Cough is one of the most common clinical symptoms and accounts for about 80% of all outpatient visits to the Department of Whistling. In addition to diseases of the whistle, cough is often caused by heart disease, gastrointestinal diseases, nasopharyngeal diseases, and even rheumatism and uremia, and there are hundreds of diseases that can cause cough.
Depending on the duration of the cough, coughs can be classified as acute coughs or chronic coughs. Acute cough is defined as a cough that lasts less than 3 weeks; chronic cough is defined as a condition that lasts more than 3 weeks. It is also believed that 3 weeks to 8 weeks is a subacute cough, and it is only when it lasts for more than 8 weeks that it is called a chronic cough. Depending on whether the cause of the cough is easy to diagnose, it is sometimes divided into coughs with a clear cause and coughs with an unclear cause. A cough with a clear cause is usually diagnosed without special tests based on symptoms and medical history alone, while a cough with an unclear cause is one that has a long duration, is not well treated and requires special tests to determine the cause. It should be noted that it is not impossible to determine the cause of an unexplained cough. The cause of most coughs can be determined by careful history taking, reasoning and analysis, and by using the necessary tests.
The cause of chronic cough is more complex and can be misdiagnosed and mistreated, or even treated blindly with large amounts of antibiotics over a long period of time, whereas in reality chronic cough is rarely caused by bacterial infection. The following is a breakdown of cough into acute and chronic coughs.
I. Acute cough
As mentioned earlier, acute cough is defined as a cough lasting less than 3 weeks. Acute cough is relatively easy to diagnose. Acute upper whistle infection and acute tracheobronchitis are the most common causes, and the history and symptoms are typical, so diagnosis and treatment are not difficult.
1, acute upper whistle infection
Acute upper whistle infection refers to the general term for acute inflammation from the nasal cavity to the larynx, including the common cold, viral pharyngitis, tonsillitis, etc., is the most common infectious disease. 90% or so caused by viruses, bacterial infections are often secondary to viral infections. The disease can develop in all seasons and at any age, and is spread by droplets and droplets containing virus, or by contaminated utensils. It often occurs when the body’s resistance is lowered, such as by cold, exertion, and rain. The disease has a good prognosis and is self-limiting, usually cured in 5-7 days. In general, patients with acute upper whistle infection do not have prominent cough symptoms, but rather a dry throat, itchy throat, sore throat, nasal congestion, sneezing, runny nose, and low fever. However, if further developed, the virus can invade the trachea and bronchus and become acute tracheobronchitis, at which time obvious symptoms of coughing and phlegm will appear.
2. Acute tracheobronchitis
Acute inflammation of the tracheobronchial tubes is generally self-limiting and can eventually heal completely and restore function. Most popular in winter, often as part of an acute upper whistle infection. It can occur after the common cold or other viral infections of the nasopharynx, larynx and tracheobronchial tree, and is often accompanied by secondary bacterial infections. Viruses that cause acute bronchitis include adenovirus, coronavirus, influenza viruses A and B, parainfluenza virus, whistle syncytial virus, coxsackievirus A21, rhinovirus, and viruses that cause rubella and measles. Mycoplasma pneumoniae, Bordetella pertussis and Chlamydia pneumoniae can also cause acute infectious bronchitis, which is common in young adults.
The onset of a severe cough is usually a sign of bronchitis. It starts as a dry cough without sputum, but after a few hours or days a small amount of mucous sputum appears, followed later by more mucus or mucopurulent sputum. Pus sputum indicates bacterial infection. Some patients have burning retrosternal pain, which is aggravated by coughing. The fever may last for 3 to 5 days. The acute symptoms then disappear, the temperature returns to normal, and the purulent sputum changes to white sputum or a small amount of clear sputum or no sputum. However, in many patients, cough symptoms may continue for several weeks or even a month or more.
The patient should rest until the temperature is normal. The patient should be encouraged to drink water (up to 3-4L/d) during the fever. Antipyretic and analgesic drugs (e.g., aspirin 650 mg or acetaminophen 650 mg every 4-6 hours for adults; acetaminophen 10-15 mg/kg every 4-6 hours for children) can relieve discomfort and lower body temperature.
