a chronic cough in an attempt to treat protracted bacterial bronchitis or asthma respectively. [5] There is insufficient evidence to recommend treating children who have a cough that is not related to a specific condition with inhaled anti-cholinergics. [27]

Because coughing can spread disease through infectious aerosol droplets, it is recommended to cover one's mouth and nose with the forearm, the inside of the elbow, a tissue or a handkerchief while coughing. [28]

Epidemiology

A cough is the most common reason for visiting a primary care physician in the United States. [5]

Other animals

A coughing deer hind 20191124Wildfreigehege Wolfsrat 10.jpg
A coughing deer hind

Marine mammals such as dolphins and whales cannot cough. [29] Some invertebrates such as insects and spiders cannot cough or sneeze. Alligators can cough. [30] Domestic animals and vertebrates such as dogs and cats can cough, because of diseases, allergies, dust or choking. [31] In particular, cats are known for coughing before spitting up a hairball. [31]

In other domestic animals, horses can cough because of infections, or due to poor ventilation and dust in enclosed spaces. [32] Kennel cough in dogs can result from a viral or bacterial infection.

Deer can cough similarly to humans as a result of respiratory tract infections, such as parasitic bronchitis caused by a species of Dictyocaulus. [33]

Related Research Articles

<span class="mw-page-title-main">Asthma</span> Long-term inflammatory disease of the airways of the lungs

Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath. These may occur a few times a day or a few times per week. Depending on the person, asthma symptoms may become worse at night or with exercise.

<span class="mw-page-title-main">Sputum</span> Mucus that is coughed up from the lower airways

Sputum is mucus that is coughed up from the lower airways. In medicine, sputum samples are usually used for a naked eye examination, microbiological investigation of respiratory infections and cytological investigations of respiratory systems. It is crucial that the specimen does not include any mucoid material from the nose or oral cavity.

<span class="mw-page-title-main">Respiratory tract</span> Organs involved in transmission of air to and from the point where gases diffuse into tissue

The respiratory tract is the subdivision of the respiratory system involved with the process of conducting air to the alveoli for the purposes of gas exchange in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa.

<span class="mw-page-title-main">Acute bronchitis</span> Medical condition

Acute bronchitis, also known as a chest cold, is short-term bronchitis – inflammation of the bronchi of the lungs. The most common symptom is a cough. Other symptoms include coughing up mucus, wheezing, shortness of breath, fever, and chest discomfort. The infection may last from a few to ten days. The cough may persist for several weeks afterward with the total duration of symptoms usually around three weeks. Some have symptoms for up to six weeks.

<span class="mw-page-title-main">Phlegm</span> Mucus produced by the respiratory system (excluding the nasal passages)

Phlegm is mucus produced by the respiratory system, excluding that produced by the throat nasal passages. It often refers to respiratory mucus expelled by coughing, otherwise known as sputum. Phlegm, and mucus as a whole, is in essence a water-based gel consisting of glycoproteins, immunoglobulins, lipids and other substances. Its composition varies depending on climate, genetics, and state of the immune system. Its color can vary from transparent to pale or dark yellow and green, from light to dark brown, and even to dark grey depending on the contents. The body naturally produces about 1 quart of phlegm every day to capture and clear substances in the air and bacteria from the nose and throat.

<span class="mw-page-title-main">Bronchiectasis</span> Permanent enlargement of the lung airways

Bronchiectasis is a disease in which there is permanent enlargement of parts of the airways of the lung. Symptoms typically include a chronic cough with mucus production. Other symptoms include shortness of breath, coughing up blood, and chest pain. Wheezing and nail clubbing may also occur. Those with the disease often get lung infections.

<span class="mw-page-title-main">Laryngitis</span> Inflammation of the larynx (voice box)

Laryngitis is inflammation of the larynx. Symptoms often include a hoarse voice and may include fever, cough, pain in the front of the neck, and trouble swallowing. Typically, these last under two weeks.

