Treatments, sign & Symptoms, Diagnosis of COUGH

Treatments, sign & Symptoms, Diagnosis of COUGH

Essential Inquiries:
Age.
Duration of cough.
Dyspnea (at rest or with exertion).
Tobacco use history.
 Vital signs (heart rate, respiratory rate, body
temperature).
Chest examination.
Chest radiography when unexplained cough lasts
more than 3–6 weeks.

General Considerations
Cough adversely affects personal and work-related interactions, disrupts sleep, and often causes discomfort of the throat and chest wall. Most people seeking medical attention for acute cough desire symptom relief; few are worried about serious illness. Cough results from stimulation of mechanical or chemical afferent nerve receptors in the bronchial tree. Effective cough depends on an intact afferent–efferent reflex arc, adequate expiratory and chest wall muscle strength, and normal mucociliary production and clearance.
 

Clinical Findings

A. Symptoms: - Distinguishing acute (< 3 weeks), persistent (3–8 weeks), and chronic (> 8 weeks) cough illness syndromes is a useful first step in evaluation. Postinfectious cough lasting
3–8 weeks has also been referred to as subacute cough to distinguish this common, distinct clinical entity from acute and chronic cough.
1. Acute cough—In healthy adults, most acute cough syndromes are due to viral respiratory tract infections. Additional features of infection such as fever, nasal congestion, and sore throat help confirm the diagnosis.
2. Persistent and chronic cough—Cough due to acute respiratory tract infection resolves within 3 weeks in the vast majority of patients (over 90%). Pertussis infection should be considered in adolescents and adults who present with persistent or severe cough lasting more than 3 weeks.
In selected geographic areas, the prevalence of pertussis approaches 20% when cough has persisted beyond 3 weeks, although the exact prevalence of pertussis is difficult to ascertain due to the limited sensitivity of diagnostic tests.
B. Physical Examination: - Physical examination of patients with persistent cough should look for evidence of chronic sinusitis, contributing to postnasal drip syndrome or asthma. Chest and cardiac signs may help distinguish COPD from CHF.

C. Diagnostic Studies

1. Acute cough—Chest radiography should be considered for any adult with acute cough who shows abnormal vital signs or in whom the chest examination is suggestive of pneumonia. The relationship between specific clinical findings and the probability of pneumonia. In patients with dyspnea, pulse oximetry and peak flow help exclude hypoxemia or obstructive airway disease.
2. Persistent and chronic cough—Chest radiography is indicated when ACE inhibitor therapy–related and postinfectious cough are excluded by history or further diagnostic testing. If pertussis infection is suspected, testing should be performed using polymerase chain reaction on a nasopharyngeal swab or nasal wash specimen—keeping in mind that the ability to detect pertussis decreases as the duration of cough increases. When the chest film is normal,
postnasal drip, asthma, and GERD are the most likely causes.

Treatment

A. Acute Cough: - Treatment of acute cough should target the underlying etiology of the illness, the cough reflex itself, and any additional factors that exacerbate the cough. When influenza is
diagnosed, treatment with amantadine, rimantadine, oseltamivir, or zanamivir is equally effective (1 less day of illness) when initiated within 30–48 hours of illness onset, although treatment is recommended regardless of illness duration when patients present with severe illness requiring hospitalization. Furthermore, in the setting of H1N1 influenza, neuraminidase inhibitors are the preferred treatment due to resistance to amantadine/rimantidine. In
the setting of Chlamydia or Mycoplasma-documented infection or outbreaks, first-line antibiotics include erythromycin, 250 mg orally four times daily for 7 days, or doxycycline, 100 mg orally twice daily for 7 days. In patients diagnosed with acute bronchitis, inhaled b2-agonist
therapy reduces severity and duration of cough in some patients.

B. Persistent and Chronic Cough: - Evaluation and management of persistent cough often
requires multiple visits and therapeutic trials, which frequently lead to frustration, anger, and anxiety. When pertussis infection is suspected, treatment with a macrolide antibiotic (azithromycin 500 mg on day 1, then 250 mg once daily for days 2–5; clarithromycin 500 mg twice daily for 7 days; erythromycin 250 mg four times daily for 14 days) is appropriate to reduce shedding and transmission of the organism. When pertussis infection has lasted more than 7–10 days, antibiotic treatment does not affect the duration of cough, which can last up to 6 months.

When to Admit: - Patient at high risk for tuberculosis for whom compliance.
with respiratory precautions is uncertain. Need for urgent bronchoscopy, such as suspected
foreign body. Smoke or toxic fume inhalational injury. Intractable cough despite treatment, when cough impairs gas exchange or in patients at high risk for barotraumas (eg, recent pneumothorax).