Jindal Clinics, Chandigarh
Intractable and Refractory Cough
What is cough? 1. Respiratory defense mechanism to clear the airways of large amounts of • Inhaled material • Mucus/secretions • Abnormal substances –edema fluid, pus, blood 2. Receptor stimulation –Irritant 3. Warning symptom of an illness Cough is a vital protective reflex preventing aspiration and enhancing airway clearance. Cough is a vital protective reflex preventing aspiration and enhancing airway clearance. Pathologically excessive and protracted cough is a common and disabling complaint: 5–10% of the adult Pathologicallypopulation.excessive and protracted cough is a common and disabling complaint: 5–10% of the adult population. When severe: major decrement in the quality of life, with comorbidities such as incontinence, cough syncope andWhendysphoniasevere: major decrement in the quality of life, with comorbidities such as incontinence, cough syncope and dysphonia
Intrathoracic pressures: Up to 300 mmHg; Expiratory velocities: 28000 cm/s or 500 miles/h Haemodynamic: Sys pr- Up to 140 mmHg Energy 1 to 25 Joules
Vigorous Cough: Complications
RespiratoryExacerbation of asthma Lung GenitourinaryCardiovasculartraumaAirLaryngealherniationoedemaleaks,TracheobronHypotension,ArrhythmiasCath.malfunctionVenousruptureIncontinence,inversion MusculoskeletalNeurologicalGastrointestinalGEreflux,Hernia,Rupture(spleen)Syncope,seizuresRadiculopathy,HeadacheCPK , Rib fracture •Constitutional,Miscellaneouslife style changes, self consciousness, fear, wound disruption, petechiae, purpura
Classification & Causes of cough Acute cough: < 3 weeks; no more than 28 days • Upper respiratory tract infections/ allergies • Pneumonia of any cause • TB • Asthma • CHF • Pulm Embolism Chronic cough – Cough that lasts longer than 8 weeks in adults or 4 weeks in children. • Common causes: gastroesophagealAsthma, reflux disease, COPD or bronchitis. • Less commonly, it can be a sign of a more severe condition, such as ILDs, heart disease.
Chronic refractory & intractable cough Refractory Cough: Cough that persists despite guideline based treatment- seen in 20-46% of patients presenting to specialist cough clinics Intractable Cough: Chronic cough whose aetiology is not clear in spite of standard investigations Uncommon and unrecognized causes: Laryngeal neuropathy Non-acid GE Reflux
The concept of cough hypersensitivity syndrome has been endorsed as an overarching syndromic diagnosis and can be found concomitant with any of the other above causes of chronic cough.
Cough is often triggered by changes in temperature, perfumes, aerosols, strong smells, talking, laughing and singing.
Patients often describe sensations of ‘itch’, ‘irritation’ and ‘unpleasantness’ in the throat region or even describe it as ‘something physically stuck on the throat’.
Patients often describe sensations of ‘itch’, ‘irritation’ and ‘unpleasantness’ in the throat region or even describe it as ‘something physically stuck on the throat’.
Chronic cough has also been described as “cough hypersensitivity syndrome” as many patients have coughing which is triggered by exposure to low levels of thermal, chemical or mechanical stimulation
Cough is often triggered by changes in temperature, perfumes, aerosols, strong smells, talking, laughing and singing.
Chronic cough has also been described as “cough hypersensitivity syndrome” as many patients have coughing which is triggered by exposure to low levels of thermal, chemical or mechanical stimulation
The concept of cough hypersensitivity syndrome has been endorsed as an overarching syndromic diagnosis and can be found concomitant with any of the other above causes of chronic cough.
Chronic cough or “cough syndrome”hypersensitivity
Red flags for Chronic cough Presence of one or more of the following signs/ symptoms • Difficulty breathing/ shortness of breath. • Shallow, rapid breathing. • Wheezing. Chest pain. Fever. • Coughing up blood or yellow or green phlegm. • Severe coughing induced vomit. • Unexplained weight loss. Red flag may indicate a more serious infection (bronchitis, pneumonia, TB, another respiratory infection), ILDs, malignancy, Heart disease, PTE, others
Management Principles • Symptomatic treatment • Home and SOS remedies • Identify the underlying cause and manage accordingly: Chronic cough disappears once the underlying problem is treated. • Removal of triggers • Psychosocial support • Management of complications • Maintenance treatment
Symptomatic: Anti-cough agents Anti tussives (cough center suppressants)- for dry unproductive cough: Inhibit cough reflex by suppressing cough center in medulla; both centrally and peripherally acting agents are available • Pharyngeal demulcents (Soothing agents): logenges, linctuses, liquorice • Expectorants (Encourage expectoration): sodium and potassium citrate, potassium iodide, guaiphensin, ammonium chloride • Mucolytics (Liquify thick mucus): bromhexine, acetylcysteine, carbocisteine, ambroxol.