STUDY - Technical - New Dacian's Medicine
Cough
and Hemoptysis (1)
Translation Draft
Cough is an explosive breath that achieves a protective mechanism by cleaning the tracheobronsic shaft of foreign secretions and bodies. However, when it is excessive and troublesome it also becomes one of the most common symptoms for which medical attention is needed. The latter is necessary due to the discomfort caused by the cough itself, interference with the normal lifestyle and for determining the causes of cough, especially the fear of cancer and AIDS.
From the point of view of the mechanism, cough can be voluntary and reflex. as a defensive reflex, it has both related and efferent paths. The related pathway includes receptors within the sensory distribution of trigeminal, glossopharynx, upper and vague nerves. The efferent pathway includes the recurrent larynx nerve and spinal nerves.
The cough sequence begins with a deep breath followed by the glottic closure, relaxation of the diaphragm and muscle contraction on a closed bullet. Positive marked chest pressure leads to narrowing of the trachea. Once the bullet is open, the high pressure due to the difference between the airways and the atmosphere, coupled with the tracheal narrowing produces rapid air flows through the trachea. Developing shear forces help remove mucus and foreign materials.
Let's go to a few presentations on etiology. As a protective mechanism against harmful or foreign materials, coughing can be initiated by a variety of irritating air stimuli (smoke, dust, steam) or by suction (secretions from the upper airways, gastric contents, foreign bodies).
When coughing is caused by irritation through secretions of the upper airways (as in postnasal hypersecretion) or pri gastric contents (as in gastroesophageal reflux), the originator may not be recognized as such and the cough may persist. In addition, prolonged exposure to these irritants may initiate inflammation of the airways, which itself triggers coughing and sensitizes the airways to other irritants.
Any abnormality leading to inflammation, constriction, infiltration or compression of the airways may be associated with coughing. Inflammation generally results from respiratory infections, from viral or bacterial bronchitis to bronchiectasis. In the case of viral bronchitis, inflammation of the airways can sometimes persist long after the resolution of typical acute symptoms, producing a prolonged cough, which persists for weeks.
Pertussis infection is another possible cause of persistent cough in adults, however the diagnosis is generally based on clinical, with confirmation requiring serological testing for antibodies, which is not always possible. Asthma, which is associated with inflammation of the airways as well as with potentially reversible bronchoconstriction, is a common cause of coughing.
Although clinical data generally suggest that cough is secondary to asthma, some patients experience coughing in the absence of wheezing or breathlessness, making the diagnosis more difficult (atypical cough asthma). A neoplastic process that infiltrates the walls of the airways, such as bronchogen carcinoma or a carcinoid tumor is commonly associated with coughing.
Granulomatous infiltration of the airways can also cause coughing, as in endobronsic sarcoidosis or tuberculosis. Compression of the airways is produced by extrinsic masses, such as lymph nodes, mediastinal tumors and aortic aneurysms.
Examples of parenchymal lung diseases that may be accompanied by cough are interstitial lung disease, pneumonia and pulmonary abscess. Congestive heart failure may be associated with cough, probably as a consequence of both interstitial and peribronsic pulmonary edema.
An unproductive cough complicates the use of angiotensin conversion enzyme (ACE) inhibitors in 5-20% of patients treated with these therapeutic agents. Cough usually occurs within the first week after starting treatment, but its onset may be delayed up to 6 months. Although the mechanism of production is not known with certainty, it is assumed to be related to the accumulation of bradykinin or substance P, both of which are degraded by ECA.
From the point of view of the patient's approach, a detailed anamnesis frequently provides the most valuable clues for the etiology of cough. Important questions such as: 1. cough is acute or chronic, 2. at its onset, has been associated with symptoms suggestive of respiratory infections, 3. is seasonal or associated with wheezing, 4. is associated with symptoms suggestive of postnasal hypersecretions (rhinorea, frequent "voice dregeres") or gastroesophageal reflux (pyrosis or regurgitation sensation), 5. is associated with fever or sputum elimination, and if sputum is present, what characteristics it has, 6. the patient has associated diseases or risk factors for the disease present (e.g. smoking, risk factors for human immunodeficiency virus infection, exposure to toxic environment, etc.) or 7. the patient is being treated with an ACE inhibitor.
General physical examination may indicate a cause other than the lung of cough, such as heart failure, primary nonpulmonary neoplasm or AIDS. Examination of the oropharyngeal may provide suggestive evidence of postnasal hypersecretion, including nasopharyngeal secretions, erythema or the appearance of "pavement stone" of the mucosa.