Eosinophilic pneumonia is a disease in which an eosinophil, a type of white blood cell, accumulates in the lungs. These cells cause disruption of the normal air spaces (alveoli) where oxygen is extracted from the atmosphere. Several different kinds of eosinophilic pneumonia exist and can occur in any age group. The most common symptoms include cough, fever, difficulty breathing, and sweating at night. Eosinophilic pneumonia is diagnosed by a combination of characteristic symptoms, findings on a physical examination by a health provider, and the results of blood tests and X-rays. Prognosis is excellent once most eosinophilic pneumonia is recognized and treatment with corticosteroids is begun.

<span class="mw-page-title-main">Respiratory disease</span> Disease of the respiratory system

Respiratory diseases, or lung diseases, are pathological conditions affecting the organs and tissues that make gas exchange difficult in air-breathing animals. They include conditions of the respiratory tract including the trachea, bronchi, bronchioles, alveoli, pleurae, pleural cavity, the nerves and muscles of respiration. Respiratory diseases range from mild and self-limiting, such as the common cold, influenza, and pharyngitis to life-threatening diseases such as bacterial pneumonia, pulmonary embolism, tuberculosis, acute asthma, lung cancer, and severe acute respiratory syndromes, such as COVID-19. Respiratory diseases can be classified in many different ways, including by the organ or tissue involved, by the type and pattern of associated signs and symptoms, or by the cause of the disease.

Acute severe asthma, also known as status asthmaticus, is an acute exacerbation of asthma that does not respond to standard treatments of bronchodilators (inhalers) and corticosteroids. Asthma is caused by multiple genes, some having protective effect, with each gene having its own tendency to be influenced by the environment although a genetic link leading to acute severe asthma is still unknown. Symptoms include chest tightness, rapidly progressive dyspnea, dry cough, use of accessory respiratory muscles, fast and/or labored breathing, and extreme wheezing. It is a life-threatening episode of airway obstruction and is considered a medical emergency. Complications include cardiac and/or respiratory arrest. The increasing prevalence of atopy and asthma remains unexplained but may be due to infection with respiratory viruses.

<span class="mw-page-title-main">Airway obstruction</span> Blockage in the respiratory system

Airway obstruction is a blockage of respiration in the airway that hinders the free flow of air. Airway obstructions can occur either in the upper airway (UPA) or lower airway (LOA). The upper airway consists of the nose, throat, and larynx. The lower airway comprises the trachea, bronchi, and bronchioles.

Reactive airway disease (RAD) is an informal label that physicians apply to patients with symptoms similar to those of asthma. An exact definition of the condition does not exist. Individuals who are typically labeled as having RAD generally have a history of wheezing, coughing, dyspnea, and production of sputum that may or may not be caused by asthma. Symptoms may also include, but are not limited to, coughing, shortness of breath, excess mucus in the bronchial tube, swollen mucous membrane in the bronchial tube, and/or hypersensitive bronchial tubes. Physicians most commonly label patients with RAD when they are hesitant about formally diagnosing a patient with asthma, which is most prevalent in the pediatric setting. While some physicians may use RAD and asthma synonymously, there is controversy over this usage.

<span class="mw-page-title-main">Bronchitis</span> Inflammation of the large airways in the lungs

Bronchitis is inflammation of the bronchi in the lungs that causes coughing. Bronchitis usually begins as an infection in the nose, ears, throat, or sinuses. The infection then makes its way down to the bronchi. Symptoms include coughing up sputum, wheezing, shortness of breath, and chest pain. Bronchitis can be acute or chronic.

<span class="mw-page-title-main">Diffuse panbronchiolitis</span> Inflammatory lung disease

Diffuse panbronchiolitis (DPB) is an inflammatory lung disease of unknown cause. It is a severe, progressive form of bronchiolitis, an inflammatory condition of the bronchioles. The term diffuse signifies that lesions appear throughout both lungs, while panbronchiolitis refers to inflammation found in all layers of the respiratory bronchioles. DPB causes severe inflammation and nodule-like lesions of terminal bronchioles, chronic sinusitis, and intense coughing with large amounts of sputum production.

