Cough Clinical Approach

Coughing is the reflex mechanism of the body to clear breathing passages from irritants, foreign particles, and secretions like mucus. But the main question is, how do we approach a patient who is Coughing?

Earlier, we discussed how to take Clinical History Taking in medical words, and Respiratory system examination, while in this blog, we will reveal everything that can be asked about Cough to reach the diagnosis. Go through the questions and memorize them, for coughing is one of the most common symptoms of the disease.

QUESTION 1- HOW LONG HAVE YOU BEEN SUFFERING FROM THESE COUGH EPISODES?

Duration of cough can classify Cough in three subtypes:-

1. Acute cough

It is a cough for less than 3 weeks.

Causes

• Upper respiratory tract infection- Common cold, acute bacterial sinusitis, pertussis, exacerbations of chronic obstructive pulmonary disease (COPD), allergic rhinitis.
• Lower respiratory tract infection- Pneumonia, aspiration, other infections.
• Miscellaneous- Left ventricular failure.

2. Subacute cough

It is a cough with a duration ranging between 3 to 8 weeks.

Causes

Post-infectious cough, bacterial sinusitis, asthma.

3. Chronic cough

Cough for more than 8 weeks can be due to any of the following causes:

Causes

• 95% cases- Upper airway cough syndrome (UACS) caused by nose and sinuses, asthma, gastroesophageal reflux disease (GERD), chronic bronchitis due to cigarette or other irritants, bronchiectasis, non-asthmatics eosinophilic bronchitis (NAEB) or ACE-Inhibitors.
• 5% remaining cases- Bronchogenic carcinoma, carcinomatosis, sarcoidosis, tuberculosis, left ventricular failure, aspiration.

QUESTION 2- DO THE COUGH EPISODES SHOW VARIATION IN DAYTIME, NIGHT, OR MORNING?

It is known as the Diurnal variation of Cough. It can be significant as:

• Worse at night and early morning- Asthma, congestive heart failure (CHF).
• Worse about waking up in the morning- chronic bronchitis.

QUESTION 3- IS THERE ANY DIFFERENCE IN COUGH IN RELATION TO POSTURE?

It is a Postural variation of the Cough. It can be significant in bronchiectasis, lung abscess, and bronchopleural fistula.

• Increased supine position- GERD and cardiac diseases.

QUESTION 4- WHAT ARE THE PRECIPITATING FACTORS?

• Cold/ Smoke/ Dust/ Exertion- Asthma
• Swallowing of liquids- Neuromuscular disease of the oropharynx

QUESTION 5- DO YOU GET SPUTUM ON COUGHING?

This can categorize as cough in terms of Dry cough and Productive cough. Dry cough is without sputum while Productive cough is associated with sputum often coming out during cough.

• Dry cough– Interstitial lung disease (ILD), acute dry pleurisy.
• Wet cough– Bronchiectasis, lung abscess, empyema, resolution stage of lobar pneumonia, pulmonary edema, bronchitis, COPD, asthma, pneumonia.

QUESTION 6- WHAT IS THE COLOR OF SPUTUM IF ANY?

The color of sputum greatly helps in the differential diagnosis of the coughing symptom. The following are the causes of sputum colors:-

Serous (watery)

• Clear sputum- Normal
• Clear, White, or Pinky froth- Pulmonary edema
• Clear to white (acute)- Viral respiratory tract infections

Mucoid

• Clear to gray- Chronic bronchitis (COPD)
• Yellow to white- Asthma
• Yellow – Acute bronchitis
• Rusty golden yellow- Acute pneumonia
• Green- Pneumonia, lung abscess, chronic bronchitis, bronchiectasis, cystic fibrosis
• Brown- Chronic bronchitis (could be green, yellow, or brown)
• Brown to green- Chronic pneumonia
• Brown to black- Coal worker’s pneumoconiosis
• Brown to red/black- Tuberculosis, lung cancer
• Bloody- Pulmonary embolism (Refer to hemoptysis)

QUESTION 7- WHAT IS THE NATURE OF COUGH? IS ANYTHING IN PARTICULAR?

