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| Cough,
Cronic, Causes |
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Cough Causes |
It is not uncommon to have cough for complex (several combined
reasons) reasons...meaning that it is not due just to one single
cause. "In several studies of patients with chronic cough
who were referred to pulmonologists: postnasal drip, asthma and/or
GERD were found to be the cause of cough in 99 percent of immunocompetent
nonsmokers who were not taking an ACE inhibitor (or beta blocker)...high
blood pressure & cardiac drugs...and who had a normal or stable,
near-normal chest radiograph. The methacholine inhalation challenge
test (for asthma) was the most helpful test in making a diagnosis
of asthma if the history was not suggestive. In 57 percent of patients
diagnosed with asthma, the positive methacholine inhalation challenge
was the only test indicative of the disease. In 23 percent of patients
diagnosed with GERD, the prolonged esophageal pH monitoring test
was the only indication of the disease. GERD is a recently recognized
cause of chronic cough and is identified as the etiology of cough
more frequently in studies that use prolonged esophageal pH monitoring
as part of their diagnostic work-up. Sputum cytology may help if
eosinophiles are identified (may indicate asthma or others, see
chart below); lipid laden macrophages tend to reflect pulmonary
aspiration of GERD material.
"In children, cough-variant asthma is the most common cause
of chronic cough. However, in children younger than 18 months of
age, congenital etiologies are an important cause. Chronic cough
frequently has multiple causes. The authors of the studies cited
in Table 1 found a single cause for cough in only 41 to 73 percent
of patients, two causes in 23 to 42 percent of patients and three
causes in 3 to 17 percent of patients (it is a "complicated" cough
when more than one cause at same time). Many patients were correctly
diagnosed by their primary physicians before being referred to
a pulmonary specialist but had not been treated aggressively enough
to stop the cough. The family physician is capable of directing
the work-up, making the diagnosis and treating chronic cough in
an estimated 90 percent of cases of chronic cough.1" Cough
causes can be mixed and not just a single cause, see above.
As a patient, you know what your habits are; but you may need
to check your medications to see if any of them cause a chronic
cough. There are two types of cough, (1) dry (non-productive) cough
and (2) productive (sputum is produced) cough. A productive cough
is more likely due to asthma, chronic irritant or allergic bronchitis,
aspiration of gastric juices into the airways (post-stroke or GERD),
and infections. Non-productive cough is more likely related to
medications and non-lung causes. But some of the potentially fatal
infectious "atypical pnuemonias" can be non-productive.
Fever is a typical indicator of infectious causes of cough...but "low
grade" infections may not cause obvious fever. "Dry
weather" or winter cough in normally moist geographic areas
can complicate colds and other cough causes.
Some insight can be gained medically by looking at sputum coughed
up from the lung (not snorted or coughed from the back of
the throat or nose and not "spit" or saliva). Noticeable
amounts of actual sputum are most likely available just after getting
up from a night's sleep. Coughing the sputum into a white lavatory
sink allows one to note slight color differences that are important.
And, that same sputum can be used for bacterial or fungal cultures
or for microscopic exam by smear or cell block. Put it into a cup
or container and take to your doctor or the lab.
Acute bronchitis is when the process lasts 3 weeks or less. True
chronic bronchitis is a cough that lasts at least 3 months per
year for at least 2 consecutive years; and when more frequent or
sustained, it is called ACEB (acute exacerbation of chronic bronchitis)
and often in those with COPD (chronic obstructive pulmonary disease). |
Common causes of chronic cough:
| Disorder |
Clinical |
Sputum Character |
Sputum Micro |
| 20% of acute bronchitis go well beyond 3 weeks |
look out for whooping cough, especially if
paroxysmal cough (hear it here); also Strep., Moraxella, & Haemophilus; and "atypical pneumonia" organisms |
sticky grey to yellowish |
polys |
| smoking |
|
white with faint brownish areas |
pigment macrophages |
| environmental irritants |
|
usually not sputum producer |
|
| dry environment cough (especially seasonal dryness in
usually moist environment) |
by itself, non-productive |
usually not sputum producer |
n/a |
| allergens (broncho-pulmonary allergic reaction) |
|
clear with faint rusty tint |
eosinophiles |
| postnasal drip (PND) due to nasal congestion (alpha blockers
like Flomax can do it) |
|
usually not sputum producer |
no particular cells |
| asthma (see VCD, below) |
|
sputum producer |
eosinophiles |
| GERD |
|
clear-whitish |
no eos. & no polys unless complicated by allergy or infection; lipid laden macrophages |
| chronic bronchitis |
see causes below |
as below |
|
| COPD |
|
usually sputum producer |
polys |
| AECB3 (acute exacerbation of chronic bronchitis) |
chest X-ray no different than chronic bronchitis & this
helps distinguish AECB from pneumonia. These features:- cough
- dyspnea
- productive
- purulent
- RR
>25/min.
