COUGH

·        Cough is a noisy, forceful expulsion of air from the lungs.

·        One of the most common complaints of patients with respiratory disorders.

·        Coughing is a protective mechanism that clears airway passages.

·        The cough reflex generally occurs when mechanical, chemical, thermal, inflammatory, or psychogenic stimuli activate cough receptors.

Cough Mechanism

Cough receptors are located in the nose, sinuses, auditory canals, nasopharynx, larynx, trachea, bronchi, pleurae, diaphragm and, possibly, the pericardium and GI tract.

When a cough receptor is stimulated, the vagus and glossopharyngeal nerves transmit the impulse to the “cough center” in the medulla. From there, the impulse is transmitted to the larynx and to the intercostal and abdominal muscles.

Deep inspiration is followed by closure of the glottis, relaxation of the diaphragm, and contraction of the abdominal and intercostal muscles. The resulting increased pressure in the lungs opens the glottis to release the forceful, noisy expiration known as a cough.

CLASSIFICATION

Cough is classified as –

·         Non-productive Cough

·         Productive Cough

Non-productive Cough -

·        A non-productive cough is a noisy, forceful expulsion of air from the lungs that is dry, doesn’t bring up any mucus, and may yield a scant amount of sputum.

·        A non-productive cough that later becomes productive is a classic sign of progressive respiratory disease, such as pneumonia.

·        Non-productive cough is ineffective and can cause damage, such as airway collapse or rupture of alveoli or blebs.

·        A non-productive cough may occur in paroxysms (a sudden attack or outburst of a particular emotion or activity) and can worsen by becoming more frequent.

·        An acute cough has a sudden onset and may be self-limiting; a cough that persists beyond 1 month is considered chronic and commonly results from cigarette smoking.

Causes

·        Airway occlusion

·        Anthrax

·        Aortic aneurysm (thoracic) - outward bulging

·        Asthma

·        Atelectasis- a complete or partial collapse of a lung—alveoli deflated.

·        Avian flu. The avian flu, also known as the bird flu (H5N1),

·        Swine Flu (H1N1)

·        Blast lung injury

·        Bronchitis (chronic).

·        Bronchogenic carcinoma.

·        Common cold.

·        Esophageal achalasia- is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter (LES).

·        Esophageal diverticula- pouches (diverticula )

·        Esophageal occlusion.

·        Gastroesophageal reflux (GER).

·        Hantavirus pulmonary syndrome.

·        Hypersensitivity pneumonitis.

·        Interstitial lung disease or diffuse parenchymal lung disease (DPLD)

·        Laryngeal tumor.

·        Laryngitis.

·        Lung abscess. liquefactive necrosis of the lung tissue

·        Pleural effusion.

·        Pneumonia.

·        Pneumothorax.

·        Pulmonary edema. `

·        Pulmonary embolism.

·        Sarcoidosis.

·        Severe acute respiratory syndrome (SARS).

·        Tracheobronchitis (acute).

·        Tularemia. also known as rabbit fever, is an infectious disease caused by the bacterium Francisella tularensis.

·        Other Causes

o   Diagnostic tests.

§  Pulmonary function tests (PFTs)

§  bronchoscopy

o   Treatments.

§  Irritation of the carina during suctioning

§  Intermittent positive-pressure breathing

§  spirometry

o   Some inhalants, such as pentamidine.

Productive Cough

·        It’s a sudden, forceful, noisy expulsion of air from the lungs that contains sputum, blood, or both.

·        Productive coughing is the body’s mechanism for clearing airway passages of accumulated secretions that normal mucociliary action doesn’t remove.

·        The sputum’s color, consistency, and odor provide important clues about the patient’s condition.

·        A productive cough can occur as a single cough or as paroxysmal coughing, and it can be voluntarily induced, although it’s usually a reflexive response to stimulation of the airway mucosa.

·        Productive coughing commonly results from an acute or chronic infection that causes inflammation, edema, and increased mucus production in the airways.

·        A productive cough may signal a severe life-threatening disorder. For example, coughing due to pulmonary edema produces thin, frothy, pink sputum, and coughing due to an asthma attack produces thick, mucoid sputum. Assist the patient to clear excess mucous with tracheal suctioning if necessary.

·        Avoid using measures that suppress a productive cough because retention of sputum may interfere with alveolar aeration or impair pulmonary resistance to infection.

Causes

·        Actinomycosis.

·        Aspiration pneumonitis.

·        Bronchiectasis.

·        Bronchitis (chronic).

·        Chemical pneumonitis.

·        Common cold.

·        Lung abscess (ruptured).

·        Lung cancer.

·        Nocardiosis.

·        Plague (Yersinia pestis).

·        Pneumonia.

·        Popcorn lung disease.

·        Psittacosis.

·        Pulmonary coccidioidomycosis.

·        Pulmonary edema.

·        Pulmonary embolism.

·        Pulmonary tuberculosis (TB).

·        Silicosis.

·        Tracheobronchitis.

·        Other Causes

o   Diagnostic tests.

§  Bronchoscopy and

§  pulmonary function tests (PFTs)

o   Drugs.

§  Expectorants - include ammonium chloride, calcium iodide, guaifenesin, iodinated glycerol, potassium iodide, and terpin hydrate.

o   Respiratory therapy.

§  Intermittent positive-pressure breathing,

§  nebulizer therapy, and

§  incentive spirometry

DIAGNOSTIC TESTS

·        Chest X-Ray

·        Bronchoscopy

·        Lung Scan

·        PFTs.

·        Collect sputum samples for culture and sensitivity testing.

NURSING MANAGEMENT

·        Ineffective Airway clearance related to Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

1. Auscultate breath sounds q 4 h.

2. Monitor respiratory patterns, including rate, depth, and effort.

3. Monitor blood gas values and pulse oxygen saturation levels as available.

4. Position client to optimize respiration (e.g., head of bed elevated 45 degrees and repositioned at least every 2 hours).

5. If the client has unilateral lung disease, alternate a semi-Fowler's position with a lateral position (with a 10- to 15-degree elevation and "good lung down") for 60 to 90 minutes. This method is contraindicated for a client with a pulmonary abscess or hemorrhage or with interstitial emphysema.

6. Help client to deep breathe and perform controlled coughing. Have client inhale deeply, hold breath for several seconds, and cough two to three times with mouth open while tightening the upper abdominal muscles.

7. If the client has COPD, consider helping the client use the "huff cough." The client does a series of coughs while saying the word "huff."

8. Encourage client to use incentive spirometer, to prevent atelectasis and retention of bronchial secretions.

9. Observe sputum, noting color, odor, and volume.

10. Document results of coughing and suctioning, particularly client tolerance and secretion characteristics such as color, odor, and volume.

11. Provide oral care every 4 hours.

12. Encourage activity and ambulation as tolerated. If unable to ambulate client, turn client from side to side at least every 2 hours.

13. Encourage increased fluid intake of up to 3000 ml/day within cardiac or renal reserve.

14. Administer oxygen as ordered.

15. Administer medications such as bronchodilators or inhaled steroids as ordered. Watch for side effects such as tachycardia or anxiety with bronchodilators, inflamed pharynx with inhaled steroids.

16. Provide postural drainage, percussion, and vibration as ordered.