Cough

Cough
ICD-10	R05
ICD-9	786.2

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] M.Umer Tariq [3]

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Overview

A cough, also known as tussis is a sudden, often repetitive, spasmodic contraction of the thoracic cavity, resulting in violent release of air from the lungs, and usually accompanied by a distinctive sound.

Coughing is an action the body takes to get rid of substances that are irritating the air passages. A cough is usually initiated to clear a buildup of phlegm in the trachea. Coughing can also be triggered by a bolus of food entering the trachea rather than the esophagus due to a failure of the epiglottis. Frequent or chronic coughing usually indicates the presence of a disease. Provided the patient is a non-smoker and has a normal chest X-ray, the cause of chronic cough in 93% of all patients is due to asthma, heartburn or post-nasal drip. Other causes of chronic cough include chronic bronchitis and medications such as ACE inhibitors. Coughing can happen voluntarily as well as involuntarily.

Physiology

A cough is a protective, primitive reflex in healthy individuals. The cough reflex is initiated by stimulation of two different classes of afferent nerves, namely the myelinated rapidly adapting receptors, and nonmyelinated C-fibers with endings in the lungs.

Cause

A persistent cough can be debilitating, socially distressing, and adversely impair quality of life. One of the more common presentations to a medical practitioner is a dry cough. The common causes of chronic dry coughing include post-nasal drip, gastroesophageal reflux disease, asthma, post viral cough and certain drugs such as beta blockers, ACE inhibitors and aspirin. If a cough lasts for more than three weeks, multiple causes are likely and symptoms will abate only when all the causes are treated will the patient be symptom free. Individuals who smoke often have a smoker's cough, a loud, hacking cough which often results in the expiration of phlegm.

Coughing may also be used for psychological or social reasons, such as the coughing before giving a speech. This is known as psychogenic, habit or tic coughing, and may increase in frequency in social situations featuring conflict.

Given its irritant nature to mammal tissues, capsaicin is widely used to determine the cough threshold and as a tussive stimulant in clinical research of cough suppressants.

Complete List of Differential Diagnoses Sorted by Nonproductive vs Productive Nature of Cough

Nonproductive Cough

• Smoker's cough
• Aspiration
• Congestive heart failure
• Postnasal drip

  • Most common cause of chronic cough in nonsmokers

• GERD

  • Second most common cause of chronic cough in nonsmokers

• Asthma/reactive airway disease
• ACE inhibitor use
• Pneumonia

  • Typical pneumonia is characterized by acute or subacute onset of fever, dyspnea, fatigue, pleuritic chest pain, and cough
  • Atypical pneumoniais characterized by more gradual onset, dry cough,headache, fatigue, and minimal lung signs

• Acute bronchitis

  • Most commonly caused by viruses
  • Postviral bronchitis may last beyond 6 weeks

• Aspirated foreign body
• Lung cancer
• COPD
• Sarcoidosis
• Cryptogenic organizing pneumonia
• Filarial disease

Productive Cough

• Postnasal drip
• Tuberculosis
• COPD
• Lung cancer
• Smoker's cough
• Asthma with secondary infection
• Pneumonia
• Bronchitis

Complete Differential Diagnosis of Cough Sorted by Frequency of Causes

In alphabetical order.

Most Common Causes

• Allergic Rhinitis
• Asthma
• Bronchiectasis
• Gastroesophageal Reflux Disease (GERD)
• Post-nasal drip

Other Causes

Abacavir Abatacept Abrin ABVD ACE inhibitor Acetylmorphone Achalasia Acute bronchitis Acute Chest Syndrome Acute viral nasopharyngitis (common cold) Acyclovir Adalimumab Adefovir Adenoid hypertrophy Adenoviridae Albuterol Alcoholism Alefacept Alfuzosin Aliskiren Allergic bronchopulmonary aspergillosis Amiodarone Amlodipine and Benazepril Amphotericin B Anagrelide Anastrozole Aortic arch anomalies Aphthovirus Ascaris infection Aspergillosis Aspirated foreign bodies Atazanavir Atelectasis Atopic rhinitis Atrial myxoma Atypical pneumonia Benazepril Bepridil Beriberi Heart Disease Bevacizumab Bitolterol Blastomycosis Bordetella pertussis Bortezomib Brimonidine Bronchial stenosis Bronchial web Bronchiolitis Bronchitis Bronchogenic cyst Budesonide Busulfan Byssinosis Cadmium poisoning Caplan's Syndrome Captopril Carvedilol Cerumenosis Cervical mass Cetuximab Cevimeline Chest tube Chickenpox Chlamydophila pneumoniae Chlorambucil Choking Cholesterol pneumonia Chronic beryllium disease Chronic Fatigue Syndrome Chronic Obstructive Pulmonary Disease Ciliary dyskinesia Cladosporium Cladribine Clobutinol Clofarabine Clofedanol CMV Pneumonitis Coccidioidomycosis Community-acquired pneumonia Congenital nephrotic syndrome Congestive Heart Failure Co-trimoxazole Cromolyn Sodium Croup Cryptococcosis Cystic fibrosis Cytarabine Dacarbazine Dactinomycin Darbepoetin Alfa Diborane Docetaxel Domiodol Dornase alfa DTPA Ear foreign body Efalizumab Efavirenz Emtricitabine Enalapril Enfuvirtide

