A cough is the natural reflex response of the body to clear the airways, to the stimuli that may irritate the respiratory system, which consists mainly the nasopharynx, larynx, trachea, and large bronchi. It is acute when it is less than 3 weeks, and chronic if beyond 8 weeks. Cough can also be generated by issues in the upper and lower airways, psychological issues, cardiovascular system pathophysiologic disturbances, and the side effects of certain medications like the ACE inhibitors. Cough is the fifth most common symptom that prompts the patients to see their health care provider in the primary care setting (Rhoads & Jensen, 2015). Mainly, the pathogenic triad of cough, that is responsible for 92% to 100% of cough, is due to upper airway cough syndrome which is commonly known as post nasal drip syndrome; asthma, and gastroesophageal reflux disease (GERD). The other associated signs and symptoms of cough are: fatigue, rhinitis, epistaxis, tickle in the throat, pharyngitis, night sweats, dyspnea, fever, sputum production, hoarseness and post nasal drip. As cough interferes with the activities of daily living and sleeping, there is a decrease in quality of life (QOL). Therefore, patients seek treatment in the health care settings (Cash & Glass, 2017).
According to Jensen & Rhoads (2015), the history taking will be focused in asking about the following characteristics of each symptom using open-ended questions: current situation of the cough if it is improving or deteriorating, onset if acute versus gradual, characteristics of the cough as to whether it is dry or producing sputum or blood; what are the associated symptoms; aggravating factors or cough triggers and alleviating factors, and effect on daily activities.
The physical assessment would start with inspection of the general appearance for cyanosis, dyspnea, use of accessory muscles and finger clubbing. Then, examination of the ears, nose and throat for masses, deviation, inflammation, and presence of drainages. Second, auscultation of the heart and lungs with attention to tachycardia or bradycardia, wheezing, stridor, crackles, rales, or other adventitious sounds. Third, percussion of sinus cavities and mastoid process, and pulmonary fields for egophony, dullness, or consolidation. Finally, the palpation of the face for the sinus tenderness, and head and neck examination for lymph node tenderness and jugular vein distention (JVD) (Cash & Glass, 2017).
The diagnostic testing could be done to a minimum with deliberate history taking and careful physical examination. Children with chronic cough though must undergo appropriate chest imaging and spirometry. Other tests to consider would be WBC check if infection is suspected, sputum examination for eosinophils, gram stain, and/or culture; PPD testing for possible tuberculosis, sweat chloride test to rule out cystic fibrosis, pulmonary function testing, methacholine challenge for asthma; esophageal pH monitoring for GERD, and CT scan if needed (Jensen & Rhoads, 2015).
The treatment for cough must be the focused on resolving the source and triggers. According to the clinical practice guidelines of the American College of Chest Physicians (ACCP), it is recommended that cough suppressant and other over-the-counter cough drugs should not be given to young children. Furthermore, as a provider, one must remember that no cough and cold medicines for children younger than 6 years old be prescribed. As coughing is often related to environmental or chemical triggers such as smoking and perfumes, one must maintain a smoke or scent free environment. To the parents who smoke with children, they must maintain the bedroom as smoke free environment to prevent the secondhand smoke exposure of the children. Heating, humidifier, and air-conditioning unit filters must be changed regularly to keep it clean, decrease pet dander, dusts and other irritants (Cash & Glass, 2017).
For the elderly population, a medication review with the provider is sometimes necessary as some medication can cause coughing like the ACE. As the chronic cough is prevalent in the weak and debilitated population, thus the goal is to avoid forceful, uncontrolled cough that can result to exhaustion, sleep deprivation, rib fracture, and pneumothorax. As a provider, one must be careful in the use of antitussives as these patients need to expectorate the phlegm. During daytime, an expectorant is preferred to encourage coughing. In contrast, a cough suppressant at night to allow sleeping. Usually, increase fluid intake of 10 to 15 glasses per day is desirable to liquefy the phlegm but contraindicated to patients with renal failure and congestive heart failure. Complementary herbal medicines like Horehound as a cough suppressant, and the expectorant licorice to settle down the coughing, are good alternatives. However, this has a side effect of increasing the blood pressure. Educating the patient to stop smoking is a priority as it destroys the mucosal lining and ciliary hair structures of the airway linings that functions by clearing the mucus and offending pathogens in the respiratory tract (Dunphy, Winland-Brown, Porter & Thomas, 2015). Additionally, patients with chronic cough show a heightened cough reflex. This is commonly seen in patients who are coughing when there is a change in the environmental temperature or on exposure to noxious stimuli such as tobacco smoke or perfume (Faruqi, Murdoch, Allum & Morice, 2014). Though influenza vaccine does not prevent a cough, a yearly flu vaccination is highly suggested (Cash & Glass, 2017).
References:
Cash, J. C. & Glass, C.A. (2017). Family practice guidelines. (4th ed.). New York, NY: Springer Publishing Company.
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary Care: The art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F. A. Davis Company
Faruqi, S., Murdoch, R. D., Allum, F., & Morice, A. H. (2014). On the definition of chronic cough and current treatment pathways: an international qualitative study. Cough (17459974), 10(1), 1-21. doi:10.1186/1745-9974-10-5
Rhoads, J., & Jensen, M. M. (2015). Differential diagnosis for the advanced practice nurse. New York: Springer Publishing Company.
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