Cough - Wikipedia, the free encyclopedia

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Cough
From Wikipedia, the free encyclopedia

A cough ( pronunciation Latin:

tussis) is a sudden and often
repetitively occurring reflex which
helps to clear the large breathing
passages from secretions, irritants,
foreign particles and microbes. The
cough reflex consists of 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

Cough

accompanied by a distinctive sound.[1]

Coughing is either voluntary or
involuntary.
Frequent coughing usually indicates
the presence of a disease. Many
viruses and bacteria benefit
evolutionarily by causing the host to
cough, which helps to spread the
disease to new hosts. Most of the time,
irregular coughing is 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 ACE
inhibitors.

A young boy coughing due to pertussis causing whooping cough.

Coughing
The sound of a person coughing.
Problems playing this file? See media help.

ICD-10

R05
(http://apps.who.int/classifications/icd10/browse/2015/en#/R05)

ICD-9

786.2 (http://www.icd9data.com/getICD9Code.ashx?
icd9=786.2)

DiseasesDB 17149 (http://www.diseasesdatabase.com/ddb17149.htm)

MedlinePlus 003072

Treatment should target the cause; for

(http://www.nlm.nih.gov/medlineplus/ency/article/003072.htm)
example, smoking cessation or
eMedicine ENT/1048560
discontinuing ACE inhibitors. Cough
(http://www.emedicine.com/ENT/topic1048560.htm)
suppressants such as codeine or
dextromethorphan are frequently
prescribed, but have been demonstrated to have little effect. 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.[2]

Contents
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1 Classification
2 Differential diagnosis
2.1 Infections
2.2 Reactive airway disease
2.3 Gastroesophageal reflux
2.4 Air pollution
2.5 Foreign body
2.6 Angiotensin-converting enzyme inhibitor
2.7 Psychogenic cough
2.8 Neurogenic cough
2.9 Other
3 Pathophysiology
4 Diagnostic approach
5 Treatment
6 Complications
7 Epidemiology
8 References
9 External links

Classification
A cough can be classified by its duration, character, quality, and timing.[3] The duration can be either acute (of
sudden onset) if it is present less than three weeks, subacute if it is present between three and eight weeks, and
chronic when lasting longer than eight weeks.[3] A cough can be non-productive (dry) or productive (when
sputum is coughed up). It may occur only at night (then called nocturnal cough), during both night and day, or
just during the day.[3]
A number of characteristic coughs exist. While these have not been found to be diagnostically useful in adults,
they are of use in children.[3] A barky cough is part of the common presentation of croup,[4] while a staccato
cough has been classically described with chlamydia pneumonia.[5]

Differential diagnosis
A cough in children may be either a normal physiological reflex or due to an underlying cause.[3] In healthy
children it may be normal in the absence of any disease to cough ten times a day.[3] The most common cause of
an acute or subacute cough is a viral respiratory tract infection.[3] 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.[3] The causes of chronic cough are similar in children with the addition of
bacterial bronchitis.[3]

Infections
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A cough can be the result of a respiratory tract infection such as the common cold, 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.[6] 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.[7] Postinfectious cough typically does not respond to conventional cough treatments. Treatment
consists of any anti-inflammatory medicine (such as ipratropium) [7] to treat the inflammation, and a cough
suppressant to reduce frequency of the cough until inflammation clears. 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. A bronchodilator, which helps open up the airways, may also
help treat this type of cough.

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. Two related conditions are atopic
cough and eosinophilic bronchitis. Atopic cough occurs in individuals with a family history of atopy, abundant
eosinophils in the sputum, but with normal airway function and responsiveness. Eosinophilic bronchitis is also
characterized by eosinophils in the sputum, without airway hyperresponsiveness or an atopic background. 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 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.[3] 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 dont have any other symptoms. An esophageal pH monitor can confirm the
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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.[3] 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.