Antibiotics are mainly for the treatment of bacterial infectious diseases and are not effective against viruses. Acute upper whistle infections and acute bronchitis are mainly caused by viruses, and most patients do not need antibiotics, let alone intravenous fluids, only for some patients with acute bacterial pharyngitis, tonsillitis, and acute tracheobronchitis with purulent sputum need antimicrobial therapy. Overuse of antibiotics not only fails to cure the patient’s cough, but also wastes medical resources and causes bacterial resistance. Even for patients whose cough symptoms persist for weeks or even a month or more, antibiotics are mostly ineffective as long as they are free of fever and purulent sputum.
3, acute upper whistle infection and acute trachea – bronchitis and other complications of acute viral whistle infection: acute viral whistle infection is generally a disease that can be self-healing, but part of the virus, especially influenza virus, coxsackievirus infection can occasionally damage the myocardium, or through the blood into the myocardial cells to reproduce, causing myocarditis. Generally, when palpitations, shortness of breath, dyspnea, boredom in the precordial region, and arrhythmia occur within 1 to 4 weeks of a cold or acute bronchitis, one should be alert to the possibility of myocarditis and should go to the hospital for an electrocardiogram and related tests to make a clear diagnosis and receive appropriate treatment in a timely manner, never to be paralyzed. Severe myocarditis can cause sudden death, especially in patients with coronary artery disease and other heart conditions.
4. Other causes of acute cough: Pneumonia is also a common cause of cough. Pleurisy and pneumothorax can have a cough due to irritation of the pleura and are often accompanied by chest pain and inspiratory difficulties, and chest pain is often aggravated by deep inspiration. Cardiac insufficiency occurs in cardiac disease, causing pulmonary stasis and pulmonary edema, but the main symptom of cardiac insufficiency is chest tightness and shortness of breath, and the cough is only an accompanying symptom.
It should be noted that acute cough is only a temporal definition. Some diseases can be cured early if detected and treated in time, but may turn into chronic cough if not treated in time or misdiagnosed and mistreated.
II. Chronic cough
The most common causes of chronic cough are postnasal drip syndrome, bronchial asthma and gastroesophageal reflux disease, with a quarter of patients having two or more causes. There are also important causes, such as many whistling infections, that leave a chronic cough after other acute symptoms have cleared. Some chronic coughs are due to comorbidities after taking medications, especially angiotensin-converting enzyme inhibitor drugs such as captopril, elapril, lenopril, cilazapril, ramipril, perindopril, fosinopril, etc. The cough can be relieved if such drugs are stopped. In addition, chronic airway diseases (e.g., chronic bronchitis, bronchiectasis, tumors, foreign bodies) or diseases of the lung parenchyma (e.g., interstitial lung disease, lung abscess) can also cause chronic cough. The clinical manifestations of the common causes of chronic cough are discussed below.
1. Postnasal drip syndrome: This refers to nasopharyngeal diseases in which more secretions flow and adhere to the postnasal and laryngopharyngeal regions, or even backflow into the vocal cords or trachea. A variety of diseases can lead to postnasal drip, such as various allergic rhinitis, sinusitis, etc. The secretions from the nasal cavity or sinuses drip into the lower part of the throat causing mechanical irritation and can cause coughing. Some studies have shown that postnasal drip syndrome is one of the most common causes of acute cough and chronic cough. Its symptoms, in addition to coughing, are mainly the feeling of something dripping into the throat, the need to clear the throat, the feeling of something sticking to the eyes, foreign body sensation, itchy throat, and runny nose. These symptoms are not specific and can be seen in other diseases as well. Lymphatic follicles in the posterior pharyngeal wall can be seen to be hyperplastic and distributed like cobblestones on examination of the pharynx. If it is secondary to chronic sinusitis, a thickening of the sinus mucosa greater than 6 mm and a fluid level in each sinus may be found on sinus plain film or CT. The diagnosis depends on several indicators, including symptoms, physical examination, imaging, and the effectiveness of specific treatment. In case of sinusitis, appropriate antibiotics and vasoconstrictors can be chosen for at least 6 weeks; in case of sinus pus accumulation, flushing and surgery can be considered; in case of various rhinitis, beclomethasone propionate can be inhaled, while avoiding irritation and allergen exposure. It is also very important to clear the nasal cavity and throat secretions before going to bed.
2, bronchial asthma: In people’s impression, asthma is an attack of wheezing, inhalation difficulties. In fact, there is a special type of asthma, medically known as “cough variant asthma” or “cough asthma”, the main performance is a persistent cough, usually at night or early morning attacks, usually no cough or little cough during the day, the cough is mostly irritating cough The cough is usually irritating and there is no croup on lung examination. These patients are often misdiagnosed as having chronic bronchitis or chronic laryngitis, and the quality of life is seriously affected by the long-term use of antibiotics and cough suppressants without relief, which should be especially alarming. The main manifestations of this cough are.
