Contents of the training materials

Cough is the most frequent symptom of respiratory disease. It is caused by stimulation of sensory nerves in the mucosa of the pharynx, larynx, trachea and bronchi.

The explosive quality of a normal cough is lost in patients with respiratory muscle paralysis or vocal cord palsy. Paralysis of a single vocal cord gives rise to a prolonged, low-pitched, inefficient 'bovine' cough accompanied by hoarseness. Coexistence of an inspiratory noise (stridor) indicates partial obstruction of a major airway (e.g. laryngeal oedema, tracheal tumour, scarring or compression or an inhaled foreign body) and requires urgent investigation and treatment. Sputum production is common in patients with acute or chronic cough, and its nature and appearance can provide valuable clues as to the aetiology.

Causes of cough

Common causes

Clinical features

Pharynx

Post-nasal drip

History of chronic rhinitis

Larynx

Laryngitis, tumour, croup

Voice or swallowing altered, harsh or painful cough
Paroxysms of cough, often associated with stridor

Trachea

Tracheitis

retrosternal pain with cough

Bronchi

Bronchitis (acute) and COPD

Dry or productive, worse in mornings

Asthma

Usually dry, worse at night

Bronchial carcinoma

Persistent (often with haemoptysis)

Lung parenchyma

Tuberculosis

Productive, often with haemoptysis

Pneumonia

Dry initially, productive later

Bronchiectasis

Productive, changes in posture induce sputum production

Pulmonary oedema

Often at night

Interstitial fibrosis

Dry, irritant

Patients with chronic cough present more of a diagnostic challenge, especially those individuals with a normal examination, chest X-ray and lung function studies. In this context, cough can be explained by post-nasal drip secondary to nasal or sinus disease; cough-variant asthma (where cough may be the principal or exclusive clinical manifestation) or gastro-oesophageal reflux with aspiration. Ten to fifteen per cent of patients (particularly women) taking angiotensin-converting enzyme (ACE) inhibitors develop drug-induced chronic cough.

DYSPNOEA

Breathlessness or dyspnoea can be defined as the feeling of an uncomfortable need to breathe.

CAUSES OF DYSPNOEA

System

Acute dyspnoea at rest

Chronic exertional dyspnoea

Cardio -vascular

Acute pulmonary oedema

Chronic heart failure

Myocardial ischaemia

Respi -ratory

Acute severe asthma
Acute exacerbation of COPD
Pneumothorax
Pneumonia
* Pulmonary embolus
Acute respiratory distress syndrome
Inhaled foreign body
Lobar collapse
Laryngeal oedema (e.g. anaphylaxis)

COPD
Chronic asthma
Bronchial carcinoma
Interstitial lung disease (sarcoidosis, fibrosing alveolitis, pneumoconiosis)
Chronic pulmonary thromboembolism
Lymphatic carcinomatosis
Large pleural effusion(s)

Others

Metabolic acidosis (e.g. diabetic ketoacidosis, lactic acidosis, uraemia, overdose of salicylates,
Psychogenic hyperventilation

Severe anaemia
Obesity

CHRONIC EXERTIONAL DYSPNOEA

Chronic obstructive pulmonary disease (COPD)

The exertional dyspnoea in COPD typically varies little day to day, but exercise capacity falls over months or years. Patients usually report relief of dyspnoea at rest and overnight, a useful distinction from asthma. If bronchitis is present, chronic cough and sputum is usual, particularly in the mornings, but sputum may be absent when emphysema predominates. There is often a history of recurrent acute exacerbations of breathlessness, usually in winter. Most of the patients have a smoking history. In advanced disease may develop cor pulmonale

Asthma

Dyspnoea in asthma is associated with episodes of wheeze or chest tightness, usually worse in the morning. There may be a history of childhood wheeze, or of wheeze or rhinitis provoked by allergens. In exercise-induced asthma, wheeze and chest tightness typically come on immediately after exercise.

Heart disease

Left ventricular function can cause exertional dyspnoea. Orthopnoea, cough and wheeze may also be present, as in lung disease. A history of angina or hypertension may be useful in implicating a cardiac cause. On examination, an increase in heart size. The chest X-ray may show cardiomegaly and an ECG may provide evidence of left ventricular disease.

Pulmonary thromboembolism

Pulmonary thromboembolism often presents with acute breathlessness with or without chest pain. However, chronic pulmonary thromboembolic disease should be suspected in patients who present with more gradual onset of breathlessness.

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