Angiotensin-converting enzyme inhibitor

Angiotensin-converting enzyme inhibitors are drugs used in diabetics, heart disease, and high blood pressure. In
10-25% of the people who take it, it can cause them to have a cough as a side effect. Cessation of ACE Inhibitor
use is the only way to stop the cough. Such medicines for hypertension are very common in use such as ramipril
and quinapril. There are cases of "cough of unknown origin" who had resolution with stopping the drug.[8]

Psychogenic cough
A psychogenic cough ("habit cough" or "tic cough") may be the cause in the absence of a physical problem. In
these instances, emotional and psychological problems are suspected. However, other illnesses have to be ruled
out before a firm diagnosis of psychogenic cough is made. Psychogenic cough is thought to be more common in
children than in adults. A possible scenario: psychogenic cough develops in a child who has a chronically ill
brother or sister.[9]

Neurogenic cough
Some cases of chronic cough may be attributed to a sensory neuropathic disorder.[10] Treatment for neurogenic
cough may include the use of certain neuralgia medications.

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
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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.[11]
Other causes of nocturnal cough include asthma, post-nasal drip and gastroesophageal reflux disease
(GERD).[12] Another cause of cough occurring preferentially in supine position is recurrent aspiration.[11]
Coughing may also be used for social reasons, such as the coughing before giving a speech. Cough may also be
psychogenic, which is different from habit coughing and tic coughing.[9] Coughing may occur in tic disorders
such as Tourette syndrome, although it should be distinguished from throat-clearing in this disorder.
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 vegetables can develop a cough.
Coughing is not always involuntary, and can be used in social situations. Coughing can be used to attract
attention, release internal psychological tension, or become a maladaptive displacement behavior. It is believed
that the frequency of such coughing increases in environments vulnerable to psychological tension and social
conflict. In such environments, coughing may become one of many displacement behaviors and/or defense
mechanisms. Coughs can be a symptom to the common cold.

Pathophysiology
A cough is a protective reflex in healthy individuals which is influenced
by psychological factors.[3] 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 lungs. However it is not certain that the stimulation of
nonmyelinated C-fibers leads to cough with a reflex as it's meant in
physiology (with its own five components): this stimulation may cause
mast cells degranulation (through an asso-assonic reflex) and edema
which may work as a stimulus for rapidly adapting receptors.

Diagnostic approach
The determination of the cause of a cough usually begins by determining
if it is specific or nonspecific in nature.[3] A specific cough is one
associated with other symptoms and further workup is dependent on
these symptoms while a non specific cough occurs without other signs

Coughing is viewed as a public health

issue.

and symptoms.[3] Further workup may include labs, x rays, and

spirometry.[3]

Treatment

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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.[13]
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.[3] There is
tentative evidence that the use of honey is better than no treatment or diphenhydramine in decreasing
coughing.[14] It appeared similar to dextromethorphan.[14] 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.[3]

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, rupture of blebs causing spontaneous pneumothorax (although this still
remains to be proven), 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.

Epidemiology
A cough is the most common reason for visiting a primary care physician in the United States.[3]

References
1. Chung KF, Pavord ID (April 2008). "Prevalence, pathogenesis, and causes of chronic cough"
(http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(08)60595-4). Lancet 371 (9621): 136474. doi:10.1016/S01406736(08)60595-4 (https://dx.doi.org/10.1016%2FS0140-6736%2808%2960595-4). PMID 18424325
(https://www.ncbi.nlm.nih.gov/pubmed/18424325).
2. Pavord ID, Chung KF (April 2008). "Management of chronic cough" (http://linkinghub.elsevier.com/retrieve/pii/S01406736(08)60596-6). Lancet 371 (9621): 137584. doi:10.1016/S0140-6736(08)60596-6
(https://dx.doi.org/10.1016%2FS0140-6736%2808%2960596-6). PMID 18424326
(https://www.ncbi.nlm.nih.gov/pubmed/18424326).
3. Goldsobel AB, Chipps BE (March 2010). "Cough in the pediatric population". J. Pediatr. 156 (3): 352358.e1.
doi:10.1016/j.jpeds.2009.12.004 (https://dx.doi.org/10.1016%2Fj.jpeds.2009.12.004). PMID 20176183
(https://www.ncbi.nlm.nih.gov/pubmed/20176183).
4. Bjornson CL, Johnson DW (July 2007). "Croup in the paediatric emergency department"
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528757). Paediatr Child Health 12 (6): 473477. PMC 2528757
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528757). PMID 19030411
(https://www.ncbi.nlm.nih.gov/pubmed/19030411).
5. Miller KE (April 2006). "Diagnosis and treatment of Chlamydia trachomatis infection". Am Fam Physician 73 (8):
14116. PMID 16669564 (https://www.ncbi.nlm.nih.gov/pubmed/16669564).