(1) cough aggravated by cold air or irritating odors, with a predominantly dry cough and no croup.
(2) Most often a family or personal history of allergies.
(3) Seasonality, with spring and fall being the most common.
(4) Poor effect of common cough suppressants or antibiotics.
(5) Positive asthma-specific tests, such as airway excitation test and 24-hour peak flow rate variability, may reveal abnormalities. Such patients should be examined at a regular hospital as soon as possible and the diagnosis should be confirmed by pulmonary function tests. Inhaled glucocorticosteroids (e.g., pramipexole, co-codone, etc.) and bronchodilators (e.g., Oxytocin, Bolicomnic nebulizer, Helpsafe, etc.) or a combination of both (e.g., sulforaphane, Cymbalta) are preferred for treatment, and anti-allergy medications (e.g., cisplatin, ketoproterenol, etc.) can be used for allergy-induced cough. Keep away from allergens such as pollen, seafood, pets, etc.
3, eosinophilic bronchitis: In recent years, medical doctors have found that some patients show a chronic irritating dry cough or morning cough, or only a little mucous sputum, no shortness of breath, dyspnea and other symptoms, the X-ray chest film and its lung function tests are also normal, airway excitation test does not show increased airway responsiveness, but these patients sputum eosinophils increased, oral or inhaled glucocorticoid therapy Some patients may present with cough variant asthma and no abnormal findings on physical examination, and the diagnosis relies on induced sputum cytology. The technique of induced sputum cytology is complicated, and only few hospitals can carry out it.
4. Gastroesophageal reflux disease: Reflux of stomach acid and other gastric contents into the esophagus leading to coughing. Under normal circumstances, the sphincter of the cardia exists between the esophagus and the stomach, playing a role similar to a one-way switch, food can only be discharged from the esophagus into the stomach, while the food digested in the stomach and stomach acid is not allowed to enter the esophagus. However, when the cardia sphincter is relaxed and the one-way switch fails, stomach acid and stomach contents will enter the esophagus in large quantities and frequently, which is clinically known as gastroesophageal reflux disease. Reflux of gastric acid or gastric contents irritates the throat or accidentally aspirates into the trachea, stimulating the cough receptors and causing coughing, but more often, gastric acid or gastric contents irritate the esophageal mucosa and induce airway inflammation through a nerve reflex leading to coughing. Patients may present with typical symptoms such as retrosternal burning sensation, retrosternal pain, belching, acid reflux, and dysphagia, and may also present with atypical manifestations such as cough, asthma, and pharyngitis. If the patient often has symptoms such as acid reflux, heartburn, and foreign body sensation in the pharynx, and the symptoms of cough are related to satiety, recumbency, sleep, and alcohol consumption, the cough should be considered as possibly related to digestive disorders. However, there are also many patients who have no reflux symptoms and symptoms related to eating at all, and cough is their only clinical manifestation. Therefore, the possibility of gastroesophageal reflux cough cannot be excluded in patients with chronic cough without esophageal reflux symptoms. The current diagnosis of gastroesophageal reflux disease as a cause of cough is only made when the cough improves after targeted treatment; the most sensitive and specific test is the 24-hour esophageal pH test, and barium meal and gastroscopy have limited diagnostic value. Treatment focuses on reducing the duration and frequency of reflux, as well as eliminating the irritants of gastric acid secretion. Patients should adopt a weight-loss, high-protein, low-fat anti-reflux diet, fast 2-3 hours before bedtime and sleep in a head-high, foot-low position; medications are mainly H2-blockers (e.g., ranitidine, famotidine, etc.), gastroprokinetic agents (e.g., gastrodin, morpholine, etc.), and proton pump inhibitors (e.g., Loxacol, etc.). These coughs generally take longer to treat, and if treatment is ineffective, anti-reflux surgery may be considered.
