Diseases » Laryngitis » Causes

Causes of Laryngitis

List of causes of Laryngitis

Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Laryngitis) that could possibly cause Laryngitis includes:

• Viral infection - common cause of acute laryngitis
• Allergies
• Vocal straining
• Larynx cancer
• Inhaled irritants
• Persistent coughing (see Severe cough)
• Chlamydia pneumoniae - laryngitis
• Chemical poisoning - Acrylic acid - laryngitis
• Common cold
• Inhaled combined corticosteroid bronchodilator use
• B-hemolytic streptococcus
• Haemophilus influenzae
• Streptococcus pneumoniae
• Rhinovirus - laryngitis
• Tumour
• Aging changes
• Influenza
• Aspiration of caustic chemical
• Injury or compression of recurrent laryngeal nerve
• Misuse or abuse of voice
• Inhaling irritating substances
• Tuberculosis
• Barrett's esophagus - Laryngitis
• Moraxella catarrhalis infection - laryngitis
• Bacterial or fungal infection
• Inflammation due to overuse of the vocal cords
• As an isolated local infection of the larynx as part of another, more serious underlying disorder, such as pneumonia or tuberculosis
• Postnasal drip
• Inhalation of smoke fumes or caustic chemicals
• Chronic upper respiratory tract disorders such as sinusitis, bronchitis, nasal polyps
• Excessive coughing (see Coughing spasms)
• Smoking
• Alcohol consumption (see Alcohol use)

More causes: see full list of causes for Laryngitis

Causes of Laryngitis (Diseases Database):

The follow list shows some of the possible medical causes of Laryngitis that are listed by the Diseases Database:

• Common cold

Source: Diseases Database

Laryngitis Causes: Book Excerpts

• Differential Diagnosis - Hoarseness
• Differential Diagnosis - Cough - Nonproductive
• Differential Diagnosis - Cough - Productive
• Differential Diagnosis - Stridor & Wheezing
• Differential Diagnosis - Hoarseness
• Differential Diagnosis - Stridor
• Differential Diagnosis - Cough – Acute
• Differential Diagnosis - Cough – Chronic
• Medical causes - Hoarseness
• Medical causes - Stridor
• Medical causes - Cough, barking
• Medical causes - Cough, nonproductive
• Medical causes - Cough, productive
• Causes - Laryngitis
• Causes and incidence - Laryngeal cancer
• Causes and incidence - Whooping cough
• Medical causes - Hoarseness
• Medical causes - Stridor
• Medical causes - Cough, barking
• Medical causes - Cough, nonproductive
• Medical causes - Cough, productive
• Differential Overview - Hoarseness
• Differential Overview - Acute Cough
• Differential Overview - Chronic Cough
• Causes - Laryngitis
• Causes - Laryngeal cancer
• Medical causes - Stridor
• Medical causes - Cough, barking
• Medical causes - Cough, productive
• Medical causes - Hoarseness
• Medical causes - Stridor
• Medical causes - Cough, barking
• Medical causes - Cough, nonproductive
• Medical causes - Cough, productive
• Principal Causes of Cough - Cough
• Principal Causes of Hoarseness - Hoarseness
• Principal Causes of Airway Obstruction - Stertor, Stridor, and Airway Obstruction
• Medical causes - Hoarseness
• Medical causes - Stridor
• Medical causes - Cough, barking
• Medical causes - Cough, nonproductive
• Medical causes - Cough, productive

Laryngitis as a symptom:

Conditions listing Laryngitis as a symptom may also be potential underlying causes of Laryngitis. Our database lists the following as having Laryngitis as a symptom of that condition:

• Barrett's esophagus
• Chemical poisoning - Acrylic acid
• Chlamydia pneumoniae
• Moraxella catarrhalis infection
• Rhinovirus

Medications or substances causing Laryngitis:

The following drugs, medications, substances or toxins are some of the possible causes of Laryngitis as a symptom. This list is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

• Sibutramine
• Meridia
• Raloxifene
• Evista
• Betaseron
• more drugs...»

See full list of 10 medications causing Laryngitis

What causes Laryngitis?

Causes: Laryngitis: Usually a viral infection but sometimes other underlying causes

Related information on causes of Laryngitis:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Laryngitis may be found in:

• Risk factors for Laryngitis
• Medications that may cause Laryngitis
• Hidden causes of Laryngitis

Causes of Laryngitis: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Laryngitis.

Hoarseness: Differential Diagnosis
(In a Page: Signs and Symptoms)

Acute (<2 weeks)

• Infections: Laryngitis, tracheitis, epiglottitis (accompanied by stridor and “thumb sign” on lateral neck X-ray), croup, upper respiratory infections, deep space face and neck infections (e.g., peritonsillar abscess, retropharyngeal abscess, parapharyngeal abscess)
• Voice abuse: Shouting, speaking, or singing loudly; may also cause chronic hoarseness if the abuse is recurrent
• Foreign body
• Trauma: Laryngeal trauma secondary to MVA, strangulation, assault, sporting injuries, intubation, arytenoid cartilage dislocation, or surgery (e.g., damage to recurrent laryngeal nerve following thyroid surgery)
• Irritants: Vomiting, chemical inhalation
• Anaphylaxis
  Chronic (>2 weeks)
• Allergic rhinitis
• Irritants: Tobacco smoke, occupational
• GERD
• Chronic sinusitis
• Endocrine: Puberty, menopause, hypothyroidism
• Foreign body
• Aging
• Vocal cord problems: Polyps, nodules (“singer's nodules”), neoplasm (primary or metastatic), papilloma (infants and children), corditis (Reinke's edema or edema of vocal cords), vocal cord paralysis
• Malignancy: Laryngeal, esophageal, lung, and head and neck (e.g., tonsillar, tongue) cancers
• Iatrogenic: Medication side effect (e.g., pioglitazone, aerosolized steroids), postsurgical recurrent laryngeal nerve damage with vocal cord paralysis, radiation therapy
• Neurologic: Multiple sclerosis, amyotrophic lateral sclerosis, Parkinson's disease, muscular dystrophy
• Less common etiologies (“zebras”) include hemorrhage into vocal folds, psychogenic (laryngeal conversion disorders), rheumatoid arthritis, sarcoidosis, and amyloidosis

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» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Cough - Nonproductive: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Smoker's cough
• Postnasal drip (e.g., chronic sinusitis, allergic rhinitis)
  –Most common cause of chronic cough in nonsmokers

• GERD
  –Second most common cause of chronic cough in nonsmokers

• Asthma/reactive airway disease
  –Classic triad of chronic cough, dyspnea, and wheezing

ACE inhibitor use

Acute bronchitis
–Most commonly caused by viruses (e.g., influenza, adenovirus, rhinovirus, RSV)
–Postviral bronchitis may last beyond 6 weeks

Pneumonia
–“Typical” pneumonia (e.g., Streptococcus pneumoniae, Haemophilus influenzae, or influenza/parainfluenza viruses) is characterized by acute or subacute onset of fever, dyspnea, fatigue, pleuritic chest pain, and cough
–“Atypical” pneumonia (e.g., Mycoplasma, Legionella, Chlamydia) is characterized by more gradual onset, dry cough, headache, fatigue, and minimal lung signs

Aspirated foreign body
–Abrupt onset of unilateral wheezing or stridor, cough, decreased breath sounds
–Leading cause of home accidental death in children younger than 6 (boys >girls)

• Lung cancer
  –90% of cases due to smoking (other risk factors include radon, asbestos, pollutants)

COPD (emphysematous variant)

Sarcoidosis

• Cryptogenic organizing pneumonia
  –Most commonly occurs following viral infection or exposure

Congestive heart failure

Filarial disease

Aspiration

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Cough - Productive: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Postnasal drip (e.g., chronic sinusitis, allergic rhinitis)
  –Most common cause of chronic cough in nonsmokers
• Acute bronchitis
  –Most commonly caused by viruses (e.g., influenza, adenovirus, rhinovirus, RSV)
  –Bacteria are much less common (e.g., Streptococcus pneumoniae, Mycoplasma, Haemophilus influenzae)
• Pneumonia
  –May be community-acquired, hospital-acquired, or due to aspiration
  –“Typical” pneumonia (e.g., S. pneumoniae, H. influenzae, influenza virus) has acute or subacute onset of fever, dyspnea, fatigue, pleuritic chest pain, and productive cough
  –“Atypical” pneumonia (e.g., Mycoplasma, Legionella, Chlamydia, Pneumocystis carinii) has more gradual onset, dry cough, headache, fatigue
• Smoker's cough
• Lung cancer
  –90% of cases due to smoking (other risk factors include radon, asbestos, pollutants)
• Asthma with secondary infection
• COPD (chronic bronchitis component)
• Congestive heart failure
  –Associated with “frothy” sputum
• Tuberculosis

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Stridor & Wheezing: Differential Diagnosis
(In a Page: Signs and Symptoms)

Stridor (inspiratory)

• Croup (laryngotracheobronchitis)
  –Viral infection with tracheal narrowing due to airway edema
  –“Bark-like” cough, hoarseness

• Epiglottitis
  –Airway emergency most commonly due to Haemophilus influenzae or group A streptococcus infection
  –Abrupt onset of high fevers, sore throat, hoarseness, dysphagia, respiratory distress

• Foreign body lodged in the upper airway
• Allergic reaction/anaphylaxis
  –May have urticaria and angioedema (subcutaneous or mucosal swelling, often of the lips)
• Trauma
• Postendotracheal intubation
• Psychogenic (e.g., paroxysmal vocal cord dyskinesia)
  Stridor (expiratory)
• COPD (expiratory vocalization to prolong time to airway closure and avoid air trapping)
• Cardiac failure (expiratory vocalization to prolong increased intrathoracic pressure and unload left ventricle)

Wheezing

• Asthma
  –Triad of chronic cough, dyspnea, wheezing
  –Wheezing may be absent in cases of severe obstruction (insufficient air movement)

• Pulmonary edema
  –Leakage of fluid into the interstitium and alveoli due to elevated capillary pressure (cardiogenic) or abnormal capillary permeability (noncardiogenic)

COPD

GERD

Respiratory infection
–Upper respiratory infection
–Bronchiolitis
–“Atypical” pneumonia

• Aspirated foreign body
  –Abrupt onset of unilateral wheezing or stridor (if lodged in the upper airway), cough, and decreased breath sounds

Allergic reaction/anaphylaxis
–Urticaria, throat swelling (angioedema), and lip/tongue edema may be present

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Hoarseness: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Congenital
  –Glottic webs
  –Laryngeal clefts
  –Laryngocele
  –Tracheoesophageal fistula
  –Hemangiomas
• Inflammatory/infectious
  –Viral URI
  –Diphtheria
  –Laryngotracheobronchitis
  –Gastroesophageal reflux disease: Posterior laryngitis, vocal cord edema
  –Fungal laryngitis: Consider in an immunocompromised patient
• Tumors
  –Respiratory papillomas
  –Squamous cell carcinoma
  –Hemangioma
  –Lymphangioma

