Definition: the cough is a violent process of breathing out,
like an "explosive expiration", often to allow the drainage outside of foreign bodies (the
mouthful that goes in trachea it's a classic example of explosive cough) or any
secretions, for example the smoker's catarrh (smoking).
It is one of the most common causes for which the doctor is asked.
The causes of cough are the most disparate; it can be the coughing in the decubitus
of the first hours by night , due to congestion of the lung that manifests itself in the diseased
heart patient, where lung is not aspirated by the weakened heart and therefore it's
congested, a condition that causes cough; or it is the cough of the
chronic
bronchopathic smoker, of the asthmatic patient, accompanied by wheezing, the
cough of the acute bronchitis.
Still we distinguish a subtle and persistent cough of the patient with lung
tumor and with pleural effusion.
We distinguish a cough:
•Acute and subacute
•Persistent
•Chronic
Acute cough, in acute infections, which lasts for up to 3 weeks, becomes
subacute, if it lasts less than 3 weeks and up to eight weeks; persistent, which
to be defined as such must last for at least two weeks. Chronic cough is
characteristic of chronic obstructive bronchopathy.
The cough can be voluntary or reflected and as such it needs an afferent way,
that is a road that leads the signal towards the center, then the central
nervous system, and an efferent way, that is, which brings the result of the
afference and, therefore, the action of cough itself.
The afferent pathway includes signal receptors which are the terminations of the
sensitive trigeminal, superior glossopharyngeal and vague; the
efferent pathway instead follows the recurrent laryngeal nerve,
responsible for the closure of the glottis and of the spinal nerves (which
cause the contraction of the muscles of the abdominal and thoracic wall.
After a suitable stimulus, for example of the powder to which a patient can be allergic,
begins a deep inhalation followed by the closing of the glottis, the release of
the diaphragm and finally the contraction of the muscles of the abdominal and
thoracic wall which occurs at a closed glottis; then the air is expelled
violently and with the air jet even the secretions of mucus are removed out..
Foreign substances, powders, smoke, vapors
Foreign bodies
Irritation of the respiratory tract and secretions
Esophageal reflux with aspiration of liquid into the trachea
Drugs for example ace-inhibitors (eg enalapril and similar molecules) related
to the accumulation of bradykinin or substance P, by inhibition of the
conversion enzyme that degrades these substances.
Inflammation of the respiratory mucosa,
Bronchoconstriction (asthma)
Conditions of edema and pulmonary preedema (!)
Heart failure
Pertussis, that is, bordetella pertussis infection
Chronic hostile bronchitis
Attack of bronchial asthma
Lung cancer (bronchial carcinoma or carcinoid)
The anamnesis, that is the history of the patient must be indagated
Is the cough acute or chronic? Is there a possible respiratory infection, is
there a fever? Is it seasonal cough, for example in spring?
Do you associate with respiratory distress?
Is there sputum? And is the sputum streaked with blood?
Does the patient smoke? Does your patient work in industries ? Does he live at home, in dusty places, eg libraries, archives, law firms with masses of parchment practices?
Does he use enapren, enalapril, other ace inhibitors?
Does he suffer from heart and have swollen feet (see special heart failure)? Does he have dyspnoea? Does he have heart failure?
CfIt can highlight signs of extrapulmonary cough causes, such as:
Heart failure, with congestion of the pulmonary circulation; in these cases the
patient is usually elderly and at the auscultation of the chest, the signs of
the congestion of the pulmonary circuit appear, like the crackles, which are the signs of
the condition of pulmonary edema or the find of a "wet lung", badly aspirated
by a weak heart, and limited gas exchanges are found at hemogas analysis..
Sometimes at the nose inspection a chronic
rhinitis with flat and fibrous nasal mucosa and rhinorrhea, or a cobbled mucosa or a
pharyngeal hyperemia or pus plaques to the tonsils that document infections; to
the auscultation of the inspiratory
crackles that orientate
the diagnosis to an interstitial lung
diseases;
the chest x-ray may suggest
the cause of the cough, due to the presence of pleuroparenchymal lesions or
simply to the accumulation of the vascular circulation or the opaque masses, the nodules, the
pulmonary thickening, blurred, or to net margins, or lobates, or
whole lungs that appear to be affected by inflammatory processes, lobar
pneumonias, interstitiopathies, "honeycomb" appearance, etc.
