Cough

Cough

A young boy coughing due to pertussis causing

whooping cough.
Coughing

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The sound of a person coughing.
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Classification and external resources
pronunciation (helpinfo) Latin:
Pronunciation
tussis
Specialty
Infectious disease
ICD-10
R05
ICD-9-CM 786.2
DiseasesDB 17149
MedlinePlus 003072
eMedicine ENT/1048560
MeSH
D003371
[edit on Wikidata]

A cough 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 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.
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. 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

1 Classification

2 Differential diagnosis
o 2.1 Infections
o 2.2 Reactive airway disease
o 2.3 Gastroesophageal reflux
o 2.4 Air pollution
o 2.5 Foreign body
o 2.6 Angiotensin-converting enzyme inhibitor
o 2.7 Psychogenic cough
o 2.8 Neurogenic cough
o 2.9 Other

3 Pathophysiology

4 Diagnostic approach

5 Treatment

6 Complications

7 Epidemiology

8 Other animals

9 References

10 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
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.[citation needed] 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.[citation needed]
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 (an allergic condition), 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 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.[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 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%[citation needed] 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 coughing is different from habit coughing and tic coughing.[9]
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.
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.[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]
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 may also be used for social reasons, such as coughing before giving a speech.
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.
Pathophysiology

Coughing is viewed as a public health issue.

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 and symptoms.[3] Further workup may include labs, x-rays, and spirometry.[3]
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.[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]
Other animals
Marine mammals such as dolphins cannot cough.[15]
References
1.
Chung KF, Pavord ID (April 2008). "Prevalence, pathogenesis, and causes of chronic
cough". Lancet 371 (9621): 136474. doi:10.1016/S0140-6736(08)60595-4.
PMID 18424325.
Pavord ID, Chung KF (April 2008). "Management of chronic cough". Lancet 371
(9621): 137584. doi:10.1016/S0140-6736(08)60596-6. PMID 18424326.
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. PMID 20176183.
Bjornson CL, Johnson DW (July 2007). "Croup in the paediatric emergency
department". Paediatr Child Health 12 (6): 473477. PMC 2528757. PMID 19030411.
Miller KE (April 2006). "Diagnosis and treatment of Chlamydia trachomatis
infection". Am Fam Physician 73 (8): 14116. PMID 16669564.
Dicpinigaitis PV, Colice GL, Goolsby MJ, Rogg GI, Spector SL, Winther B (2009).
"Acute cough: a diagnostic and therapeutic challenge". Cough 5: 11. doi:10.1186/17459974-5-11. PMC 2802352. PMID 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.
Postinfectious cough: ACCP evidence-based clinical practice guidelines.
Kostas Koliopoulos, Cardiologist: "Cases of Cough of unknown origin, due to use of
ACE medication for hypertension", data on file, Preveza, Greece, 2010
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". Chest 129 (1 Suppl): 174S179S. doi:10.1378/chest.129.1_suppl.174S.
PMID 16428707.

 Gibson PG, Ryan NM (August 2011). "Cough pharmacotherapy: current and future
status". Expert Opinion on Pharmacotherapy 12 (11): 17451755.
doi:10.1517/14656566.2011.576249. PMID 21524236.
NCBI Bookshelf Clinical Methods The Pulmonary System Cough and
Sputum Production 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
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
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.". BMJ (Clinical research ed.) 347: f7027.
doi:10.1136/bmj.f7027. PMC 3898587. PMID 24335668.
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. PMID 22419319.
http://vet.sagepub.com/content/6/3/257.full.pdf