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6. Dicpinigaitis PV, Colice GL, Goolsby MJ, Rogg GI, Spector SL, Winther B (2009). "Acute cough: a diagnostic and
therapeutic challenge" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2802352). Cough 5: 11. doi:10.1186/1745-99745-11 (https://dx.doi.org/10.1186%2F1745-9974-5-11). PMC 2802352
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2802352). PMID 20015366
(https://www.ncbi.nlm.nih.gov/pubmed/20015366). Retrieved 2010-07-09. "In the vast majority of cases, acute cough is
due to acute viral upper respiratory tract infection (URTI), i.e., the common cold."
7. Postinfectious cough: ACCP evidence-based clinical practice guidelines.
8. Kostas Koliopoulos, Cardiologist: "Cases of Cough of unknown origin, due to use of ACE medication for hypertension",
data on file, Preveza, Greece, 2010
9. Irwin RS, Glomb WB, Chang AB (January 2006). "Habit cough, tic cough, and psychogenic cough in adult and pediatric
populations: ACCP evidence-based clinical practice guidelines" (http://www.chestjournal.org/cgi/pmidlookup?
view=long&pmid=16428707). Chest 129 (1 Suppl): 174S179S. doi:10.1378/chest.129.1_suppl.174S
(https://dx.doi.org/10.1378%2Fchest.129.1_suppl.174S). PMID 16428707
(https://www.ncbi.nlm.nih.gov/pubmed/16428707).
10. Gibson PG, Ryan NM (August 2011). "Cough pharmacotherapy: current and future status"
(http://informahealthcare.com/doi/abs/10.1517/14656566.2011.576249). Expert Opinion on Pharmacotherapy 12 (11):
17451755. doi:10.1517/14656566.2011.576249 (https://dx.doi.org/10.1517%2F14656566.2011.576249).
PMID 21524236 (https://www.ncbi.nlm.nih.gov/pubmed/21524236).
11. NCBI Bookshelf Clinical Methods The Pulmonary System Cough and Sputum Production
(http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A1188) By Sattar Farzan. Extracted from the book
Clinical Methods, 3rd edition The History, Physical, and Laboratory Examinations. Edited by H Kenneth Walker, MD,
W Dallas Hall, MD, and J Willis Hurst, MD. Boston: Butterworths; 1990. ISBN 0-409-90077-X
12. http://www.nlhep.org/books/pul_Pre/chronic-cough.html National Lung Health Education Program > C. Chronic Cough]
The Snowdrift Pulmonary Foundation, Inc. 2000. ISBN 0-9671809-2-9
13. Thompson, M; Vodicka, TA; Blair, PS; Buckley, DI; Heneghan, C; Hay, AD; TARGET Programme, Team (Dec 11,
2013). "Duration of symptoms of respiratory tract infections in children: systematic review."
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3898587). BMJ (Clinical research ed.) 347: f7027.
doi:10.1136/bmj.f7027 (https://dx.doi.org/10.1136%2Fbmj.f7027). PMC 3898587
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3898587). PMID 24335668
(https://www.ncbi.nlm.nih.gov/pubmed/24335668).
14. Oduwole, O; Meremikwu, MM; Oyo-Ita, A; Udoh, EE (Mar 14, 2012). "Honey for acute cough in children.". The
Cochrane database of systematic reviews 3: CD007094. doi:10.1002/14651858.cd007094.pub3
(https://dx.doi.org/10.1002%2F14651858.cd007094.pub3). PMID 22419319
(https://www.ncbi.nlm.nih.gov/pubmed/22419319).

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