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COUGH
LEARNING OBJECTIVES:

At the end of this tutorial you should be able to:

1. Define cough
2. Form a differential diagnosis for cough.
3. Take a history from a patient with cough, focussing on features which aid in determining the
aetiology.
4. Examine patients with cough to elicit features suggestive of underlying aetiology.
5. Choosing and justifying appropriate investigations of the patient with cough.

DEFINITION: Cough is a complex reflex initiated by the irritation of the cough receptors located in
the upper and lower airways

PATHOPHYSIOLOGY:

Cough can be initiated either voluntarily or reflexively. As a defence mechanism it has both afferent
and efferent pathways:

1. Afferent: Receptors in the sensory distribution of the trigeminal, glossopharyngeal, superior

laryngeal and vagal nerves.
2. Efferent: Includes the recurrent laryngeal nerve and spinal nerves.

Mechanism of Cough:

1. The cough starts with a deep inspiration followed by glottic closure, relaxation of the
diaphragm, and muscle contraction against a closed glottis.
2. This results in a markedly positive intra-thoracic pressure causing narrowing of the trachea.
3. Once the glottis opens, the large pressure differential between the airways and the
atmosphere, coupled with tracheal narrowing produces rapid flow rates through the trachea.

DIFFERENTIAL DIAGNOSIS:

A distinction should be made between acute and chronic as well as productive and non-productive
cough.

Acute Cough (< 3 weeks): Acute episodes of cough are common at any age and are most often due to
viral airway infections:

Chronic Cough (> 3 weeks): Usually defined as a cough which lasts three weeks or more.
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Acute Cough
1. Inhaled foreign body
2. Respiratory tract infection (viral)

Chronic Cough
Productive Non-Productive
1. Chronic obstructive pulmonary disease 1. Asthma
2. Tuberculosis 2. Upper airway cough syndrome (postnasal
3. Bronchiectasis drip).
1. Cystic fibrosis 3. Gastro-oesophageal reflux
2. Primary ciliary dyskinesia 4. Drugs (ACEI) - 5-10%
4. Lung cancer 5. Interstitial lung disease
5. Pulmonary oedema (pink, frothy)
6. Pulmonary embolism (haemoptysis)

HISTORY:

1. Age and Sex: Chronic cough is more likely to occur in middle aged women.
2. Smoking: One of the commonest causes of persistent cough is smoking, which appears to be
dose related. Patients often state that their cough changes in character with smoking
cessation. A long standing cough may suggest COPD or bronchogenic carcinoma.

Characteristics of the Cough:

1. Onset and Duration: Did the cough begin gradually or suddenly? How long has the cough
been present? The duration and onset of the cough are important in discerning acute and
chronic cough:

(a) Acute Cough: Less than 3 weeks duration. Sudden onset of an unrelenting bout of violent
coughing may be due to an inhaled foreign body.
(b) Chronic Cough: More than 3 weeks duration.

2. Relation to Infection: Did the cough begin after an initial upper respiratory tract infection,
for example a cold or sore throat? Viral infection enhances the cough reflex sensitivity and
may make sub-clinical bronchial hyper-responsiveness or reflux clinically apparent.

3. Sputum: A cough may be productive or non-productive. The appearance, quantity and

appearance of expectorated sputum can be very helpful in the differential diagnosis:

(a) Purulent Sputum: Cough continuously productive of purulent sputum is suggestive of

chronic bronchitis and bronchiectasis.
(b) Bloodstained Sputum: Complaints in patients with bronchogenic carcinoma, pulmonary
embolism and TB.
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4. Diurnal Variation: Patients cough less at night. A cough which abates overnight may be
due to reflux (closure of the lower oesophageal sphincter). Asthma, infection or heart failure
can cause coughing which wakes the patient.
5. Posture: Cough is known to be related to posture, e.g., bending or lying down. However,
there is no evidence demonstrating a connection between posture and reflux-related cough.
6. Food: Cough on eating and post-prandially may indicate reflux cough.
7. Cough on Phonation: Cough on phonation such as talking on the telephone, laughing, or
singing may indicate reflux because of lack of diaphragmatic closure of the lower
oesophageal sphincter.

Associated Symptoms:

(a) Episodic Polyphonic Wheeze: In association with shortness of breath is associated with
asthma.
(b) Monophonic Wheeze: Intra-luminal obstruction form foreign bodies or tumour.
(c) Shortness of Breath:

i. Acute Onset: Pulmonary embolism/Pulmonary oedema/Aspiration

ii. Orthopnoea: Pulmonary oedema

(d) Nocturnal Variation: Asthma may be worse at night.