Vocal cord dysfunction (VCD) is a condition affecting the vocal cords. It is characterized by abnormal closure of the vocal folds, which can result in significant difficulties and distress during breathing, particularly during inhalation.

<span class="mw-page-title-main">Acute exacerbation of chronic obstructive pulmonary disease</span> Medical condition

An acute exacerbation of chronic obstructive pulmonary disease, or acute exacerbations of chronic bronchitis (AECB), is a sudden worsening of chronic obstructive pulmonary disease (COPD) symptoms including shortness of breath, quantity and color of phlegm that typically lasts for several days.

<span class="mw-page-title-main">Eosinophilic bronchitis</span> Medical condition

Eosinophilic bronchitis (EB) is a type of airway inflammation due to excessive mast cell recruitment and activation in the superficial airways as opposed to the smooth muscles of the airways as seen in asthma. It often results in a chronic cough. Lung function tests are usually normal. Inhaled corticosteroids are often an effective treatment.

<span class="mw-page-title-main">Chronic obstructive pulmonary disease</span> Lung disease involving long-term poor airflow

Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by chronic respiratory symptoms and airflow limitation. GOLD 2024 defined COPD as a heterogeneous lung condition characterized by chronic respiratory symptoms due to abnormalities of the airways and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction.

In clinical guidelines chronic cough is defined as a cough lasting more than 8 weeks in adults and more than 4 weeks in children. there are studies suggest that a chronic cough must persist upwards of three months. The prevalence of chronic cough is about 10% although the prevalence may differ depending on definition and geographic area. Chronic cough is a common symptom in several different respiratory diseases like COPD or pulmonary fibrosis but in non-smokers with a normal chest x-ray chronic cough are often associated with asthma, rhinosinusitis, and gastroesophageal reflux disease or could be idiopathic. Generally, a cough, for example after an upper respiratory tract infection, lasts around one to two weeks; however, chronic cough can persist for an extended period of time, several years in some cases. The current theory about the cause of chronic cough, independent of associated condition, is that it is caused by a hypersensitivity in the cough sensory nerves, called cough hypersensitivity syndrome. There are a number of treatments available, depending on the associated disease but the clinical management of the patients remains a challenge. Risk factors include exposure to cigarette smoke, and exposure to pollution, especially particulates.

Asthma phenotyping and endotyping is a novel approach to asthma classification inspired by precision medicine. It seeks to separate the clinical presentations or clusters of signs and symptoms of asthma, known as asthma phenotypes, from their underlying etiologies or causes, known as asthma endotypes.

References

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  4. ↑ "Cystocele (Prolapsed Bladder) | NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 2017-12-02.
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  29. ↑ Woodard, James C.; Zam, Stephen G.; Caldwell, David K.; Caldwell, Melba C. (29 August 2016). "Some Parasitic Diseases of Dolphins". Pathologia Veterinaria. 6 (3): 257–272. doi: 10.1177/030098586900600307 . PMID   5817449. S2CID   26842976.
  30. ↑ "Crocodile 'cough' caught on camera in Florida Everglades". WFLA. 2023-08-23. Retrieved 2024-06-13.
  31. 1 2 "Is It Normal for Cats To Cough?". Pet Health Network. Retrieved 2018-04-23.
  32. ↑ "Coughing in horses explained". Your Horse Magazine. Archived from the original on 2020-07-28. Retrieved 2018-04-23.
  33. ↑ Pyziel, Anna M.; Laskowski, Zdzisław; Demiaszkiewicz, Aleksander W.; Höglund, Johan (2017). "Interrelationships of Dictyocaulusspp. In Wild Ruminants with Morphological Description of Dictyocaulus cervin. Sp. (Nematoda: Trichostrongyloidea) from Red Deer,Cervus elaphus". Journal of Parasitology. 103 (5): 506–518. doi:10.1645/16-75. PMID   28585897. S2CID   25720548.

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