So the old chest-X-ray always has the right weight in the patient's control. It must
follow, if appropriate, the tests of respiratory function or spirometry,
especially in the bronchitic patient.
With spirometry we can highlight FEV 1, which is the air flow measured in volume at the
first second of expiration, expression of obstruction of the upper airways, or bronchoconstriction which in the most stubborn cases is manifested by the "dry"
hissing noise or bronchostenosis serrata.
If sputum is present, it should be inspected and ruled out that there may be
blood traces, expression of respiratory tract injury, or on an inflammatory
basis, or on a dysplastic basis, as for tumors, or on an infectious basis, as
was the case for tuberculosis .
If there is a yellow-foamy sputum, diagnosis is oriented towards thepurulent
respiratory forms, in
general, of chronic bronchitic smokers, bronchiectasis and pneumonia with lung
abscess.
Examination that must follow these will be the sputum culture and the fresh
examination with research of resistant alcohol-acid bacterium or Koch's bacillus.
When the blood is more abundant we speak of hemoptysis, that is "aima ptiuo",
from the Greek language, a sputum with blood, and refers to the emission of
blood from the respiratory tract.
Bronchoscopy is a technique to be performed to visualize the
respiratory pathways and to exclude injuries, better if associated with BAL,
that is to wash the respiratory tract with the study of the washing or brushing
liquid, ie brushing of the suspected lesions and epithelia.
Upon inspection of the bronchus, granulomas can be detected, which often occurs
in sarcoidosis. The tac with contrast or without suggesting the neoplastic
nature of the lesions or rather a simple interstitiopathy.
It's not good to entrust your health to the first
employee of the pharmacy who sells you a cough medicine, which often only causes
damage to your money and your health.!
The drugs used for coughing are:
The sedative drugs, which, personally I use in rare cases, for example if there are
costal fractures, aren't indicated. The only indications are in the rib fractures,
because the fractures can tearing the lung if a patient has cough attacks.
Sedatives are extracts of opium, opioids, or opiates, e.g. dextromethorphan and
codeine, which are sometimes sold as counter products.
Corticosteroids, methylpredinisolone, beclometasone, fluticasone, etc., are the
right indication drugs used in chronic bronchitis. or the hypatropium bromide
that sedates the afferent way in the reflex of the cough; antibiotics
which are generally cephalosporins and macrolides or simply amoxicillin, in the more severe cases
also
piperacillin and tazobactam).
Fluidizers, excellent drugs to thin and promote the expulsion of mucus, but
dangerous in the bronchopathic patient or in a patient affected by heart disease, where they can have
very unpleasant side effects because the mucus is dissolved but often can not be
expectorated due to lack of energy and the patient has no a benefit but rather
he suffocates.
Diuretics that are used in conditions of heart failure and lung edema, to "discharge"
the small pulmonary circulation, so to speak! In the most severe cases we also
use nitroderivatives that can be administered in a vein in urgencies eg.
nitroglycerin in the attack of pulmonary edema, to reduce the resistance of the
lung.
Beta 2 stimulants for aerosols, fast-acting ones (eg salbutamol, the old
ventolin spray) and long-acting beta 2, formeterol, are indicated in chronic
bronchitic cough; not to be neglected the action of intravenous theophylline
administered in the patient with bronchostenosis;
The adrenaline that I personally see used for aerosol or under diluted skin in
the unresolvable asthma accesses for close bronchostosis
Lastly or primarily the God's intervention that you must always pray when you
are treating an asthmatic patient with a serious broncostenosis! And I know
something about it!
In the very last you must remind to your women, that a super-clean and dust-free house,
with dry and stale air, when the child is kept inside, covered with sweaters,
is more exposed to asthmatic bronchitis than any other child in the third world!
Let them live their lives in peace and "when the wind of life blows", let them
raise their sails "(Spoon River).
index pneumology