Epinastine Eplerenone Epoetin Alfa Eprosartan Erlotinib Esophageal atresia Esophageal cancer Esophageal dysmotility Estradiol Topical Etanercept Fasciolosis Fexofenadine Filariasis Floxuridine Fludarabine Phosphate Fluorouracil Fluticasone and Salmeterol Fluvastatin Fosamprenavir Fosinopril Gabapentin Ganciclovir Gefitinib Gemcitabine Hydrochloride Glyburide and Metformin Gnathostomiasis Goiter Goodpasture's syndrome Granisetron Hair in the ear canal Hamman-Rich syndrome Hay fever Histoplasmosis Histrelin Human ehrlichiosis Human flu Hypotension Ibandronate Idiopathic Pulmonary Fibrosis Ifosfamide Iloprost Imipramine Infectious mononucleosis Influenza Insulin Human (rDNA Origin) Interferon beta-1a Intramuscular Interstitial pneumonia Isoproterenol Juvenile Myelomonocytic Leukemia (JMML) Kaposi's sarcoma Ketorolac Lady Windermere syndrome Lamivudine Lamotrigine Laryngeal cancer Laryngitis Laryngopharyngeal Reflux Disease Laryngotracheal cleft Lassa fever Legionellosis Letrozole Levalbuterol Lisinopril Lomustine Low humidity Lower respiratory tract infection Lung abscess Lymphangitis carcinomatous Lymphocytic interstitial pneumonia Mallory-Weiss syndrome Measles Mechlorethamine Mediastinal tumor Melioidosis Melphalan Mercaptopurine Mesalamine Mesothelioma Metaproterenol Methotrexate Metoprolol Miliary tuberculosis Mitomycin Mitral stenosis Moexipril Moxifloxacin Mucor stolonifer Mycophenolic acid Mycoplasma pneumoniae Natalizumab Nateglinide Nedocromil Nickel carbonyl Nicotine nasal spray Nilutamide Nitrofurantoin Nocardiosis Occupational exposure of irritants Omeprazole Oxaliplatin Oxcarbazepine Paclitaxel

Pamidronate Paprika splitter's lung Paracoccidioidomycosis Papillomatosis Paragonimus Infection Passive smoking Pegaspargase Peginterferon alfa-2a Pemetrexed Penbutolol Pentamidine Perindopril Peripartum cardiomyopathy Pertussis Pharyngitis Pimecrolimus topical Pirbuterol acetate Pleurisy Pleuropulmonary blastoma Plicamycin Pneumocystis jirovecii pneumonia Polymer fume fever Post cerebrovascular accident Primaquine Procarbazine Prograf Psittacosis Psychogenic cough Pulmonary alveolar proteinosis Pulmonary Embolism Pulmonary hypertension Pulmonary sequestration Q Fever Quinapril Ramelteon Ramipril Rapidly progressive glomerulonephritis Rhinovirus Ribavirin Right Ventricular Outflow Tract Obstruction Risedronate Risperidone Rosiglitazone Rosuvastatin Saccharopolyspora rectivirgula Salicylate sensitivity Salmeterol Saquinavir Sarcoidosis Schistosomiasis Sevelamer Severe acute respiratory syndrome Sick building syndrome Silicosis Sirolimus Smoking Sodium stibogluconate Spironolactone Sporotrichosis Strep throat Subglottic hemangioma Subglottic stenosis Sulindac Superior Vena Cava Syndrome Tacrolimus Tamsulosin Thermoactinomyces sacchari Thermoactinomyces vulgaris Thioguanine Thiotepa Thoracentesis Thoracic Aortic Aneurysms Thymoma Tipranavir Tobacco smoking Tocainide Tonsillolith Topotecan Hydrochloride Tracheal stenosis Tracheitis Tracheoesophageal fistula Tracheomalacia Trandolapril Transfusion-associated graft versus host disease Trichinosis Trimetrexate Glucuronate Tuberculosis Tularemia Typhoid fever Upper respiratory tract infection Valganciclovir Vinorelbine Tartrate Viralcough Vorinostat Yersinia Pestis Infection Zanamivir Ziprasidone