Pulmonary auscultation may reveal inspiring stridor (indicating upper respiratory disease), ronhus or exhalatory wheezing (indicating lower airway suffering) or inspirational rals (suggestive for a process of lung parenchyma, such as pulmonary interstitial disease, pneumonia or pulmonary edema).
Chest X-ray may be particularly helpful in suggesting or confirming the cause of cough. Important elements revealed by the X-ray are the presence of an intraoracic mass, a localized or interstitial diffuse or alveolar pulmonary infiltration. An image of "honeycomb" or cystic may indicate the existence of brochures, while the presence of bilateral hilarious adenopathy is suggestive for sarcoidosis.
Exploring lung function is useful for highlighting functional abnormalities that accompany certain diseases associated with cough. Measurement of forced exhalation rates may indicate a reversible airway obstruction characteristic of asthma. When asthma is suspected, but fan flows are normal, bronchial challenge tests with metacholine or inhalation of cold air can demonstrate airway hyperactivity to bronchoconstrictor stimuli.
Measuring lung volumes and diffusion capacities is mainly useful for highlighting a restrictive pattern commonly found in any diffuse interstitial lung disease. If the cough is unproductive, macro and microscopic examination of sputum can give useful information. Purulent spout suggests chronic bronchitis, bronchiectasis, pneumonia or pulmonary abscess.
Blood in the sputum can occur in the same diseases, but its presence raises the suspicion of endobronsic tumor. Gram and acid-resistant bacilli as well as cultures may indicate infection with a specific pathogen, and cytological examination of sputum may diagnose malignant lung disease. More specialized explorations are used in certain circumstances.
Optical fiber bronchoscopy is the elective process for visualizing an endobronchial tumor and collecting histological and cytological samples. Inspection of the tracheo-bronchial mucosa may reveal the presence of endobronchial granulomas, commonly found in sarcoidosis, and endobronsic biopsy of these lesions or transbronsic of the pulmonary interstitis can confirm the diagnosis. Also, by inspecting the mucosa of the airways, one can observe the characteristic appearance of Kaposi endobronchial sarcoma in AIDS patients.
High resolution computer tomography (HRTC) can confirm the presence of interstitial disease and sometimes suggest a diagnosis based on a pattern of the disease, being the exploration of the election to highlight the dilation of the airways and confirm the diagnosis of bronchiectasis.
In terms of complications, paroxysmal cough can precipitate syncope (cough syncope) by developing significant positive intraoracic and alveolar pressure, which reduces venous return by producing a decrease in cardiac output. Although fractures of the ribs due to cough may occur in otherwise normal patients, their occurrence poses at least the problem of pathological fractures observed in multiple myeloma, osteoporosis and osteitis osteolithic metastases.
A curative treatment of cough is based on determining its cause and then initiating specific therapy. The elimination of exogenous irritants (smoking, ACE inhibitors) or endogenous triggers (postnasal hypersecretion, gastroesophageal reflux) is usually effective when such a precipitating agent can be identified.
Other important therapeutic measures are the treatment of specific respiratory infections, the administration of bronchodilators in case of potentially reversible obstruction of the airways, respiratory physiotherapy to enhance the elimination of secretions in patients with bronchectasis and the treatment of endobronsic tumors or interstitial lung disease when this treatment is indicated and possible to be carried out.
Symptomatic or non-specific cough therapy should be considered when: 1. the cause of the cough is not known or specific treatment is not possible and 2. cough does not perform its specific function or causes marked discomfort.
An irritating, unproductive cough can be suppressed by taking an antitussive agent that increases the latency or sensitivity of the cough center. Such agents include codeine or narcotic substances such as dextromethorphan. These drugs provide symptomatic improvement by discontinuing prolonged self-sustaining paroxysm.
However, a productive cough with significant amounts of sputum should not normally be suppressed, as sputum retention in the tracheobrosic shaft may interfere with ventilation distribution, alveolar aeration and the lung's ability to resist infection. Other therapeutic agents, acting through a variety of mechanisms, have also been used to control cough, but objective information on their beneficial effect is few.
An anticholinergic inhaler, opratropium bromide, has been used because it inhibits the efferent pathway of the cough reflex. Inhaled glucocorticoids (e.g. beclomethasone or triamicinolone) have been used to treat patients who are presumed to have airway inflammation play a role in coughing.