• Trauma
  –Traumatic birth
  –Postintubation: May result in cord edema, granulomas, vocal cord webbing, cricoarytenoid joint dislocation, or ankylosis
  –Laryngeal fracture
  –Iatrogenic: Neck or cardiopulmonary surgery may cause injury to the recurrent laryngeal nerve, leading to vocal cord paralysis
  –Vocal abuse: Vocal cord nodules or polyps

• Endocrine
  –Hypothryoidism

• Neurogenic
  –Idiopathic vocal cord paralysis
  –Arnold-Chiari or Dandy-Walker malformations may lead to brainstem compression of the vagal nerve roots, leading to vocal cord paralysis
  –Peripheral nerve: Recurrent laryngeal nerve injury or invasion by tumor, myasthenia gravis
  –Spasmodic dysphonia: Dystonia of the laryngeal muscles

• Systemic disease
  –Rheumatoid arthritis: Fixation of the cricoarytenoid joint
  –Relapsing polychondritis
• Functional

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Stridor: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Nasal cavity and nasopharynx

• Congenital
  –Piriform aperture stenosis
  –Choanal atresia
  –Lacrimal duct cyst
  –Craniofacial anomaly
  –Nasopharyngeal mass (teratoma)
• Inflammatory/infectious
  –Rhinosinusitis
  –Adenoid hypertrophy

Oral cavity, oropharynx, and hypopharynx
• Congenital
  –Macroglossia
  –Glossoptosis
  –Vallecular cyst
• Inflammatory/infectious
  –Tonsillar hypertrophy
• Tumors
  –Lingual thyroid
  –Dermoid
  –Lymphovascular malformation
• Foreign body

Laryngeal

• Congenital
  –Laryngomalacia (#1 cause in infants); usual onset is in the first 2 weeks of life, typically positional; most resolve spontaneously by age 1
  –Saccular cyst
  –Webs
  –Clefts
  –Vocal cord paralysis

• Inflammatory/infectious
  –Epiglottitis
  –Laryngotracheitis (croup)
  –Gastroesophageal reflux
• Tumors
  –Papillomas
  –Hemangiomas
• Trauma
  –Subglottic stenosis
  –Foreign bodies
  –Laryngeal fracture
  –Caustic ingestion
  Tracheobronchial
• Congenital
  –Tracheomalacia
  –Vascular rings
  –Tracheoesophageal fistula
• Inflammatory

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Cough – Acute: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Upper airway disease
  –URI or common cold accounts for much pediatric coughing (influenza, parainfluenza, rhinovirus)
  –Chronic sinusitis, tonsillitis, laryngitis, and croup are other common infections
  –Allergic disease
  –Vocal cord dysfunction (VCD)

• Lower airway disease
  –Asthma is inflammatory triad of edema, mucus, and bronchospasm, characterized by reversibility with asthma drugs (the most common triggers for asthma are viral disease, irritants such as ETS, allergic disease, and gastroesophageal reflux)
  –Infectious diseases: Bronchiolitis, caused by RSV in babies, causes cough from inflammatory changes and debris; bronchitis is more common in older children and may be secondary to smoking or ETS exposure; other viral lower airway diseases include adenovirus, influenza, and parainfluenza
  –Foreign body aspiration
  –Chronic diseases (e.g., cystic fibrosis and bronchiectasis) and structural abnormalities (e.g., PCD, TEF, or cleft, rings, and slings) may present with intermittent rather than chronic cough

• Parenchymal and pleural disease
  –Infectious diseases account almost exclusively for all parenchymal and pleural causes of cough (i.e., pneumonia and empyema)
  –Usual infectious agents include bacterial disease (e.g., streptococcal, staphylococcal) and atypical pneumonias (e.g., Mycoplasma pneumoniae), TB
  –Irritation of a branch of cranial nerve ten in the external auditory canal can trigger cough

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Cough – Chronic: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Lower airway disease
  –Asthma
       –Inflammatory triad of edema, mucus, and bronchospasm, characterized by reversibility with asthma drugs
  –The most common triggers for asthma are viral disease, irritants (e.g., ETS), allergic disease, and GER
  –Airway infections: Bronchiolitis, caused by RSV in babies, may cause chronic cough from persistent inflammatory change and debris; bronchitis is more common in older children and may be secondary to smoking or ETS exposure
  –Foreign body: Associated with endobronchial infection and damage
  –Cystic fibrosis: The most common life-threatening inherited illness of whites, is associated with production of chronically infected sputum
  –Bronchiectasis: Chronic infection and damage to the airway; may be secondary to another disease (e.g., TB or CF)
  –Structural abnormalities: PCD, TEF, or cleft, rings, slings

• Upper airway disease
  –Infectious diseases: Chronic sinusitis, tonsillitis, laryngitis, including that secondary to GER (although acute disorders, the inflammation from URI may be associated with a chronic cough if frequent enough)
• Parenchymal and pleural disease
  –Infectious disease accounts almost exclusively for all parenchymal and pleural causes of cough (e.g., pneumonia and empyema)
  • CNS causes
    –CNS causes of cough include “habit cough” (or psychogenic cough), Tourette disease associated “cough tic” or throat clearing, VCD
    –Irritation of a branch of cranial nerve ten in the external auditory canal can trigger chronic cough

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Hoarseness: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Gastroesophageal reflux

With gastroesophageal reflux, retrograde flow of gastric juices into the esophagus may then spill into the hypopharynx This, in turn, irritates the larynx, resulting in hoarseness as well as a sore throat, a cough, throat clearing, and a sensation of a lump in the throat

The arytenoids and the vocal cords may appear red and swollen.

Hypothyroidism

With hypothyroidism, hoarseness may be an early sign Others include fatigue, cold intolerance, weight gain despite anorexia, and menorrhagia.

Laryngeal cancer

Hoarseness is an early sign of vocal cord cancer, but may not occur until later in cancer of other laryngeal areas The patient usually has a long history of smoking

Other common findings include a mild, dry cough; minor throat discomfort; otalgia; and, sometimes, hemoptysis.

Laryngeal leukoplakia

Leukoplakia is a common cause of hoarseness, especially in smokers Histologic examination from direct laryngoscopy usually reveals mild, moderate, or severe dysphagia.

Laryngitis

Persistent hoarseness may be the only sign of chronic laryngitis With acute laryngitis, hoarseness or a complete loss of voice develops suddenly

Related findings include pain (especially during swallowing or speaking), a cough, a fever, profuse diaphoresis, a sore throat, and rhinorrhea.

Rheumatoid arthritis

Hoarseness may signal laryngeal involvement Other findings include pain, dysphagia, a sensation of fullness or tension in the throat, dyspnea on exertion, and stridor.

Thoracic aortic aneurysm

Thoracic aortic aneurysm typically produces no symptoms, but may cause hoarseness Its most common symptom is penetrating pain that’s especially severe when the patient is supine

Other clinical features include a brassy cough; dyspnea; wheezing; a substernal aching in the shoulders, lower back, or abdomen; a tracheal tug; facial and neck edema; jugular vein distention; dysphagia; prominent chest veins; stridor; and, possibly, paresthesia or neuralgia.

Tracheal trauma

Torn tracheal mucosa may cause hoarseness, hemoptysis, dysphagia, neck pain, airway occlusion, and respiratory distress.

Vocal cord paralysis

Unilateral vocal cord paralysis causes hoarseness and vocal weakness Paralysis may accompany signs of trauma, such as pain and swelling of the head and neck.

Vocal cord polyps or nodules

Raspy hoarseness, the chief complaint, accompanies a chronic cough and a crackling voice.

Other causes

Inhalation injury

Inhalation injury from a fire or explosion produces hoarseness and coughing, singed nasal hairs, orofacial burns, and soot-stained sputum Subsequent signs and symptoms include crackles, rhonchi, and wheezing, which rapidly deteriorate to respiratory distress.

Treatments

Occasionally, surgical trauma to the recurrent laryngeal nerve results in temporary or permanent unilateral vocal cord paralysis, leading to hoarseness

Prolonged intubation may cause temporary hoarseness.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Stridor: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Airway trauma

Local trauma to the upper airway commonly causes acute obstruction, resulting in the sudden onset of stridor. Accompanying this sign are dysphonia, dysphagia, hemoptysis, cyanosis, accessory muscle use, intercostal retractions, nasal flaring, tachypnea, progressive dyspnea, and shallow respirations. Palpation may reveal subcutaneous crepitation in the neck or upper chest.

Anaphylaxis

With a severe allergic reaction, upper airway edema and laryngospasm cause stridor and other signs and symptoms of respiratory distress: nasal flaring, wheezing, accessory muscle use, intercostal retractions, and dyspnea. The patient may also develop nasal congestion and profuse, watery rhinorrhea. Typically, these respiratory effects are preceded by a feeling of impending doom or fear, weakness, diaphoresis, sneezing, nasal pruritus, urticaria, erythema, and angioedema. Common associated findings include chest or throat tightness, dysphagia and, possibly, signs of shock, such as hypotension, tachycardia, and cool, clammy skin.

Anthrax (inhalation)

Initial signs and symptoms are flulike and include a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by stridor, a fever, dyspnea, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Aspiration of a foreign body

Sudden stridor is characteristic in foreign body aspiration, a life-threatening situation. Related findings include an abrupt onset of dry, paroxysmal coughing; gagging or choking; hoarseness; tachycardia; wheezing; dyspnea; tachypnea; intercostal muscle retractions; diminished breath sounds; cyanosis; and shallow respirations. The patient typically appears anxious and distressed.

Hypocalcemia

With hypocalcemia, laryngospasm can cause stridor. Other findings include paresthesia, carpopedal spasm, and positive Chvostek’s and Trousseau’s signs.

Inhalation injury

Within 48 hours after inhalation of smoke or noxious fumes, the patient may develop laryngeal edema and bronchospasms, resulting in stridor. Associated signs and symptoms include singed nasal hairs, orofacial burns, coughing, hoarseness, sooty sputum, crackles, rhonchi, wheezes, and other signs and symptoms of respiratory distress, such as dyspnea, accessory muscle use, intercostal retractions, and nasal flaring.

Mediastinal tumor

Commonly producing no symptoms at first, a mediastinal tumor may eventually compress the trachea and bronchi, resulting in stridor. Its other effects include hoarseness, a brassy cough, a tracheal shift or tug, dilated neck veins, swelling of the face and neck, stertorous respirations, and suprasternal retractions on inspiration. The patient may also report dyspnea, dysphagia, and pain in the chest, shoulder, or arm.

Retrosternal thyroid

Retrosternal thyroid is an anatomic abnormality that causes stridor, dysphagia, a cough, hoarseness, and tracheal deviation. It can also cause signs of thyrotoxicosis.