Complete Differential Diagnosis of the Causes of Cough

(By organ system)

Cardiovascular	Aortic arch anomalies, Atrial myxoma, Beriberi Heart Disease, Congestive Heart Failure, Hypotension, Mitral stenosis, Right Ventricular Outflow Tract Obstruction, Superior Vena Cava Syndrome, Thoracic Aortic Aneurysms,
Chemical / poisoning	Abrin, Cadmium poisoning, Polymer fume fever,
Dermatologic	No underlying causes
Drug Side Effect	Abacavir , Abatacept , ABVD, ACE inhibitor, Acetylmorphone, Acyclovir , Adalimumab , Adefovir , Albuterol , Alefacept , Alfuzosin , Aliskiren , Amiodarone , Amlodipine and Benazepril , Amphotericin B , Anagrelide , Anastrozole , Atazanavir , Benazepril, Bepridil , Bevacizumab , Bitolterol , Bortezomib , Brimonidine , Budesonide, Busulfan , Captopril, Carvedilol , Cetuximab , Cevimeline, Chlorambucil , Cladribine , Clobutinol, Clofarabine , Clofedanol, Co-trimoxazole , Cromolyn Sodium , Cytarabine , Dacarbazine , Dactinomycin , Darbepoetin Alfa , Diborane, Docetaxel , Domiodol, Dornase alfa, DTPA, Efalizumab , Efavirenz , Emtricitabine , Enalapril , Enfuvirtide, Epinastine , Eplerenone , Epoetin Alfa , Eprosartan , Erlotinib , Estradiol Topical , Etanercept , Fexofenadine , Floxuridine , Fludarabine Phosphate , Fluorouracil , Fluticasone and Salmeterol , Fluvastatin , Fosamprenavir , Fosinopril , Gabapentin , Gefitinib , Gemcitabine Hydrochloride , Glyburide and Metformin , Granisetron , Histrelin , Ibandronate , Ifosfamide , Iloprost, Imipramine, Insulin Human (rDNA Origin) , Interferon beta-1a Intramuscular , Isoproterenol , Ketorolac, Lamivudine , Lamotrigine , Letrozole , Levalbuterol , Lisinopril , Lomustine , Mechlorethamine , Melphalan , Mercaptopurine , Mesalamine , Metaproterenol , Methotrexate , Metoprolol, Mitomycin , Moexipril , Moxifloxacin , Mycophenolic acid, Natalizumab , Nateglinide , Nedocromil , Nicotine nasal spray , Nilutamide , Nitrofurantoin , Omeprazole , Oxaliplatin , Oxcarbazepine , Paclitaxel, Pamidronate , Peginterferon alfa-2a , Pemetrexed , Penbutolol , Pentamidine, Perindopril, Pegaspargase , Pimecrolimus topical , Pirbuterol acetate , Plicamycin , Primaquine , Procarbazine , Prograf, Quinapril, Ramelteon , Ramipril, Ribavirin , Risedronate , Risperidone , Rosiglitazone , Rosuvastatin , Salmeterol , Saquinavir , Sevelamer , Sirolimus , Sodium stibogluconate, Spironolactone , Sulindac , Tacrolimus, Tamsulosin , Thioguanine , Thiotepa , Tipranavir , Tocainide , Topotecan Hydrochloride , Trandolapril, Trimetrexate Glucuronate , Vinorelbine Tartrate , Vorinostat , Zanamivir , Ziprasidone ,
Ear Nose Throat	Acute viral nasopharyngitis (common cold), Adenoid hypertrophy, Allergic rhinitis, Atopic rhinitis, Croup, Goiter, Laryngitis, Laryngopharyngeal Reflux Disease, Laryngotracheal cleft, Pharyngitis, Post-nasal drip, Strep throat, Subglottic hemangioma, Subglottic stenosis, Tonsillolith,
Endocrine	Goiter,
Environmental	Caplan's Syndrome, Chronic beryllium disease (CBD), Hay fever, Low humidity, Occupational exposure of irritants Passive smoking, Sick building syndrome, Silicosis, Smoking,
Gastroenterologic	Achalasia, Esophageal atresia, Esophageal cancer, Esophageal dysmotility, Gastroesophageal reflux disease, Mallory-Weiss syndrome,
Genetic	Cystic fibrosis, Juvenile Myelomonocytic Leukemia (JMML),
Hematologic	No underlying causes
Iatrogenic	Chest tube, Thoracentesis, Transfusion-associated graft versus host disease,
Infectious Disease	Adenoviridae, Aphthovirus, Ascaris infection, Aspergillosis, Blastomycosis, Bordetella pertussis, Byssinosis, Chickenpox, Chlamydophila pneumoniae, Cladosporium, CMV Pneumonitis, Coccidioidomycosis, Community-acquired pneumonia, Cryptococcosis, Fasciolosis, Filariasis, Gnathostomiasis, Histoplasmosis, Human ehrlichiosis, Infectious mononucleosis, Influenza, Lady Windermere syndrome, Lassa fever, Legionellosis, Measles, Melioidosis, Miliary tuberculosis, Mucor stolonifer, Mycoplasma pneumoniae, Nocardiosis, Paprika splitter's lung, Paracoccidioidomycosis, Papillomatosis, Paragonimus Infection, Pneumocystis jirovecii pneumonia, Psittacosis, Q Fever, Rhinovirus, Saccharopolyspora rectivirgula, Schistosomiasis, Sporotrichosis, Strep throat, Thermoactinomyces sacchari, Thermoactinomyces vulgaris, Trichinosis, Tuberculosis, Tularemia, Typhoid fever, Upper respiratory tract infection, Yersinia Pestis Infection,
Musculoskeletal / Ortho	No underlying causes
Neurologic	No underlying causes
Nutritional / Metabolic	Beriberi Heart Disease, Cholesterol pneumonia,
Obstetric/Gynecologic	Bronchogenic cyst, Pulmonary sequestration, Esophageal atresia, Peripartum cardiomyopathy,
Oncologic	Cervical mass, Esophageal cancer, Kaposi's sarcoma, Laryngeal cancer, Lymphangitis carcinomatous, Mediastinal tumor, Mesothelioma, Papillomatosis, Thymoma,
Opthalmologic	No underlying causes
Overdose / Toxicity	Ganciclovir , Nickel carbonyl, Valganciclovir , Salicylate sensitivity,
Psychiatric	Psychogenic cough,
Pulmonary	Acute bronchitis, Acute Chest Syndrome, Allergic bronchopulmonary aspergillosis, Asthma, Atelectasis, Atypical pneumonia, Aspergillosis, Blastomycosis, Bronchial stenosis, Bronchial web, Bronchiectasis, Bronchiolitis, Bronchitis, Bronchogenic cyst, Chronic Obstructive Pulmonary Disease, Ciliary dyskinesia, Cystic fibrosis, Goodpasture's syndrome, Hamman-Rich syndrome, Idiopathic Pulmonary Fibrosis, Interstitial pneumonia, Lady Windermere syndrome, Lung abscess, Pleurisy, Pleuropulmonary blastoma, Pulmonary alveolar proteinosis, Pulmonary Embolism, Pulmonary hypertension, Severe acute respiratory syndrome, Tracheal stenosis, Tracheitis, Tracheoesophageal fistula, Tracheomalacia,
Renal / Electrolyte	Congenital nephrotic syndrome, Rapidly progressive glomerulonephritis,
Rheum / Immune / Allergy	Sarcoidosis,
Sexual	No underlying causes
Trauma	Post cerebrovascular accident,
Urologic	No underlying causes
Miscellaneous	Alcoholism, Aspirated foreign bodies, Cerumenosis, Choking, Chronic Fatigue Syndrome, Ear foreign body, Hair in the ear canal,