(e) Chest Pain:

i. Pleuritic: Pulmonary embolism or pneumonia.

ii. Unrelenting: Bony metastases from lung cancer.
iii. Retrosternal Burning Sensation: Gastro-oesophageal reflux disease.

Past Medical History:

Chronic cough is a common association of respiratory diseases and a thorough history should be
sought:

1. COPD: Although patients with COPD commonly report cough, it is usually in association
with production of phlegm and breathlessness.
2. Bronchiectasis: Although usually associated with sputum production, 'dry' bronchiectasis can
cause persistent cough and a history of past respiratory insult as a potential trigger should be
sought.
3. Lung Cancer: Cough may arise as a result of cancer itself, the treatment or other co-existent
disease.
4. Pertussis Infection: Can lead to chronic cough.
5. Atopic Disease: There is an increase in respiratory symptoms in atopic individuals.
6. Cardiovascular Disease: Patients with heart disease can develop chronic cough and are at
risk of myocardial infarction.

Medications: Note all medications, particularly ACEI and consider which might be causing or
potentiating the cough.
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Family History: Chronic cough may be familial, suggesting either an inherited anatomical
abnormality or neurological condition.

EXAMINATION:

1. General Appearance: Cachexia is associated with lung cancer, TB or CCF.

2. Vitals: Pyrexia may be associated with pyrexia, tachycardia as might a pulmonary embolism.
3. Hands: Cyanosis is associated with PE and COPD. Clubbing is suggestive of bronchial
carcinoma, chronic suppurative lung disease (bronchiectasis, lung abscess, empyema, cystic
fibrosis) and idiopathic pulmonary fibrosis.
4. JVP: Increased in CCF
5. Supraclavicular Nodes: May be palpable in TB and lung cancer.
6. Auscultation:

(a) Coarse Crepitations: A feature of bronchiectasis and pulmonary oedema.

(b) Fine Crepitations: Pulmonary fibrosis.
(c) Wheeze: May be suggestive of asthma/COPD

INVESTIGATIONS:

Acute Cough

Life History, Non-Life-

Threatening Examination, Threatening
Diagnosis Investigations Diagnosis

Pneumonia, Exacerbation
Environmental
Severe Infectious of Pre-
/Occupational
Exacerbation of Existing
Asthma/COPD,
PE, Heart
Failure.
URTI LRTI Asthma Bronchiectasis UACS COPD

A. Chest X-ray:

Symptoms associated with acute cough prompting a chest radiograph:

1. Haemoptysis
2. Breathlessness
3. Fever
4. Chest Pain
5. Weight loss
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CXR Findings:

1. Pneumonia: Consolidation
2. Bronchiectasis: Dilated bronchi
3. Tuberculosis: Apical consolidation with calcification and hilar lymphadenopathy
4. Pulmonary Oedema: Bilateral patchy shadowing in association with other features
suggestive of CCF including cardiomegaly, upper lobe venous diversion, bilateral pleural
effusions and Kerley B-lines.
5. Lung Cancer: May present as a hilar mass, peripheral mass or with collapse and
consolidation of the lung due to airway obstruction.
6. Sarcoidosis: Bilateral hilar lymphadenopathy is suggestive of sarcoidosis.

B. Spirometry: This may be used in the diagnosis of asthma, COPD, bronchiectasis and
represent airway obstruction.
C. Sputum: Send for C&S including ZN staining for TB.
D. WCC: May be raised non-specifically in infection or PE.
E. 24-Hour Oesophageal pH Monitoring: Be used in the diagnosis of GORD.
F. OGD: Diagnosis of GORD
G. Sinus Imaging: Chronic rhinosinusitis
H. HRCT: Diagnosis of bronchiectasis/interstitial lung disease.
I. Bronchoscopy: Cytology of malignancy and culture and sensitivity of infections such as TB,
pseudomonas.
J. Echocardiogram: Evaluation of left ventricular function (congestive cardiac failure).
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Chronic Cough

A Cause of H istory,
Investigate Smoking
Cough is Examination, Discontinue
and Treat ACEi
Suggested Investigations
Inadequate Response Inadequate Response
Upper Airway Cough
Syndrome: Empiric Treatment

Asthma: Evaluate with pre and

post-bronchodilator spirometry
or histamine challenge test.

GORD: Empiric treatment

Inadequate Response
Special Investigations:
1. 24 Hour Esophageal pH Monitoring
2. OGD
3. Barium Swallow
4. Sinus Imaging
5. HRCT
6. Bronchoscopy
7. Echocardiogram