Other causes

Diagnostic tests

Bronchoscopy or laryngoscopy may precipitate laryngospasm and stridor.

Treatments

After prolonged intubation, the patient may exhibit laryngeal edema and stridor when the tube is removed. Aerosol therapy with epinephrine may reduce stridor. Reintubation may be necessary in some cases. Neck surgery, such as thyroidectomy, may cause laryngeal paralysis and stridor.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Cough, barking: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Aspiration of foreign body.

Partial obstruction of the upper airway first produces sudden hoarseness, and then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing and, possibly, cyanosis.

Epiglottiditis.

 Epiglottiditis is a life-threatening disorder that has become less common since the use of influenza vaccines. It occurs nocturnally, heralded by a barking cough and a high fever. The child is hoarse, dysphagic, dyspneic, and restless and appears extremely ill and panicky. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia. The child will struggle to get sufficient air as epiglottic edema increases. Epiglottiditis is a true medical emergency.

Laryngotracheobronchitis (acute).

Also known as viral croup, laryngotracheobronchitis is most common in children between ages 9 and 18 months and usually occurs in the fall and early winter. It initially produces a low to moderate fever, a runny nose, a poor appetite, and an infrequent cough. When the infection descends into the laryngotracheal area, a barking cough, hoarseness, and inspiratory stridor occur.

As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.

Spasmodic croup.

 Acute spasmodic croup usually occurs during sleep with the abrupt onset of a barking cough that awakens the child. Typically, he doesn't have a fever, but may be hoarse, restless, and dyspneic. As his respiratory distress worsens, the child may exhibit sternal and intercostal retractions, nasal flaring, tachycardia, cyanosis, and an anxious, frantic appearance. The signs usually subside within a few hours, but attacks tend to recur.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Cough, nonproductive: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Airway occlusion.

Partial occlusion of the upper airway produces a sudden onset of dry, paroxysmal coughing. The patient is gagging, wheezing, and hoarse, with stridor, tachycardia, and decreased breath sounds.

Anthrax (inhalation).

Anthrax is an acute infectious disease that's caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in the cutaneous, inhalation, or GI form.

Inhalation anthrax is caused by inhaling aerosolized spores. Initial signs and symptoms are flulike and include a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages, with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Aortic aneurysm (thoracic).

Aortic aneurysm causes a brassy cough with dyspnea, hoarseness, wheezing, and a substernal ache in the shoulders, lower back, or abdomen. The patient may also have facial or neck edema, jugular vein distention, dysphagia, prominent veins over his chest, stridor and, possibly, paresthesia or neuralgia.

Asthma.

Asthma attacks typically occur at night, starting with a nonproductive cough and mild wheezing; this progresses to severe dyspnea, audible wheezing, chest tightness, and a cough that produces thick mucus. Other signs include apprehension, rhonchi, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis.

Atelectasis.

As lung tissue deflates, it stimulates cough receptors, causing a nonproductive cough. The patient may also have pleuritic chest pain, anxiety, dyspnea, tachypnea, and tachycardia. His skin may be cyanotic and diaphoretic, his breath sounds may be decreased, his chest may be dull on percussion, and he may exhibit inspiratory lag, substernal or intercostal retractions, decreased vocal fremitus, and tracheal deviation toward the affected side.

Bronchitis (chronic).

Bronchitis starts with a nonproductive, hacking cough that later becomes productive. Other findings include prolonged expiration, wheezing, dyspnea, accessory muscle use, barrel chest, cyanosis, tachypnea, crackles, and scattered rhonchi. Clubbing can occur in late stages.

Bronchogenic carcinoma.

The earliest indicators of bronchogenic carcinoma can be a chronic, nonproductive cough; dyspnea; and vague chest pain. The patient may also be wheezing.

Common cold.

 The common cold generally starts with a nonproductive, hacking cough and progresses to some mix of sneezing, headaches, malaise, fatigue, rhinorrhea, myalgia, arthralgia, nasal congestion, and a sore throat.

Esophageal achalasia.

 In esophageal achalasia, regurgitation and aspiration produce a dry cough. The patient may also have recurrent pulmonary infections and dysphagia.

Esophageal diverticula.

 The patient with esophageal diverticula has a nocturnal nonproductive cough, regurgitation and aspiration, dyspepsia, and dysphagia. His neck may appear swollen and have a gurgling sound. He may also exhibit halitosis and weight loss.

Esophageal occlusion.

 Esophageal occlusion is marked by immediate nonproductive coughing and gagging, with a sensation of something stuck in the throat. Other findings include neck or chest pain, dysphagia, and the inability to swallow.

Hantavirus pulmonary syndrome.

A nonproductive cough is common in patients with Hantavirus pulmonary syndrome, which is marked by noncardiogenic pulmonary edema. Other findings include a headache, myalgia, fever, nausea, and vomiting.

Hypersensitivity pneumonitis.

 With hypersensitivity pneumonitis, an acute nonproductive cough, a fever, dyspnea, and malaise usually occur 5 to 6 hours after exposure to an antigen.

Interstitial lung disease.

A patient with interstitial lung disease has a nonproductive cough and progressive dyspnea. He may also be cyanotic and have clubbing, fine crackles, fatigue, variable chest pain, and weight loss.

Laryngeal tumor.

 A mild, nonproductive cough is an early sign of a laryngeal tumor, in addition to minor throat discomfort and hoarseness. Later, dysphagia, dyspnea, cervical lymphadenopathy, stridor, and an earache may occur.

Laryngitis.

 In its acute form, laryngitis causes a nonproductive cough with localized pain (especially when the patient is swallowing or speaking) as well as fever and malaise. His hoarseness can range from mild to complete loss of voice.

Lung abscess.

Lung abscess typically begins with a nonproductive cough, weakness, dyspnea, and pleuritic chest pain. The patient may also exhibit diaphoresis, a fever, a headache, malaise, fatigue, crackles, decreased breath sounds, anorexia, and weight loss. Later, his cough produces large amounts of purulent, foul-smelling, and possibly bloody sputum.

Pleural effusion.

 A nonproductive cough along with dyspnea, pleuritic chest pain, and decreased chest motion are characteristic of pleural effusion. Other findings include a pleural friction rub, tachycardia, tachypnea, egophony, flatness on percussion, decreased or absent breath sounds, and decreased tactile fremitus.

Pneumonia.

Bacterial pneumonia usually starts with a nonproductive, hacking, painful cough that rapidly becomes productive. Other findings include shaking chills, a headache, a high fever, dyspnea, pleuritic chest pain, tachypnea, tachycardia, grunting respirations, nasal flaring, decreased breath sounds, fine crackles, rhonchi, and cyanosis. The patient's chest may be dull on percussion.

With mycoplasma pneumonia, a nonproductive cough arises 2 to 3 days after the onset of malaise, a headache, and a sore throat. The cough can be paroxysmal, causing substernal chest pain. Fever commonly occurs, but the patient doesn't appear seriously ill.

Viral pneumonia causes a nonproductive, hacking cough and the gradual onset of malaise, headache, anorexia, and a low-grade fever.

Pneumothorax.

 Pneumothorax is a life-threatening disorder that causes a dry cough and signs of respiratory distress, such as severe dyspnea, tachycardia, tachypnea, and cyanosis. The patient experiences sudden, sharp chest pain that worsens with chest movement as well as subcutaneous crepitation, hyperresonance or tympany, decreased vocal fremitus, and decreased or absent breath sounds on the affected side.

Pulmonary edema.

Pulmonary edema initially causes a dry cough, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, tachycardia, tachypnea, dependent crackles, and a ventricular gallop. If pulmonary edema is severe, the patient's respirations become more rapid and labored, with diffuse crackles and coughing that produces frothy, bloody sputum.

Pulmonary embolism.

A life-threatening pulmonary embolism may suddenly produce a dry cough along with dyspnea and pleuritic or anginal chest pain. Typically, however, the cough produces blood-tinged sputum. Tachycardia and a low-grade fever are also common; less common signs and symptoms include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and jugular vein distention. The patient may also have a pleural friction rub, diffuse wheezing, dullness on percussion, and decreased breath sounds.

Sarcoidosis.

With sarcoidosis, a nonproductive cough is accompanied by dyspnea, substernal pain, and malaise. The patient may also develop fatigue, arthralgia, myalgia, weight loss, tachypnea, crackles, lymphadenopathy, hepatosplenomegaly, skin lesions, visual impairment, difficulty swallowing, and arrhythmias.

Severe acute respiratory syndrome (SARS).

SARS is an acute infectious disease of unknown etiology; however, a novel coronavirus has been implicated as a possible cause. Although most cases have been reported in Asia (China, Vietnam, Singapore, Thailand), cases have cropped up in Europe and North America. The incubation period is 2 to 7 days; the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include a headache; malaise; a dry, nonproductive cough; and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Tracheobronchitis (acute).

Initially, tracheobronchitis produces a dry cough that later becomes productive as secretions increase. Chills, a sore throat, a slight fever, muscle and back pain, and substernal tightness generally precede the cough's onset. Rhonchi and wheezes are usually heard. Severe illness causes a fever of 101° to 102° F (38.3° to 38.9° C) and possibly bronchospasm, with severe wheezing and increased coughing.

Tularemia.

Also known as rabbit fever, tularemia is caused by the gram-negative, non–spore-forming bacterium Francisella tularensis. It's typically a rural disease found in wild animals, water, and moist soil. It's transmitted to humans through the bite of an infected insect or tick, handling infected animal carcasses, drinking contaminated water, or inhaling the bacteria. It's considered a possible airborne agent for biological warfare. Signs and symptoms following inhalation of the organism include the abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Diagnostic tests.

 Pulmonary function tests (PFTs) and bronchoscopy may stimulate cough receptors and trigger coughing.

Treatments.

 Irritation of the carina during suctioning or deep endotracheal or tracheal tube placement can trigger a paroxysmal or hacking cough. Intermittent positive-pressure breathing or spirometry can also cause a nonproductive cough. Some inhalants, such as pentamidine, may stimulate coughing.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Cough, productive: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Actinomycosis.

 Actinomycosis begins with a cough that produces purulent sputum. A fever, weight loss, fatigue, weakness, dyspnea, night sweats, pleuritic chest pain, and hemoptysis may also occur.

Aspiration pneumonitis.

Aspiration pneumonitis causes coughing that produces pink, frothy and, possibly, purulent sputum. The patient also has marked dyspnea, a fever, tachypnea, tachycardia, wheezing, and cyanosis.

Bronchiectasis.

The chronic cough of bronchiectasis produces copious, mucopurulent sputum that has characteristic layering (top, frothy; middle, clear; bottom, dense with purulent particles). The patient has halitosis; his sputum may smell foul or sickeningly sweet. Other characteristic findings include hemoptysis, persistent coarse crackles over the affected lung area, occasional wheezing, rhonchi, exertional dyspnea, weight loss, fatigue, malaise, weakness, a recurrent fever, and late-stage finger clubbing.