Complications

The complications of coughing can be classified as either acute or chronic. Acute complications include cough syncope (fainting spells due to decreased blood flow to the brain when coughs are prolonged and forceful), insomnia, cough-induced vomiting, rupture of blebs causing spontaneous pneumothorax, subconjunctival hemorrhage or "red eye", coughing defecation and in women with a prolapsed uterus, cough urination. Chronic complications are common and include abdominal or pelvic hernias, fatigue fractures of lower ribs and costochondritis.

Treatment

Coughs can be treated with cough medicines. Dry coughs are treated with cough suppressants (antitussives) that suppress the body's urge to cough, while productive coughs (coughs that produce phlegm) are treated with expectorants that loosen mucus from the respiratory tract. Centrally acting cough suppressants, such as codeine and dextromethorphan reduce the urge to cough by inhibiting the response of the sensory endings by depolarization of the vagus nerve. A recent study indicates that, because of the presence of theobromine in chocolate, 50 grams of dark chocolate may be an effective treatment for a persistent cough.

Gargling with salt and warm water can also be helpful by reducing phlegm.

During injections

Coughing during an injection can lessen the pain of the needle stick caused by a sudden, temporary rise in pressure in the chest and spinal canal, inhibiting the pain-conducting structures of the spinal cord.

See also

• Whooping cough
• Kennel cough
• Cough medicine

Additional Resource

• McCool F (2006). "Global physiology and pathophysiology of cough: ACCP evidence-based clinical practice guidelines". Chest. 129 (1 Suppl): 48S–53S. PMID 16428691.Full text

External links

• FamilyDoctor.org – Chronic cough: causes and cures
• Coughing:Quick tips to help stop a coughing fit.

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