- decreased FEV
- constitutional
symptoms/signs
|
as per causes |
|
| transient (say, after virus infection) airway hyper-responsiveness |
|
usually not sputum producer |
not eosinophiles |
| meds: ACE inhibitors & beta blockers |
dry bronchospastic; worse @ night |
not sputum producer |
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Less common causes of chronic cough:
| Disorder |
Clinical |
Sputum Character |
Sputum Micro |
| congestive heart failure |
|
usually not sputum producer |
|
| vocal cord dysfunction (VCD) |
asthma like & can overlap with asthma |
non-productive cough |
n/a |
| endotracheal growths |
|
usually not sputum producer |
|
| esophagus or lung ca. |
|
usually not sputum producer |
|
| interstitial lung diseased &/or COPD |
|
usually not sputum producer |
|
| bronchiectasis (with or without PCD...primary
ciliary dyskinesia) |
|
yellow purulent |
polys |
| chronic infections (TB & Fungal) |
|
yellowish or contains whitish particles |
polys; eosinophiles if producing allergic,
asthma like complications |
| recurrent aspiration (post-stroke; druggie; alcoholic; bad or neglected GERD) |
|
usually a sputum producer |
|
| mediastinal mass |
|
usually not sputum producer |
|
| irritation of cough receptors in external ear canal |
|
not sputum producer |
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| occupational irritant inhalation |
|
usually not sputum producer |
|
| foreign body |
|
likely a sputum producer |
|
| as a reflex to premature atrial beats or PVCs |
|
not sputum producer |
n/a |
| nervous habit |
especially preteens & teens |
not a sputum producer |
|
| psychogenic |
|
not sputum producer |
|
| Carrington's chronic eosinophilic pneumonia |
elevated CBC eos |
usually not much of a sputum producer |
eosinophiles |
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| Check familydoctor.org for
their diagnosis decision chart. |
Acute (lasting less than 3 weeks) Cough:
| |
Clinical |
Sputum |
Sputum Micro |
| acute bacterial bronchitis in healthy people |
5-10% of acute cases & due to mycoplasmas, chlamydias,
and B. pertussis (whooping cough...20% with cough greater than 2 weeks
have this3) |
yellowish sputum |
polys |
| acute bacterial bronchitis in people who have broncial (even just smokers or GERD injury) or lung disease
or just had viral bronchitis |
any of the above 3; or, also, Strep. pneumoniae, Hem.
influenzae, & Moraxella catarrhalis. |
yellowish sputum |
polys |
| acute viral bronchitis |
90% of acute cases |
mild amount of sputum |
polys |
| acute allergic bronchitis |
|
sputum producer |
eosinophiles |
| acute asthmatic bronchitis |
|
sputum producer |
eosinophiles |
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References:
- An Office Approach to the Diagnosis of Chronic Cough, W.
Ross Lawler
American Family Physician, Dec. 1998.By way of search engine in "Find
Articles".
- Chronic Cough, ELIZABETH B. PHILP, M.B., CH.B., University
of Alabama School of Medicine, Tuscaloosa, Alabama, American
Family Physician, Oct.1,
1997.
- Lipsky M, Le J, Therapeutic Management of Bronchitis, Preventive
Medicine ion Managed Care 5(1 sup):1-8, February 2005.
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| (posted 2002; latest addition 17 February 2008) |
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1999 - 2006, all rights reserved, Pathology Associates Of Lexington,
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