Bronchitis (chronic).

Bronchitis causes a cough that may be nonproductive initially. Eventually, however, it produces mucoid sputum that becomes purulent. Secondary infection can also cause mucopurulent sputum, which may become blood-tinged and foul-smelling. The coughing, which may be paroxysmal during exercise, usually occurs when the patient is recumbent or rises from sleep.

The patient also exhibits prolonged expirations, increased use of accessory muscles for breathing, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea, scattered rhonchi, coarse crackles (which can be precipitated by coughing), and late-stage clubbing.

Chemical pneumonitis.

Chemical pneumonitis causes a cough with purulent sputum. It can also cause dyspnea, wheezing, orthopnea, a fever, malaise, and crackles; mucous membrane irritation of the conjunctivae, throat, and nose; laryngitis; or rhinitis. Signs and symptoms may increase for 24 to 48 hours after exposure, then resolve; if severe, however, they may recur 2 to 5 weeks later.

Common cold.

 When the common cold causes productive coughing, the sputum is mucoid or mucopurulent. Early indications include a dry hacking cough, sneezing, a headache, malaise, fatigue, rhinorrhea (watery to tenacious, mucopurulent secretions), nasal congestion, a sore throat, myalgia, and arthralgia.

Lung abscess (ruptured).

The cardinal sign of a ruptured lung abscess is coughing that produces copious amounts of purulent, foul-smelling, and possibly blood-tinged sputum. A ruptured abscess can also cause diaphoresis, anorexia, clubbing, weight loss, weakness, fatigue, a fever with chills, dyspnea, a headache, malaise, pleuritic chest pain, halitosis, inspiratory crackles, and tubular or amphoric breath sounds. The patient's chest is dull on percussion on the affected side.

Lung cancer.

One of the earliest signs of bronchogenic carcinoma is a chronic cough that produces small amounts of purulent (or mucopurulent), blood-streaked sputum. In a patient with bronchoalveolar cancer, however, coughing produces large amounts of frothy sputum. Other signs and symptoms include dyspnea, anorexia, fatigue, weight loss, chest pain, a fever, diaphoresis, wheezing, and clubbing.

Nocardiosis.

 Nocardiosis causes a productive cough (with purulent, thick, tenacious, and possibly blood-tinged sputum) and fever that may last several months. Other findings include night sweats, pleuritic pain, anorexia, malaise, fatigue, weight loss, and diminished or absent breath sounds. The patient's chest is dull on percussion.

North American blastomycosis.

 North American blastomycosis is a chronic disorder that produces coughing that's dry and hacking or produces bloody or purulent sputum. Other findings include pleuritic chest pain, a fever, chills, anorexia, weight loss, malaise, fatigue, night sweats, cutaneous lesions (small, painless, nonpruritic macules or papules), and prostration.

Plague

(Yersinia pestis).  Plague is one of the most virulent acute bacterial infections and, if untreated, one of the most potentially lethal diseases known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to a human when bitten by an infected flea. Signs and symptoms include a fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the flea bite. Septicemic plague develops as a fulminant illness generally with the bubonic form. The pneumonic form may be contracted from person-to-person through direct contact via the respiratory system or through biological warfare from aerosolization and inhalation of the organism. The onset is usually sudden with chills, a fever, a headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pneumonia.

 Bacterial pneumonia initially produces a dry cough that becomes productive. Associated signs and symptoms develop suddenly and include shaking chills, a high fever, myalgia, a headache, pleuritic chest pain that increases with chest movement, tachypnea, tachycardia, dyspnea, cyanosis, diaphoresis, decreased breath sounds, fine crackles, and rhonchi.

Mycoplasma pneumonia may cause a cough that produces scant blood-flecked sputum. Typically, however, a nonproductive cough starts 2 to 3 days after the onset of malaise, a headache, a fever, and a sore throat. Paroxysmal coughing causes substernal chest pain. Patients may develop crackles, but generally don't appear seriously ill.

Psittacosis.

 As psittacosis progresses, the characteristic hacking cough, nonproductive at first, may later produce a small amount of mucoid, blood-streaked sputum. The infection may begin abruptly, with chills, a fever, a headache, myalgia, and prostration. Other signs and symptoms include tachypnea, fine crackles, chest pain (rare), epistaxis, photophobia, abdominal distention and tenderness, nausea, vomiting, and a faint macular rash. Severe infection may produce stupor, delirium, and coma.

Pulmonary coccidioidomycosis.

 Pulmonary coccidioidomycosis causes a nonproductive or slightly productive cough with a fever, occasional chills, pleuritic chest pain, a sore throat, a headache, backache, malaise, marked weakness, anorexia, hemoptysis, and an itchy macular rash. Rhonchi and wheezing may be heard. The disease may spread to other areas, causing arthralgia, swelling of the knees and ankles, and erythema nodosum or erythema multiforme.

Pulmonary edema.

When severe, pulmonary edema, which is a life-threatening disorder, causes a cough that produces frothy, bloody sputum. Early signs and symptoms include exertional dyspnea; paroxysmal nocturnal dyspnea, followed by orthopnea; and coughing, which may be nonproductive initially. Others include a fever, fatigue, tachycardia, tachypnea, dependent crackles, and a ventricular gallop. As the patient's respirations become increasingly rapid and labored, he develops more diffuse crackles and a productive cough, worsening tachycardia and, possibly, arrhythmias. His skin becomes cold, clammy, and cyanotic; his blood pressure falls; and his pulse becomes thready.

Pulmonary embolism.

Pulmonary embolism is a life-threatening disorder that causes a cough that may be nonproductive or may produce blood-tinged sputum. Usually, the first symptom of a pulmonary embolism is severe dyspnea, which may be accompanied by angina or pleuritic chest pain. The patient experiences marked anxiety, a low-grade fever, tachycardia, tachypnea, and diaphoresis. Less-common signs include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and jugular vein distention. The patient may also have a pleural friction rub, diffuse wheezing, crackles, chest dullness on percussion, decreased breath sounds, and signs of circulatory collapse.

Pulmonary tuberculosis (TB).

 Pulmonary TB causes a mild to severe productive cough along with some combination of hemoptysis, malaise, dyspnea, and pleuritic chest pain. Sputum may be scant and mucoid or copious and purulent. Typically, the patient experiences night sweats, easy fatigability, and weight loss. His breath sounds are amphoric. He may have chest dullness on percussion and, after coughing, increased tactile fremitus with crackles.

Silicosis.

 A productive cough with mucopurulent sputum is the earliest sign of silicosis. The patient also has exertional dyspnea, tachypnea, weight loss, fatigue, general weakness, and recurrent respiratory infections. Auscultation reveals end-inspiratory, fine crackles at the lung bases.

Tracheobronchitis.

Inflammation initially causes a nonproductive cough that later — following the onset of chills, a sore throat, a slight fever, muscle and back pain, and substernal tightness — becomes productive as secretions increase. Sputum is mucoid, mucopurulent, or purulent. The patient typically has rhonchi and wheezes; he may also develop crackles. Severe tracheobronchitis may cause a fever of 101° to 102° F (38.3° to 38.9° C) and bronchospasm.

Other causes

Diagnostic tests.

Bronchoscopy and pulmonary function tests (PFTs) may increase productive coughing.

Drugs.

 Expectorants increase productive coughing. These include ammonium chloride, calcium iodide, guaifenesin, iodinated glycerol, potassium iodide, and terpin hydrate.

Respiratory therapy.

Intermittent positive-pressure breathing, nebulizer therapy, and incentive spirometry can help loosen secretions and cause or increase productive coughing.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Laryngitis: Causes
(Professional Guide to Diseases (Eighth Edition))

Acute laryngitis usually results from infection (primarily viral) or excessive use of the voice, an occupational hazard in certain vocations (teaching, public speaking, or singing, for example). It may also result from leisure activities (such as cheering at a sports event), inhalation of smoke or fumes, or aspiration of caustic chemicals. Chronic laryngitis may be caused by chronic upper respiratory tract disorders (sinusitis, bronchitis, nasal polyps, or allergy), mouth breathing, smoking, constant exposure to dust or other irritants, and alcohol abuse.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Laryngeal cancer: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

In laryngeal cancer, major predisposing factors include smoking and alcoholism; minor factors include chronic inhalation of noxious fumes and familial tendency. Cancer of the larynx rarely occurs in nonsmokers.

Laryngeal cancer is classified according to its location:

❑supraglottis (false vocal cords)

❑glottis (true vocal cords)

❑subglottis (downward extension from vocal cords [rare]).

The ratio of male to female incidence is 3.8:1. Most victims are between ages 50 and 65.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Whooping cough: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Whooping cough is usually transmitted by the direct inhalation of contaminated droplets from a patient in the acute stage; it may also be spread indirectly through soiled linen and other articles contaminated by respiratory secretions.

Whooping cough is endemic throughout the world, usually occurring in late winter and early spring. In about 50% of cases, it strikes unimmunized children younger than age 1, because the immunization series hasn’t been completed and the child has had contact with an adult harboring the organisms.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Hoarseness: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Gastroesophageal reflux

In this disorder, retrograde flow of gastric juices into the esophagus may then spill into the hypopharynx. This, in turn, irritates the larynx, resulting in hoarseness as well as a sore throat, a cough, throat clearing, and a sensation of a lump in the throat. The arytenoids and the vocal cords may appear red and swollen.

Hypothyroidism

Hoarseness may be an early sign of hypothyroidism. Others include fatigue, cold intolerance, weight gain despite anorexia, and menorrhagia.

Laryngeal cancer

Hoarseness is an early sign of vocal cord cancer, but it may not occur until later in cancer of other laryngeal areas. The patient usually has a long history of smoking. Other common findings include a mild, dry cough; minor throat discomfort; otalgia; and, sometimes, hemoptysis.

Laryngeal leukoplakia

Leukoplakia is a common cause of hoarseness, especially in smokers. Histologic examination by direct laryngoscopy usually reveals mild, moderate, or severe dysphagia.

Laryngitis

Persistent hoarseness may be the only sign of chronic laryngitis. In acute laryngitis, hoarseness or a complete loss of voice develops suddenly. Related findings include pain (especially during swallowing or speaking), a cough, fever, profuse diaphoresis, sore throat, and rhinorrhea.

Rheumatoid arthritis

Hoarseness may signal laryngeal involvement. Other findings include pain, dysphagia, a sensation of fullness or tension in the throat, dyspnea on exertion, and stridor.