5. Chronic bronchitis: Chronic bronchitis is recurrent cough and sputum for more than 3 months per year for more than 2 years, with other etiologies excluded, mostly in the morning, and nocturnal cough can also occur during episodes. The treatment of chronic bronchitis is, firstly, to quit smoking, secondly, to avoid aggravation of the disease, to strengthen exercise and enhance physical fitness in order to reduce the number of whistling infections, and also to use immunomodulators, etc. The stable phase does not require antimicrobial therapy. In case of acute exacerbation, you should visit the hospital in time, and treat the cough and phlegm as prescribed by the doctor, and the cough and phlegm symptoms will gradually improve.
6, chronic pharyngitis: a diffuse inflammation of the pharyngeal mucosa, submucosa and lymphatic tissue, often as part of the chronic inflammation of the upper whistle tract. The general course of the disease is lengthy, stubborn and difficult to heal. It can be caused by recurrent episodes of acute pharyngitis turned chronic, or long-term excessive smoking and drinking, or stimulated by dust, harmful gases, and many patients are caused by gastroesophageal reflux disease recurrent gastric acid or gastric contents reflux stimulation of the throat, or due to post-nasal drip syndrome nasal or sinus secretions dripping into the lower part of the throat.
The typical symptoms of chronic pharyngitis are: foreign body sensation in the pharynx, itchy and slightly painful, dry and burning, etc. There is often sticky secretions attached to the back wall of the pharynx that are not easily removed, especially at night, “uttering” and wanting to be removed. The secretions can cause irritating cough, or even nausea, vomiting.
Chronic pharyngitis generally does not require antibacterial medication, usually quit smoking and alcohol, avoid spicy, acid and other strong condiments when eating. Improve the working and living environment, combined with the transformation of production equipment, to reduce the dust, harmful gas stimulation. Live a normal life, ensure sleep, and control the use of sound appropriately. Improper use of voice, excessive use of voice, too much talking is not conducive to the treatment of laryngitis.
7, bronchiectasis: bronchiectasis refers to the expansion and deformation of the bronchial cavity, often caused by mastitis, diphtheria, pertussis and bronchopneumonia in early childhood. The typical manifestations are long-term chronic cough, copious pus sputum, recurrent hemoptysis and recurrent lung infections. Mild bronchiectasis is not easy to diagnose, and ordinary chest X-rays often reveal only “enhanced lung texture”, requiring high-resolution CT examinations to confirm the diagnosis.
8. Psychogenic cough: It is worth noting that some children and adolescents have a psychogenic cough. These children do not have “organic diseases” of the heart and lungs, but exhibit chronic coughing symptoms, and even chest tightness and sighing. The more parents and teachers pay attention to the child, the more frequently he coughs. When sleeping, playing games and sports or when he is in a happy mood, he does not cough or have chest congestion. The reason may be due to reasons such as not wanting to go to school, stressful studies, etc. Some of them are also habitual coughs after whistling diseases. Treatment measures are mainly speech therapy, whistling training, psychotherapy and relaxation skills training.
9. Heart disease: When cardiac insufficiency is accompanied by pulmonary stasis or pulmonary edema, the exudate contained in the alveoli or bronchi can irritate the bronchial mucosa and cause coughing. Inflammation of the pleura can also cause coughing through reflexes. Correction of symptoms associated with heart failure can provide relief.
10. Drug-induced cough: Some chronic coughs are due to comorbidities after taking drugs. Taking anti-hypertensive drugs such as angiotensin-converting enzyme inhibitors, such as captopril, elapril, lenopril, cilazapril, ramipril, perindopril, fosinopril, etc., about 15-20% of patients may develop a cough that can be relieved if they stop taking such drugs.
Coughing is actually a protective whistle reflex of the body. When there is excessive secretion irritation in the upper and lower whistle tracts, noxious gases, or foreign bodies mistakenly enter the airway, a persistent or strong cough is produced in an attempt to remove the foreign body. Therefore, coughing is generally a beneficial action and is sometimes seen in healthy humans. In general, a mild and infrequent cough can be relieved spontaneously without the use of cough suppressants, as long as the sputum or foreign body is expelled. However, frequent and prolonged coughing can affect the patient’s life, sleep, and even the function of the whistle and heart, making it a pathological condition. To cure a cough, one should first look for the cause of the cough. In addition to treatment for the cause of chronic cough, there is also non-specific treatment, mainly cough suppressant treatment. Cough medicines are usually applied only when the cough affects the patient’s life and work, when etiological treatment is not effective, or when the cause of the cough is difficult to determine. When the cough has phlegm, expectorants can be used in combination. In addition, traditional Chinese medicine and acupuncture are also effective in relieving cough.