Intractable and Refractory Cough | Jindal Chest Clinic

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Intractable and Refractory Cough

• Jindal Clinics, Chandigarh

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What is cough?

• Respiratory defense mechanism to clear the
  airways of large amounts of
• Inhaled material
• Mucus/secretions
• Abnormal substances edema fluid, pus, blood
• 2. Receptor stimulation Irritant
• 3. Warning symptom of an illness

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Vigorous Cough ComplicationsIntrathoracic
pressures Up to 300 mmHg Expiratory
velocities 28000 cm/s or 500
miles/hHaemodynamic Sys pr- Up
to 140 mmHgEnergy
1 to 25 Joules

• Respiratory
• Exacerbation of asthma Lung herniation
  Laryngeal oedema Air leaks, Tracheobron trauma
• Cardiovascular
• Hypotension, Arrhythmias
• Cath. malfunction
• Venous rupture
• Genitourinary
• Incontinence, inversion

• Gastrointestinal
• GE reflux, Hernia,
• Rupture (spleen)
• Neurological
• Syncope, seizures
• Radiculopathy, Headache
• Musculoskeletal
• CPK?, Rib fracture
• Miscellaneous
• Constitutional, life style changes, self
  consciousness, fear, wound disruption, petechiae,
  purpura

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Classification Causes of cough

• Chronic cough Cough that lasts longer than 8
  weeks in adults or 4 weeks in children.

• Acute cough lt 3 weeks no more than 28 days

• Upper respiratory tract infections/ allergies
• Pneumonia of any cause
• TB
• Asthma
• CHF
• Pulm Embolism

• Common causes Asthma, gastroesophageal reflux
  disease, COPD or bronchitis.
• Less commonly, it can be a sign of a more severe
  condition, such as ILDs, heart disease.

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Chronic refractory intractable cough

• Refractory Cough Cough that persists despite
  guideline based treatment- seen in 20-46 of
  patients presenting to specialist cough clinics
• Intractable Cough Chronic cough whose aetiology
  is not clear in spite of standard investigations
• Uncommon and unrecognized causes
• Laryngeal neuropathy
• Non-acid GE Reflux

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Chronic cough or cough hypersensitivity
syndrome
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Red flags for Chronic cough

• Presence of one or more of the following signs/
  symptoms
• Difficulty breathing/ shortness of breath.
• Shallow, rapid breathing.
• Wheezing. Chest pain. Fever.
• Coughing up blood or yellow or green phlegm.
• Severe coughing induced vomit.
• Unexplained weight loss.
• Red flag may indicate a more serious infection
  (bronchitis, pneumonia, TB, another respiratory
  infection), ILDs, malignancy, Heart disease, PTE,
  others

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Management Principles

• Symptomatic treatment
• Home and SOS remedies
• Identify the underlying cause and manage
  accordingly Chronic cough disappears once the
  underlying problem is treated.
• Removal of triggers
• Psychosocial support
• Management of complications
• Maintenance treatment

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Symptomatic Anti-cough agents

• Anti tussives (cough center suppressants)- for
  dry unproductive cough Inhibit cough reflex by
  suppressing cough center in medulla both
  centrally and peripherally acting agents are
  available
• Pharyngeal demulcents (Soothing agents)
  logenges, linctuses, liquorice
• Expectorants (Encourage expectoration) sodium
  and potassium citrate, potassium iodide,
  guaiphensin, ammonium chloride
• Mucolytics (Liquify thick mucus) bromhexine,
  acetylcysteine, carbocisteine, ambroxol.