Sjögren’s syndrome

This rheumatic disorder produces hoarseness, but its cardinal signs are dry eyes, nose, and mouth. Initially, the patient complains of gritty, burning pain around the eyes and under the lids. Ocular dryness also leads to redness, photosensitivity, impaired vision, itching, and eye fatigue. Examination reveals enlarged lacrimal glands and corneal ulcers.

The patient may complain of a dry, sore mouth and difficulty chewing, talking, or swallowing. He may also exhibit nasal crusting, epistaxis, enlarged parotid and submaxillary glands, dry and scaly skin, a nonproductive cough, abdominal discomfort, and polyuria.

Thoracic aortic aneurysm

Depending on the size and exact location of the aneurysm, patients may remain asymptomatic. When the aneurysm exerts pressure on surrounding structures, however, patients may experience a variety of symptoms. Hoarseness occurs when the aneurysm compresses nerves associated with the larynx. Other clinical features may include a brassy cough; dyspnea; wheezing; a substernal aching in the shoulders, lower back, or abdomen; a tracheal tug; facial and neck edema; jugular vein distention; dysphagia; prominent chest veins; stridor; penetrating pain that’s especially severe when the patient is supine; and, possibly, paresthesia or neuralgia.

Tracheal trauma

Torn tracheal mucosa may cause hoarseness, hemoptysis, dysphagia, neck pain, airway occlusion, and respiratory distress.

Vocal cord nodules or polyps

Raspy hoarseness, the chief complaint, accompanies a chronic cough and a crackling voice.

Vocal cord paralysis

Unilateral vocal cord paralysis causes hoarseness and vocal weakness. Paralysis may accompany signs of trauma, such as pain and swelling of the head and neck.

Other causes

Inhalation injury

An inhalation injury from a fire or an explosion produces hoarseness and coughing, singed nasal hairs, orofacial burns, and soot-stained sputum. Subsequent signs and symptoms include crackles, rhonchi, and wheezing, which rapidly lead  to respiratory distress.

Treatments

Occasionally, surgical trauma to the recurrent laryngeal nerve results in temporary or permanent unilateral vocal cord paralysis, leading to hoarseness. Prolonged intubation may cause temporary hoarseness.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Stridor: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Airway trauma

Local trauma to the upper airway commonly causes acute obstruction, resulting in the sudden onset of stridor. Accompanying this sign are dysphonia, dysphagia, hemoptysis, cyanosis, accessory muscle use, intercostal retractions, nasal flaring, tachypnea, progressive dyspnea, and shallow respirations. Palpation may reveal subcutaneous crepitation in the neck or upper chest.

Anaphylaxis

With a severe allergic reaction, upper airway edema and laryngospasm cause stridor and other signs and symptoms of respiratory distress: nasal flaring, wheezing, accessory muscle use, intercostal retractions, and dyspnea. The patient may also develop nasal congestion and profuse, watery rhinorrhea. Typically, these respiratory effects are preceded by a feeling of impending doom or fear, weakness, diaphoresis, sneezing, nasal pruritus, urticaria, erythema, and angioedema. Common associated findings include chest or throat tightness, dysphagia and, possibly, signs of shock, such as hypotension, tachycardia, and cool, clammy skin.

Anthrax, inhalation

Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by stridor, fever, dyspnea, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Aspiration of a foreign body

Sudden stridor is characteristic in this life-threatening situation. Related findings include abrupt onset of dry, paroxysmal coughing, gagging or choking, hoarseness, tachycardia, wheezing, dyspnea, tachypnea, intercostal muscle retractions, diminished breath sounds, cyanosis, and shallow respirations. The patient typically appears anxious and distressed.

Epiglottiditis

With this inflammatory condition, stridor is caused by an erythematous, edematous epiglottis that obstructs the upper airway. Stridor occurs along with fever, sore throat, and a croupy cough.

Hypocalcemia

With this disorder, laryngospasm can cause stridor. Other findings include paresthesia, carpopedal spasm, and positive Chvostek’s and Trousseau’s signs.

Inhalation injury

Within 48 hours after inhalation of smoke or noxious fumes, the patient may develop laryngeal edema and bronchospasms, resulting in stridor. Associated signs and symptoms include singed nasal hairs, orofacial burns, coughing, hoarseness, sooty sputum, crackles, rhonchi, wheezes, and other signs and symptoms of respiratory distress, such as dyspnea, accessory muscle use, intercostal retractions, and nasal flaring.

Laryngeal tumor

Stridor is a late sign and may be accompanied by dysphagia, dyspnea, enlarged cervical nodes, and pain that radiates to the ear. Typically, stridor is preceded by hoarseness, minor throat pain, and a mild, dry cough.

Laryngitis (acute)

This disorder may cause severe laryngeal edema, resulting in stridor and dyspnea. Its chief sign, however, is mild to severe hoarseness, perhaps with transient voice loss. Other findings include sore throat, dysphagia, dry cough, malaise, and fever.

Mediastinal tumor

Commonly producing no symptoms at first, this type of tumor may eventually compress the trachea and bronchi, resulting in stridor. Its other effects include hoarseness, brassy cough, tracheal shift or tug, dilated neck veins, swelling of the face and neck, stertorous respirations, and suprasternal retractions on inspiration. The patient may also report dyspnea, dysphagia, and pain in the chest, shoulder, or arm.

Retrosternal thyroid

This anatomic abnormality causes stridor, dysphagia, cough, hoarseness, and tracheal deviation. It can also cause signs of thyrotoxicosis.

Thoracic aortic aneurysm

If this aneurysm compresses the trachea, it may cause stridor accompanied by dyspnea, wheezing, and a brassy cough. Other findings include hoarseness or complete voice loss, dysphagia, jugular vein distention, prominent chest veins, tracheal tug, paresthesia or neuralgia, and edema of the face, neck, and arms. The patient may also complain of substernal, lower back, abdominal, or shoulder pain.

Other causes

Diagnostic tests

Bronchoscopy or laryngoscopy may precipitate laryngospasm and stridor.

Treatments

After prolonged intubation, the patient may exhibit laryngeal edema and stridor when the tube is removed. Aerosol therapy with epinephrine may reduce stridor. Reintubation may be necessary in some cases. Neck surgery, such as thyroidectomy, may cause laryngeal paralysis and stridor.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Cough, barking: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Aspiration of foreign body

Partial obstruction of the upper airway first produces sudden hoarseness, then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing, and possibly cyanosis.

Epiglottiditis

This life-threatening disorder has become less common since the use of influenza vaccines. It occurs nocturnally, heralded by a barking cough and a high fever. The child is hoarse, dysphagic, dyspneic, and restless and appears extremely ill and panicky. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia. The child will struggle to get sufficient air as epiglottic edema increases. Epiglottiditis is a true medical emergency.

Laryngotracheobronchitis (acute)

Also known as viral croup, this infection is most common in children between ages 9 and 18 months and usually occurs in the fall and early winter. It initially produces low to moderate fever, runny nose, poor appetite, and infrequent cough. When the infection descends into the laryngotracheal area, a barking cough, hoarseness, and inspiratory stridor occur.

As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.

Spasmodic croup

Acute spasmodic croup usually occurs during sleep with the abrupt onset of a barking cough that awakens the child. Typically, he doesn’t have a fever but may be hoarse, restless, and dyspneic. As his respiratory distress worsens, the child may exhibit sternal and intercostal retractions, nasal flaring, tachycardia, cyanosis, and an anxious, frantic appearance. The signs usually subside within a few hours, but attacks tend to recur.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Cough, nonproductive: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Airway occlusion

Partial occlusion of the upper airway produces a sudden onset of dry, paroxysmal coughing. The patient exhibits gagging, wheezing, hoarseness, stridor, tachycardia, and decreased breath sounds.

Anthrax (inhalation)

This acute infectious disease is caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological agents. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in cutaneous, inhalation, or GI forms.

Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly and causes rapid deterioration marked by fever, dyspnea, stridor, and hypotension; death generally results within 24 hours. Radiologic findings include mediastinitis and symmetrical mediastinal widening.

Aortic aneurysm (thoracic)

This disorder causes a brassy cough with dyspnea, hoarseness, wheezing, and a substernal ache in the shoulders, lower back, or abdomen. The patient may also have facial or neck edema, jugular vein distention, dysphagia, prominent veins over his chest, stridor, and possibly paresthesia or neuralgia.

Asthma

Asthma attacks commonly occur at night, starting with a nonproductive cough and mild wheezing and progressing to severe dyspnea, audible wheezing, chest tightness, and a cough that produces thick mucus. Other signs include apprehension, rhonchi, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis.

Atelectasis

As lung tissue deflates in atelectasis, it stimulates cough receptors, causing a nonproductive cough. The patient may also have pleuritic chest pain, anxiety, dyspnea, tachypnea, tachycardia, decreased breath sounds, cyanotic skin, and diaphoresis. His chest may be dull on percussion, and he may exhibit inspiratory lag, substernal or intercostal retractions, decreased vocal fremitus, and tracheal deviation toward the affected side.

Avian influenza

These potentially life-threatening viruses are spread to humans through infected poultry and surfaces contaminated with infected bird excretions. Infected individuals may initially have symptoms of conventional influenza, including a nonproductive cough, fever, sore throat, and muscle aches. The most virulent avian virus, influenza A (H5N1), may lead to severe and life-threatening complications, such as acute respiratory distress and pneumonia. To date this strain of the virus has not surfaced in the United States; however, a recent outbreak in Asian and European countries has caused worldwide concern that the virus may spread through both infected humans and birds. Treatment with two of the four FDA-approved antiviral medications has proven effective with some virus strains, and an experimental vaccine is currently under investigation.

Bronchitis (chronic)

This disorder starts with a nonproductive, hacking cough that later becomes productive. Other findings include prolonged expiration, wheezing, dyspnea, accessory muscle use, barrel chest, cyanosis, tachypnea, crackles, and scattered rhonchi. Clubbing can occur in late stages.

Bronchogenic carcinoma

The earliest indicators of this disease can be a chronic nonproductive cough, dyspnea, and vague chest pain. The patient may also be wheezing.

Common cold

Most colds start with a nonproductive, hacking cough and progress to some mix of sneezing, rhinorrhea, nasal congestion, sore throat, headache, malaise, fatigue, myalgia, and arthralgia.

Esophageal achalasia

In this disorder, regurgitation and aspiration produce a dry cough and, possibly, recurrent pulmonary infections and dysphagia.

Esophageal diverticula

The patient with this disorder has a nocturnal nonproductive cough, regurgitation and aspiration, dyspepsia, and dysphagia. His neck may appear swollen and have a gurgling sound. He may also exhibit halitosis and weight loss.

Esophageal occlusion

This disorder is marked by sudden nonproductive coughing and gagging with a sensation of something stuck in the throat. Other findings include neck or chest pain and dysphagia.