Cough can present with very specific characteristics which can be tracked down to a typical diagnosis:

1. Bovine cough– Non-explosive cough which is seen in recurrent laryngeal nerve palsy which is commonly due to bronchogenic carcinoma.
2. Whooping cough– High-pitched whoop sound or gasp causing severe coughing fits. It follows a cough and then deep inspiration with a whooping noise. It occurs in bordetella pertussis.
3. Barking cough– It occurs in Croup (viral, mild fever of 100 F, shows steeple sign on x-ray), epiglottitis (muffed up/hot potato voice with high fever, thumbprint sign on x-ray) or bacterial tracheitis (high-grade fever).
4. Brassy cough– It has a typical metallic sound and occurs in laryngeal carcinoma.
5. Spluttering cough– Cough during swallowing which occurs in the tracheoesophageal fistula.
6. Foul-smelling cough– It is typical of bronchiectasis, lung abscess, or empyema.
7. Hacking cough– It is a pharyngeal cough which occurs in heavy smokers, beginning with tuberculosis (short and dry cough with rough and loud sound).

QUESTION 8- IS THERE ANY BLOOD IN THE COUGH?

Hemoptysis or coughing blood is a serious sign and should be immediately considered during differential diagnosis. The following are the causes of blood in sputum:

• Inflammatory lung disease– Bronchitis, tuberculosis, pneumonia, bronchiectasis, lung abscess.
• Neoplasm of lung– Bronchial adenoma, lung cancer.
• Cardiovascular system– Mitral stenosis, left ventricular failure, deep venous thrombosis (DVT) with pulmonary embolism.
• Miscellaneous– Pulmonary vasculitis, hemorrhagic diathesis, anticoagulant therapy, Good-Pasteur’s syndrome, trauma to the legs.

QUESTION 9- WHAT ARE THE ASSOCIATED SYMPTOMS WITH THE COUGH?

The following associated symptoms with cough are better clues in further assessing the diseases:

• Fever– Respiratory tract infection, lung abscess.
• Chest pain– Bronchitis, cancer, pulmonary embolism, pneumonia, gastroesophageal reflux disease (GERD).
• Pleuritic chest pain– Pleurisy, pleural effusion, bronchiectasis.Dyspnoea- COPD, asthma, bronchiectasis, bronchial adenoma/cancer, acute pneumonia, tuberculosis, sarcoidosis, cor pulmonale, congestive heart failure, occupational (eg. pneumoconiosis).
• Wheeze– Asthma, COPD.
• Stridor– Foreign body, laryngeal nerve involvement.
• Nasal discharge or tickling sensation in the throat– Post-nasal drip.
• Loss of weight– Bronchogenic cancer.
• Hoarseness of voice– Laryngeal nerve involvement.
• Heartburn/Regurgitation– GERD
• Erythema nodosum– Sarcoidosis

QUESTION 10- WHAT IS THE TREATMENT HISTORY?

Certain drugs can cause coughing of which, most important are ACE-Inhibitors and Beta-Blockers.

DIFFERENTIAL DIAGNOSIS FOR SOME COMMON CONDITIONS

Following diseases show characteristic patterns of symptoms:

1. Pneumonia– Cough, fever, dyspnoea, rigor, night sweats, chest pain.
2. Asthma– Cough- chronic and dry/productive at night, episodic wheezes, dyspnea, chest tightness.
3. Chronic obstructive pulmonary disease (COPD)– Cough- persistent, large amount of sputum, shortness of breath. {COPD= Emphysema, chronic bronchitis, some forms of bronchiectasis, and refractory asthma}
4. Bronchiectasis– Cough- a chronic, copious amount of foul-smelling sputum, hemoptysis, pleuritic chest pain, dyspnoea, loss of weight, and anemia.
5. Bronchogenic carcinoma– Cough- new/changed pattern, dyspnoea, hemoptysis, anorexia, loss of weight, chest pain.
6. Tuberculosis– Cough (dry/purulent/blood streaks), anorexia, night sweats, evening rise of temperature, loss of weight.
7. Interstitial lung disease (ILD)– Cough, insidious onset exertional dyspnoea.
8. Congestive heart failure (CHF)– Cough, exertional dyspnoea, cough, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea (PND), edema.
9. Sarcoidosis– Cough, dyspnoea, erythema nodosum, eye inflammation, fatigue, fever.
10. Cystic fibrosis– Cough- chronic or relapsing with sputum, dyspnea, wheeze, hemoptysis, mostly young adults affected.
11. Post-nasal drip– Cough, nasal discharge which is mucoid or mucopurulent, tickle in the throat.
12. GERD– Cough, heartburns, regurgitation.