We continue tomorrow with hemoptysis...
Cough is an explosive breath that achieves a protective mechanism by cleaning the tracheobronsic shaft of foreign secretions and bodies. However, when it is excessive and troublesome it also becomes one of the most common symptoms for which medical attention is needed. The latter is necessary due to the discomfort caused by the cough itself, interference with the normal lifestyle and for determining the causes of cough, especially the fear of cancer and AIDS.
From the point of view of the mechanism, cough can be voluntary and reflex. as a defensive reflex, it has both related and efferent paths. The related pathway includes receptors within the sensory distribution of trigeminal, glossopharynx, upper and vague nerves. The efferent pathway includes the recurrent larynx nerve and spinal nerves.
The cough sequence begins with a deep breath followed by the glottic closure, relaxation of the diaphragm and muscle contraction on a closed bullet. Positive marked chest pressure leads to narrowing of the trachea. Once the bullet is open, the high pressure due to the difference between the airways and the atmosphere, coupled with the tracheal narrowing produces rapid air flows through the trachea. Developing shear forces help remove mucus and foreign materials.
Let's go to a few presentations on etiology. As a protective mechanism against harmful or foreign materials, coughing can be initiated by a variety of irritating air stimuli (smoke, dust, steam) or by suction (secretions from the upper airways, gastric contents, foreign bodies).
When coughing is caused by irritation through secretions of the upper airways (as in postnasal hypersecretion) or pri gastric contents (as in gastroesophageal reflux), the originator may not be recognized as such and the cough may persist. In addition, prolonged exposure to these irritants may initiate inflammation of the airways, which itself triggers coughing and sensitizes the airways to other irritants.
Any abnormality leading to inflammation, constriction, infiltration or compression of the airways may be associated with coughing. Inflammation generally results from respiratory infections, from viral or bacterial bronchitis to bronchiectasis. In the case of viral bronchitis, inflammation of the airways can sometimes persist long after the resolution of typical acute symptoms, producing a prolonged cough, which persists for weeks.
Pertussis infection is another possible cause of persistent cough in adults, however the diagnosis is generally based on clinical, with confirmation requiring serological testing for antibodies, which is not always possible. Asthma, which is associated with inflammation of the airways as well as with potentially reversible bronchoconstriction, is a common cause of coughing.
Although clinical data generally suggest that cough is secondary to asthma, some patients experience coughing in the absence of wheezing or breathlessness, making the diagnosis more difficult (atypical cough asthma). A neoplastic process that infiltrates the walls of the airways, such as bronchogen carcinoma or a carcinoid tumor is commonly associated with coughing.
Granulomatous infiltration of the airways can also cause coughing, as in endobronsic sarcoidosis or tuberculosis. Compression of the airways is produced by extrinsic masses, such as lymph nodes, mediastinal tumors and aortic aneurysms.
Examples of parenchymal lung diseases that may be accompanied by cough are interstitial lung disease, pneumonia and pulmonary abscess. Congestive heart failure may be associated with cough, probably as a consequence of both interstitial and peribronsic pulmonary edema.
An unproductive cough complicates the use of angiotensin conversion enzyme (ACE) inhibitors in 5-20% of patients treated with these therapeutic agents. Cough usually occurs within the first week after starting treatment, but its onset may be delayed up to 6 months. Although the mechanism of production is not known with certainty, it is assumed to be related to the accumulation of bradykinin or substance P, both of which are degraded by ECA.
From the point of view of the patient's approach, a detailed anamnesis frequently provides the most valuable clues for the etiology of cough. Important questions such as: 1. cough is acute or chronic, 2. at its onset, has been associated with symptoms suggestive of respiratory infections, 3. is seasonal or associated with wheezing, 4. is associated with symptoms suggestive of postnasal hypersecretions (rhinorea, frequent "voice dregeres") or gastroesophageal reflux (pyrosis or regurgitation sensation), 5. is associated with fever or sputum elimination, and if sputum is present, what characteristics it has, 6. the patient has associated diseases or risk factors for the disease present (e.g. smoking, risk factors for human immunodeficiency virus infection, exposure to toxic environment, etc.) or 7. the patient is being treated with an ACE inhibitor.
General physical examination may indicate a cause other than the lung of cough, such as heart failure, primary nonpulmonary neoplasm or AIDS. Examination of the oropharyngeal may provide suggestive evidence of postnasal hypersecretion, including nasopharyngeal secretions, erythema or the appearance of "pavement stone" of the mucosa.