Esophagitis with reflux

This disorder commonly causes a nonproductive nocturnal cough due to regurgitation and aspiration. The patient may also experience chest pain that mimics angina pectoris, heartburn that worsens if he lies down after eating, increased salivation, dysphagia, hematemesis, and melena. Hantavirus Pulmonary Syndrome A nonproductive cough is common in patients with this disorder, which is marked by noncardiogenic pulmonary edema. Other findings include headache, myalgia, fever, nausea, and vomiting.

Hodgkin’s disease

This disease may cause a crowing nonproductive cough. However, the earliest sign is usually painless swelling of one of the cervical lymph nodes or, occasionally, of the axillary, mediastinal, or inguinal lymph nodes. Another early sign is pruritus. Other findings depend on the degree and location of systemic involvement and include dyspnea, dysphagia, hepatosplenomegaly, edema, jaundice, nerve pain, and hyperpigmentation.

Hypersensitivity pneumonitis

In this disorder, an acute nonproductive cough, fever, dyspnea, and malaise usually occur 5 to 6 hours after exposure to an antigen.

Interstitial lung disease

A patient with this disorder has a nonproductive cough and progressive dyspnea. He may also be cyanotic and have clubbing, fine crackles, fatigue, variable chest pain, and weight loss.

Laryngeal tumor

A mild nonproductive cough, minor throat discomfort, and hoarseness are early signs of this disorder. Later, dysphagia, dyspnea, cervical lymphadenopathy, stridor, and earache may occur.

Laryngitis

Acute laryngitis causes a nonproductive cough with localized pain (especially when the patient swallows or speaks) as well as fever and malaise. His hoarseness can range from mild to complete loss of voice.

Legionnaires’ disease

After a prodrome of malaise, headache and, possibly, diarrhea, anorexia, diffuse myalgia, and general weakness, legionnaires’disease causes a nonproductive cough that later produces mucoid, nonpurulent and, possibly, blood-tinged sputum.

Lung abscess

This disorder typically begins with a nonproductive cough, weakness, dyspnea, and pleuritic chest pain. The patient may also exhibit diaphoresis, fever, headache, malaise, fatigue, crackles, decreased breath sounds, anorexia, and weight loss. Later, his cough produces large amounts of purulent, foul-smelling and, possibly, blood-tinged sputum.

Mediastinal tumor

A large mediastinal tumor produces a nonproductive cough, dyspnea, and retrosternal pain. The patient may also develop stertorous respirations with suprasternal retraction on inspiration, hoarseness, dysphagia, tracheal shift or tug, jugular vein distention, and facial or neck edema.

Pericardial effusion

The most common signs and symptoms of this disorder are dysphagia, fever, pleuritic chest pain, and pericardial friction rub. A severe nonproductive cough occurs rarely.

Pleural effusion

A nonproductive cough, dyspnea, pleuritic chest pain, and decreased chest motion are characteristic of pleural effusion. Other findings include pleural friction rub, tachycardia, tachypnea, egophony, flatness on percussion, decreased or absent breath sounds, and decreased tactile fremitus.

Pneumonia

Bacterial pneumonia usually starts with a nonproductive, hacking, painful cough that rapidly becomes productive. Other findings include shaking chills, headache, high fever, dyspnea, pleuritic chest pain, tachypnea, tachycardia, grunting respirations, nasal flaring, decreased breath sounds, fine crackles, rhonchi, and cyanosis. The patient’s chest may be dull on percussion.

In mycoplasmal pneumonia, a nonproductive cough develops 2 to 3 days after the onset of malaise, headache, and sore throat. The cough may be paroxysmal, causing substernal chest pain. The patient commonly has a fever but doesn’t appear seriously ill.

Viral pneumonia causes a nonproductive, hacking cough and the gradual onset of malaise, headache, anorexia, and low-grade fever.

Pneumothorax

This life-threatening disorder causes a dry cough and signs of respiratory distress, such as severe dyspnea, tachycardia, tachypnea, and cyanosis. The patient experiences sudden, sharp chest pain that worsens with chest movement as well as subcutaneous crepitation, hyperresonance or tympany, decreased vocal fremitus, and decreased or absent breath sounds on the affected side.

Psittacosis

In this disorder, an initially dry, hacking cough later produces small amounts of blood-streaked, mucoid sputum. Psittacosis may begin abruptly with chills, fever, headache, myalgia, and prostration. The patient may also have tachypnea, fine crackles, epistaxis and, rarely, chest pain.

Pulmonary edema

This disorder initially causes a dry cough, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, tachycardia, tachypnea, dependent crackles, and ventricular gallop. If pulmonary edema is severe, the patient’s respirations become more rapid and labored, with diffuse crackles and a cough that produces frothy, blood-streaked sputum.

Pulmonary embolism

A life-threatening pulmonary embolism may suddenly produce a dry cough, dyspnea, and pleuritic or anginal chest pain. In most cases, though, the cough produces blood-tinged sputum. Tachycardia and low-grade fever are also common; less common signs and symptoms include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and distended jugular veins. The patient may also have a pleural friction rub, diffuse wheezing, dullness on percussion, and decreased breath sounds.

Sarcoidosis

In this disorder, a nonproductive cough is accompanied by dyspnea, substernal pain, and malaise. The patient may also develop fatigue, arthralgia, myalgia, weight loss, tachypnea, crackles, lymphadenopathy, hepatosplenomegaly, skin lesions, vision impairment, difficulty swallowing, and arrhythmias.

Severe acute respiratory syndrome (SARS)

SARS is an acute infectious disease of unknown etiology; however, a novel coronavirus has been implicated as a possible cause. Although most cases have been reported in Asia (China, Vietnam, Singapore, Thailand), cases have cropped up in Europe and North America. The incubation period is 2 to 7 days, and the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include headache, malaise, a nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Sinusitis (chronic)

This disorder can cause a chronic nonproductive cough due to postnasal drip. The patient’s nasal mucosa may appear inflamed, and he may have nasal congestion and profuse drainage. Usually, his breath smells musty.

Tracheobronchitis (acute)

Initially, this disorder produces a dry cough that later becomes productive as secretions increase. Chills, sore throat, slight fever, muscle and back pain, and substernal tightness generally precede the cough’s onset. Rhonchi and wheezing are usually heard. Severe illness causes a fever of 101° to 102° F (38.3° to 38.9° C) and possibly bronchospasm, severe wheezing, and increased coughing.

Tularemia

Also known as “rabbit fever,” this infectious disease is caused by the gram-negative, non–spore-forming bacterium Francisella tularensis. This organism is found in wild animals, water, and moist soil, typically in rural areas. It’s transmitted to humans through the bite of an infected insect or tick, the handling of infected animal carcasses, the drinking of contaminated water, or the inhalation of the bacterium. It’s considered a possible airborne agent for biological warfare. Signs and symptoms following inhalation of the organism include the abrupt onset of fever, chills, headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Diagnostic tests

Pulmonary function tests and bronchoscopy may stimulate cough receptors and trigger coughing.

Drugs

Certain drugs, such as angiotensin-converting enzyme inhibitors, may also cause a nonproductive cough.

Treatments

Irritation of the carina during suctioning or deep endotracheal or tracheal tube placement can trigger a paroxysmal or hacking cough. Intermittent positive-pressure breathing or spirometry can also cause a nonproductive cough. Some inhalants, such as pentamidine, may stimulate coughing.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Cough, productive: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Actinomycosis

This disorder begins with a cough that produces purulent sputum. Fever, weight loss, fatigue, weakness, dyspnea, night sweats, pleuritic chest pain, and hemoptysis may also occur.

Aspiration pneumonitis

This disorder causes coughing that produces pink, frothy, possibly purulent sputum. The patient also has marked dyspnea, fever, tachypnea, tachycardia, wheezing, and cyanosis.

Asthma (acute)

A severe asthma attack, which can be life-threatening, may produce tenacious mucoid sputum and mucus plugs. Such an attack typically starts with a dry cough and mild wheezing, then progresses to severe dyspnea, audible wheezing, chest tightness, and a productive cough. Other findings include apprehension, prolonged expiration, intercostal and supraclavicular retraction on inspiration, accessory muscle use, rhonchi, crackles, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis. Attacks commonly occur at night or during sleep.

Bronchiectasis

The chronic cough of this disorder produces copious mucopurulent sputum that has characteristic layering (top, frothy; middle, clear; bottom, dense with purulent particles). The patient has halitosis: His sputum may smell foul or sickeningly sweet. Other characteristic findings include hemoptysis, persistent coarse crackles over the affected lung area, occasional wheezing, rhonchi, exertional dyspnea, weight loss, fatigue, malaise, weakness, recurrent fever, and late-stage finger clubbing.

Bronchitis (chronic)

The cough associated with chronic bronchitis may be nonproductive initially; eventually, however, it produces mucoid sputum that becomes purulent. Secondary infection can also cause mucopurulent sputum, which may become blood tinged and foul smelling. The cough, which may be paroxysmal during exercise, usually occurs when the patient is recumbent or rises from sleep.

The patient also exhibits prolonged expiration, accessory muscle use, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea, scattered rhonchi, coarse crackles (which can be precipitated by coughing), and late-stage clubbing.

Chemical pneumonitis

This disorder causes a cough with purulent sputum. It may also cause dyspnea, wheezing, orthopnea, fever, malaise, crackles, laryngitis, rhinitis, and mucous membrane irritation of the conjunctivae, throat, and nose. Signs and symptoms may increase for 24 to 48 hours after exposure, then resolve; in severe pneumonitis, however, they may recur 2 to 5 weeks later.

Common cold

The common cold may cause a productive cough with mucoid or mucopurulent sputum, but it usually starts with a dry, hacking cough, sore throat, sneezing, rhinorrhea, and nasal congestion. Headache, malaise, fatigue, myalgia, and arthralgia may also occur.

Emphysema

This disorder causes a chronic productive cough with scant mucoid, translucent, grayish white sputum that can become mucopurulent. Patients with emphysema are typically thin and have the characteristic pink or red complexion (“pink puffer” appearance). They may also exhibit increased accessory muscle use, tachypnea, grunting expirations through pursed lips, diminished breath sounds, exertional dyspnea, rhonchi, barrel chest, anorexia, and weight loss. Clubbing is a late sign.

Legionnaires’ disease

This disorder causes a cough that produces scant mucoid, nonpurulent and, possibly, blood-streaked sputum. Prodromal signs and symptoms typically include malaise, fatigue, weakness, anorexia, diffuse myalgia, and possibly diarrhea. Within 12 to 48 hours, the patient develops a dry cough and a sudden high fever with chills. Many patients also have pleuritic chest pain, headache, tachypnea, tachycardia, nausea, vomiting, dyspnea, crackles, mild temporary amnesia, disorientation, confusion, flushing, mild diaphoresis, and prostration.

Lung abscess (ruptured)

The cardinal sign of a ruptured lung abscess is a cough that produces copious amounts of purulent, foul-smelling and, possibly, blood-tinged sputum. A ruptured abscess can also cause diaphoresis, anorexia, clubbing, weight loss, weakness, fatigue, fever with chills, dyspnea, headache, malaise, pleuritic chest pain, halitosis, inspiratory crackles, and tubular or amphoric breath sounds. The patient’s chest is dull on percussion on the affected side.

Lung cancer

One of the earliest signs of bronchogenic carcinoma is a chronic cough that produces small amounts of purulent (or mucopurulent), blood-streaked sputum. In a patient with bronchoalveolar cancer, however, coughing produces large amounts of frothy sputum. Other signs and symptoms of lung cancer include dyspnea, anorexia, fatigue, weight loss, chest pain, fever, diaphoresis, wheezing, and clubbing.

Nocardiosis

This disorder causes a productive cough (with purulent, thick, tenacious, and possibly blood-tinged sputum) and fever that may last several months. Other findings include night sweats, pleuritic pain, anorexia, weight loss, malaise, fatigue, and diminished or absent breath sounds. The patient’s chest is dull on percussion.

North American blastomycosis

This chronic disorder may produce a dry hacking cough or a productive cough with bloody or purulent sputum. Other findings include pleuritic chest pain, fever, chills, anorexia, weight loss, malaise, fatigue, night sweats, cutaneous lesions (small, painless, nonpruritic macules or papules), and prostration.

Plague

Caused by Yersinia pestis, plague is one of the most virulent and, if untreated, most lethal bacterial infections known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to man from the bite of infected fleas. Signs and symptoms include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the fleabite. Septicemic plague may develop as a complication of untreated bubonic or pneumonic plague and occurs when plague bacteria enter the bloodstream and multiply. The pneumonic form can be contracted by inhaling respiratory droplets from an infected person or inhaling the organism that has been dispersed in the air through biological warfare. The onset is usually sudden with chills, fever, headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pneumonia

Bacterial pneumonia initially produces a dry cough that becomes productive. Associated signs and symptoms develop suddenly and include shaking chills, high fever, myalgia, headache, pleuritic chest pain that increases with chest movement, tachypnea, tachycardia, dyspnea, cyanosis, diaphoresis, decreased breath sounds, fine crackles, and rhonchi.

Mycoplasmal pneumonia may cause a cough that produces scant blood-flecked sputum. In most cases, however, a nonproductive cough starts 2 to 3 days after the onset of malaise, headache, fever, and sore throat. Paroxysmal coughing causes substernal chest pain. Patients may develop crackles but generally don’t appear seriously ill.

Psittacosis

As this disorder progresses, the characteristic hacking cough, nonproductive at first, may later produce a small amount of mucoid, blood-streaked sputum. The infection may begin abruptly with chills, fever, headache, myalgia, and prostration. Other signs and symptoms include tachypnea, fine crackles, chest pain (rare), epistaxis, photophobia, abdominal distention and tenderness, nausea, vomiting, and a faint macular rash. Severe psittacosis may produce stupor, delirium, and coma.

Pulmonary coccidioidomycosis

This disorder causes a nonproductive or slightly productive cough with fever, occasional chills, pleuritic chest pain, sore throat, headache, backache, malaise, marked weakness, anorexia, hemoptysis, and an itchy macular rash. Rhonchi and wheezing may be heard. The disease may spread to other areas, causing arthralgia, swelling of the knees and ankles, and erythema nodosum or erythema multiforme.

Pulmonary edema

When severe, this life-threatening disorder causes a cough that produces frothy, blood-tinged sputum. Early signs and symptoms include exertional dyspnea, paroxysmal nocturnal dyspnea followed by orthopnea, and a cough that may be nonproductive initially. Fever, fatigue, tachycardia, tachypnea, dependent crackles, and ventricular gallop may also occur. As the patient’s respirations become increasingly rapid and labored, he develops more diffuse crackles and the productive cough, worsening tachycardia, and possibly arrhythmias. His skin becomes cold, clammy, and cyanotic; his blood pressure falls; and his pulse becomes thready.

Pulmonary embolism

This life-threatening disorder causes a cough that may be nonproductive or may produce blood-tinged sputum. Usually, the first symptom of a pulmonary embolism is severe dyspnea, which may be accompanied by angina or pleuritic chest pain. The patient experiences marked anxiety, a low-grade fever, tachycardia, tachypnea, and diaphoresis. Less common signs include massive hemoptysis, chest splinting, leg edema and, in a large embolus, cyanosis, syncope, and distended jugular veins. The patient may also have a pleural friction rub, diffuse wheezing, crackles, chest dullness on percussion, decreased breath sounds, and signs of circulatory collapse.

Pulmonary tuberculosis

This disorder causes a mild to severe productive cough along with some combination of hemoptysis, malaise, dyspnea, and pleuritic chest pain. Sputum may be scant and mucoid or copious and purulent. Typically, the patient experiences night sweats, easy fatigability, and weight loss. His breath sounds are amphoric. He may exhibit chest dullness on percussion and, after coughing, increased tactile fremitus with crackles.

Silicosis

A productive cough with mucopurulent sputum is the earliest sign of this disorder. The patient also has exertional dyspnea, tachypnea, weight loss, fatigue, general weakness, and recurrent respiratory infections. Auscultation reveals end-inspiratory, fine crackles at the lung bases.

Tracheobronchitis

Inflammation initially causes a nonproductive cough followed by chills, sore throat, slight fever, muscle and back pain, and substernal tightness. As secretions increase, the cough produces mucoid, mucopurulent, or purulent sputum. The patient typically has rhonchi and wheezing; he may also develop crackles. Severe tracheobronchitis may cause a fever of 101° to 102° F (38.3° to 38.9° C) and bronchospasm.

Other causes

Diagnostic tests

Bronchoscopy and pulmonary function tests may increase productive coughing.

Drugs

Expectorants, such as ammonium chloride, guaifenesin, potassium iodide, and terpin hydrate, increase productive coughing.

Respiratory therapy

Intermittent positive-pressure breathing, nebulizer therapy, and incentive spirometry can help loosen secretions and cause or increase productive coughing.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Hoarseness: Differential Overview
(Field Guide to Bedside Diagnosis)

Acute

❑ Acute laryngitis

❑ Vocal overuse

❑ Vocal cord trauma

❑ Angioedema

❑ Epiglottitis

Chronic

❑ Smoking

❑ Recurrent vocal abuse

❑ Gastroesophageal reflux

❑ Vocal cord polyp

❑ Vocal cord nodule

❑ Laryngeal nerve injury

❑ Hypothyroidism

❑ Laryngeal carcinoma

❑ Conversion reaction

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Source: Field Guide to Bedside Diagnosis, 2007

Acute Cough: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Viral upper respiratory infection

❑ Asthma

❑ Sinusitis

❑ Mycoplasma bronchitis

❑ Pneumonia

❑ Gastroesophageal reflux

❑ Congestive heart failure

❑ ACE inhibitor

❑ Aspiration

❑ Cough in HIV

❑ Thermal

❑ Fume inhalation

❑ Pertussis

❑ Lung abscess

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Source: Field Guide to Bedside Diagnosis, 2007

Chronic Cough: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Upper respiratory infection

❑ Allergy

❑ Asthma

❑ Chronic bronchitis

❑ Chronic sinusitis

❑ Gastroesophageal reflux

❑ ACE inhibitor

❑ Pollutants

❑ Psychogenic

❑ Foreign body

❑ Congestive heart failure

❑ Lung cancer

❑ Tuberculosis

❑ Mediastinal mass

❑ Bronchiectasis

❑ Pulmonary fibrosis

❑ Cystic fibrosis

❑ Aspergillosis

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Source: Field Guide to Bedside Diagnosis, 2007

Laryngitis: Causes
(Handbook of Diseases)

Acute laryngitis usually results from infection (primarily viral) or excessive use of the voice, an occupational hazard in certain vocations (for example, teaching, public speaking, and singing). It may also result from leisure activities (such as cheering at a sports event), inhalation of smoke or fumes, or aspiration of caustic chemicals. Causes of chronic laryngitis include chronic upper respiratory tract disorders (sinusitis, bronchitis, nasal polyps, or an allergy), mouth breathing, smoking, constant exposure to dust or other irritants, and alcohol abuse. Reflux laryngitis is caused by regurgitation of gastric acid into the hypopharynx. (See Managing reflux laryngitis.)

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Source: Handbook of Diseases, 2003

Laryngeal cancer: Causes
(Handbook of Diseases)

With laryngeal cancer, major predisposing factors include smoking and alcoholism; minor factors include chronic inhalation of noxious fumes and familial tendency.

Laryngeal cancer is classified according to its location:

❑ supraglottis (false vocal cords)

❑ glottis (true vocal cords)

❑ subglottis (downward extension from the vocal cords [rare]).

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Source: Handbook of Diseases, 2003

Stridor: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Airway trauma

Local trauma to the upper airway commonly causes acute obstruction, resulting in the sudden onset of stridor. Accompanying this sign are dysphonia, dysphagia, hemoptysis, cyanosis, accessory muscle use, intercostal retractions, nasal flaring, tachypnea, progressive dyspnea, and shallow respirations. Palpation may reveal subcutaneous crepitation in the neck or upper chest.

Anaphylaxis

With a severe allergic reaction, upper airway edema and laryngospasm cause stridor and other signs and symptoms of respiratory distress — nasal flaring, wheezing, accessory muscle use, intercostal retractions, and dyspnea. The patient may also develop nasal congestion and profuse, watery rhinorrhea. Typically, these respiratory effects are preceded by a feeling of impending doom or fear, weakness, diaphoresis, sneezing, nasal pruritus, urticaria, erythema, and angioedema. Common associated findings include chest or throat tightness, dysphagia and, possibly, signs of shock, such as hypotension, tachycardia, and cool, clammy skin.

Anthrax (inhalation)

Initial signs and symptoms of inhalation anthrax are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by stridor, fever, dyspnea, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Aspiration of a foreign body

Sudden stridor is characteristic in this life-threatening situation. Related findings include an abrupt onset of dry, paroxysmal coughing, gagging or choking, hoarseness, tachycardia, wheezing, dyspnea, tachypnea, intercostal muscle retractions, diminished breath sounds, cyanosis, and shallow respirations. The patient typically appears anxious and distressed.

Epiglottiditis

With epiglottiditis, an inflammatory condition, stridor is caused by an erythematous, edematous epiglottis that obstructs the upper airway. Stridor occurs along with fever, sore throat, and a croupy cough.

Hypocalcemia

With hypocalcemia, laryngospasm can cause stridor. Other findings include paresthesia, carpopedal spasm, and positive Chvostek’s and Trousseau’s signs.