Pulmonary auscultation may reveal inspiring stridor (indicating upper respiratory disease), ronhus or exhalatory wheezing (indicating lower airway suffering) or inspirational rals (suggestive for a process of lung parenchyma, such as pulmonary interstitial disease, pneumonia or pulmonary edema).
Chest X-ray may be particularly helpful in suggesting or confirming the cause of cough. Important elements revealed by the X-ray are the presence of an intraoracic mass, a localized or interstitial diffuse or alveolar pulmonary infiltration. An image of "honeycomb" or cystic may indicate the existence of brochures, while the presence of bilateral hilarious adenopathy is suggestive for sarcoidosis.
Exploring lung function is useful for highlighting functional abnormalities that accompany certain diseases associated with cough. Measurement of forced exhalation rates may indicate a reversible airway obstruction characteristic of asthma. When asthma is suspected, but fan flows are normal, bronchial challenge tests with metacholine or inhalation of cold air can demonstrate airway hyperactivity to bronchoconstrictor stimuli.
Measuring lung volumes and diffusion capacities is mainly useful for highlighting a restrictive pattern commonly found in any diffuse interstitial lung disease. If the cough is unproductive, macro and microscopic examination of sputum can give useful information. Purulent spout suggests chronic bronchitis, bronchiectasis, pneumonia or pulmonary abscess.
Blood in the sputum can occur in the same diseases, but its presence raises the suspicion of endobronsic tumor. Gram and acid-resistant bacilli as well as cultures may indicate infection with a specific pathogen, and cytological examination of sputum may diagnose malignant lung disease. More specialized explorations are used in certain circumstances.
Optical fiber bronchoscopy is the elective process for visualizing an endobronchial tumor and collecting histological and cytological samples. Inspection of the tracheo-bronchial mucosa may reveal the presence of endobronchial granulomas, commonly found in sarcoidosis, and endobronsic biopsy of these lesions or transbronsic of the pulmonary interstitis can confirm the diagnosis. Also, by inspecting the mucosa of the airways, one can observe the characteristic appearance of Kaposi endobronchial sarcoma in AIDS patients.
High resolution computer tomography (HRTC) can confirm the presence of interstitial disease and sometimes suggest a diagnosis based on a pattern of the disease, being the exploration of the election to highlight the dilation of the airways and confirm the diagnosis of bronchiectasis.
In terms of complications, paroxysmal cough can precipitate syncope (cough syncope) by developing significant positive intraoracic and alveolar pressure, which reduces venous return by producing a decrease in cardiac output. Although fractures of the ribs due to cough may occur in otherwise normal patients, their occurrence poses at least the problem of pathological fractures observed in multiple myeloma, osteoporosis and osteitis osteolithic metastases.
A curative treatment of cough is based on determining its cause and then initiating specific therapy. The elimination of exogenous irritants (smoking, ACE inhibitors) or endogenous triggers (postnasal hypersecretion, gastroesophageal reflux) is usually effective when such a precipitating agent can be identified.
Other important therapeutic measures are the treatment of specific respiratory infections, the administration of bronchodilators in case of potentially reversible obstruction of the airways, respiratory physiotherapy to enhance the elimination of secretions in patients with bronchectasis and the treatment of endobronsic tumors or interstitial lung disease when this treatment is indicated and possible to be carried out.
Symptomatic or non-specific cough therapy should be considered when: 1. the cause of the cough is not known or specific treatment is not possible and 2. cough does not perform its specific function or causes marked discomfort.
An irritating, unproductive cough can be suppressed by taking an antitussive agent that increases the latency or sensitivity of the cough center. Such agents include codeine or narcotic substances such as dextromethorphan. These drugs provide symptomatic improvement by discontinuing prolonged self-sustaining paroxysm.
However, a productive cough with significant amounts of sputum should not normally be suppressed, as sputum retention in the tracheobrosic shaft may interfere with ventilation distribution, alveolar aeration and the lung's ability to resist infection. Other therapeutic agents, acting through a variety of mechanisms, have also been used to control cough, but objective information on their beneficial effect is few.
An anticholinergic inhaler, opratropium bromide, has been used because it inhibits the efferent pathway of the cough reflex. Inhaled glucocorticoids (e.g. beclomethasone or triamicinolone) have been used to treat patients who are presumed to have airway inflammation play a role in coughing.
We continue tomorrow with hemoptysis...
Have a good day!
Dorin, Merticaru