Inhalation injury

Within 48 hours after inhalation of smoke or noxious fumes, the patient may develop laryngeal edema and bronchospasms, resulting in stridor. Associated signs and symptoms include singed nasal hairs, orofacial burns, coughing, hoarseness, sooty sputum, crackles, rhonchi, wheezes, and other signs and symptoms of respiratory distress, such as dyspnea, accessory muscle use, intercostal retractions, and nasal flaring.

Laryngeal tumor

Stridor is a late sign and may be accompanied by dysphagia, dyspnea, enlarged cervical nodes, and pain that radiates to the ear. Typically, stridor is preceded by hoarseness, minor throat pain, and a mild, dry cough.

Laryngitis (acute)

Acute laryngitis may cause severe laryngeal edema, resulting in stridor and dyspnea. Its chief sign, however, is mild to severe hoarseness, perhaps with transient voice loss. Other findings include sore throat, dysphagia, dry cough, malaise, and fever.

Mediastinal tumor

Commonly producing no symptoms at first, this type of tumor may eventually compress the trachea and bronchi, resulting in stridor. Its other effects include hoarseness, brassy cough, tracheal shift or tug, jugular vein distention, face and neck swelling, stertorous respirations, and suprasternal retractions on inspiration. The patient may also report dyspnea, dysphagia, and pain in the chest, shoulder, or arm.

Retrosternal thyroid

An anatomic abnormality, retrosternal thyroid causes stridor, dysphagia, cough, hoarseness, and tracheal deviation. It can also cause signs of thyrotoxicosis.

Thoracic aortic aneurysm

If this aneurysm compresses the trachea, it may cause stridor accompanied by dyspnea, wheezing, and a brassy cough. Other findings include hoarseness or complete voice loss, dysphagia, jugular vein distention, prominent chest veins, tracheal tug, paresthesia or neuralgia, and edema of the face, neck, and arms. The patient may also complain of substernal, lower back, abdominal, or shoulder pain.

Other causes

Diagnostic tests

Bronchoscopy or laryngoscopy may precipitate laryngospasm and stridor.

Medical treatments

After prolonged intubation, the patient may exhibit laryngeal edema and stridor when the tube is removed. Aerosol therapy with epinephrine may reduce stridor. Reintubation may be necessary in some cases. Neck surgery, such as thyroidectomy, may cause laryngeal paralysis and stridor.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Cough, barking: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Partial obstruction of the upper airway first produces sudden hoarseness, and then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing and, possibly, cyanosis.

Epiglottiditis.

Epiglottiditis is a life-threatening disorder that has become less common since the use of influenza vaccines. It occurs nocturnally, heralded by a barking cough and high fever. The child is hoarse, dysphagic, dyspneic, and restless and appears extremely ill and panicky. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia. The child will struggle to get sufficient air as epiglottic edema increases. Epiglottiditis is a true medical emergency. Also known as viral croup, laryngotracheobronchitis is most common in children between ages 9 and 18 months and usually occurs in the fall and early winter. It initially produces low to moderate fever, runny nose, poor appetite, and infrequent cough. When the infection descends into the laryngotracheal area, barking cough, hoarseness, and inspiratory stridor occur.

As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.

Spasmodic croup.

Acute spasmodic croup usually occurs during sleep with the abrupt onset of a barking cough that awakens the child. Typically, he doesn’t have fever but may be hoarse, restless, and dyspneic. As his respiratory distress worsens, the child may exhibit sternal and intercostal retractions, nasal flaring, tachycardia, cyanosis, and an anxious, frantic appearance. The signs usually subside within a few hours, but attacks tend to recur.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Cough, productive: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Actinomycosis begins with a cough that produces purulent sputum. Fever, weight loss, fatigue, weakness, dyspnea, night sweats, pleuritic chest pain, and hemoptysis may also occur. Aspiration pneumonitis causes coughing that produces pink, frothy, and possibly purulent sputum. The patient also has marked dyspnea, fever, tachypnea, tachycardia, wheezing, and cyanosis. A severe asthma attack, which can be life-threatening, may produce mucoid, tenacious sputum and mucus plugs. Such an attack typically starts with a dry cough and mild wheezing, and then progresses to severe dyspnea, audible wheezing, chest tightness, and a productive cough. Other findings include apprehension, prolonged expirations, intercostal and supraclavicular retraction on inspiration, accessory muscle use, rhonchi, crackles, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis. Attacks commonly occur at night or during sleep. The chronic cough of bronchiectasis produces copious, mucopurulent sputum that has characteristic layering (top, frothy; middle, clear; bottom, dense with purulent particles). The patient has halitosis; his sputum may smell foul or sickeningly sweet. Other characteristic findings include hemoptysis, persistent coarse crackles over the affected lung area, occasional wheezing, rhonchi, exertional dyspnea, weight loss, fatigue, malaise, weakness, recurrent fever, and late-stage finger clubbing. Bronchitis causes a cough that may be nonproductive initially. Eventually, however, it produces mucoid sputum that becomes purulent. Secondary infection can also cause mucopurulent sputum, which may become blood-tinged and foul-smelling. The coughing, which may be paroxysmal during exercise, usually occurs when the patient is recumbent or rises from sleep.

The patient also exhibits prolonged expirations, increased use of accessory muscles for breathing, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea, scattered rhonchi, coarse crackles (which can be precipitated by coughing), and late-stage clubbing. Chemical pneumonitis causes a cough with purulent sputum. It can also cause dyspnea, wheezing, orthopnea, fever, malaise, and crackles; mucous membrane irritation of the conjunctivae, throat, and nose; laryngitis; or rhinitis. Signs and symptoms may increase for 24 to 48 hours after exposure, and then resolve; if severe, however, they may recur 2 to 5 weeks later.

Common cold.

When the common cold causes productive coughing, the sputum is mucoid or mucopurulent. Early indications of the common cold include a dry, hacking cough, sneezing, headache, malaise, fatigue, rhinorrhea (watery to tenacious mucopurulent secretions), nasal congestion, sore throat, myalgia, and arthralgia. Legionnaires’ disease causes a cough that produces scant mucoid, nonpurulent, and possibly blood-streaked sputum. Prodromal signs and symptoms typically include malaise, fatigue, weakness, anorexia, diffuse myalgia and, possibly, diarrhea. Then, within 48 hours, the patient develops a dry cough and sudden high fever with chills. Many patients also have pleuritic chest pain, headache, tachypnea, tachycardia, nausea, vomiting, dyspnea, crackles, mild temporary amnesia, disorientation, confusion, flushing, mild diaphoresis, and prostration. The cardinal sign of ruptured lung abscess is coughing that produces copious amounts of purulent, foul-smelling, and possibly blood-tinged sputum. A ruptured abscess can also cause diaphoresis, anorexia, clubbing, weight loss, weakness, fatigue, fever with chills, dyspnea, headache, malaise, pleuritic chest pain, halitosis, inspiratory crackles, and tubular or amphoric breath sounds. The patient’s chest is dull on percussion on the affected side. One of the earliest signs of bronchogenic carcinoma is a chronic cough that produces small amounts of purulent (or mucopurulent), blood-streaked sputum. In a patient with bronchoalveolar cancer, however, coughing produces large amounts of frothy sputum. Other signs and symptoms include dyspnea, anorexia, fatigue, weight loss, chest pain, fever, diaphoresis, wheezing, and clubbing.

Nocardiosis.

Nocardiosis causes a productive cough with purulent, thick, tenacious, and possibly blood-tinged sputum and fever that may last several months. Other findings include night sweats, pleuritic pain, anorexia, malaise, fatigue, weight loss, and diminished or absent breath sounds. The patient’s chest is dull on percussion.

North American blastomycosis.

With North American blastomycosis — a chronic disorder — coughing is dry and hacking, or produces bloody or purulent sputum. Other findings include pleuritic chest pain, fever, chills, anorexia, weight loss, malaise, fatigue, night sweats, cutaneous lesions (small, painless, nonpruritic macules or papules), and prostration. Plague is an acute bacterial infection caused by Yersinia pestis. It’s one of the most virulent infections and, if untreated, one of the most potentially lethal diseases known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to man when bitten by infected fleas. Signs and symptoms include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the fleabite. Septicemic plague develops as a fulminant illness generally with the bubonic form. The pneumonic form may be contracted from person-to-person through direct contact via the respiratory system or through biological warfare from aerosolization and inhalation of the organism. The onset is usually sudden with chills, fever, headache, and myalgia. Pulmonary signs and symptoms include productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pneumonia.

Bacterial pneumonia initially produces a dry cough that becomes productive. Associated signs and symptoms develop suddenly and include shaking chills, high fever, myalgia, headache, pleuritic chest pain that increases with chest movement, tachypnea, tachycardia, dyspnea, cyanosis, diaphoresis, decreased breath sounds, fine crackles, and rhonchi.

Mycoplasma pneumonia may cause a cough that produces scant blood-flecked sputum. Most common, however, is a nonproductive cough that starts 2 to 3 days after the onset of malaise, headache, fever, and sore throat. Paroxysmal coughing causes substernal chest pain. Patients may develop crackles but generally don’t appear seriously ill.

Psittacosis.

As psittacosis progresses, the characteristic hacking cough, nonproductive at first, may later produce a small amount of mucoid, blood-streaked sputum. The infection may begin abruptly, with chills, fever, headache, myalgia, and prostration. Other signs and symptoms include tachypnea, fine crackles, chest pain (rare), epistaxis, photophobia, abdominal distention and tenderness, nausea, vomiting, and a faint macular rash. Severe infection may produce stupor, delirium, and coma.

Pulmonary coccidioidomycosis.

Pulmonary coccidioidomycosis causes a nonproductive or slightly productive cough with fever, occasional chills, pleuritic chest pain, sore throat, headache, backache, malaise, marked weakness, anorexia, hemoptysis, and an itchy macular rash. Rhonchi and wheezing may be heard. The disease may spread to other areas, causing arthralgia, swelling of the knees and ankles, and erythema nodosum or erythema multiforme. When severe, pulmonary edema — a life-threatening disorder — causes a cough that produces frothy, bloody sputum. Early signs and symptoms include exertional dyspnea as well as paroxysmal nocturnal dyspnea, followed by orthopnea. Coughing may be nonproductive initially. Other signs and symptoms include fever, fatigue, tachycardia, tachypnea, dependent crackles, and ventricular gallop. As the patient’s respirations become increasingly rapid and labored, he develops more diffuse crackles and productive cough, worsening tachycardia and, possibly, arrhythmias. The patient’s skin becomes cold, clammy, and cyanotic, his blood pressure falls, and his pulse becomes thready.

Pulmonary embolism.

Pulmonary embolism is a life-threatening disorder that causes a cough that may be nonproductive or may produce blood-tinged sputum. Usually, the first symptom of pulmonary embolism is severe dyspnea, which may be accompanied by angina or pleuritic chest pain. The patient experiences marked anxiety, low-grade fever, tachycardia, tachypnea, and diaphoresis. Less-common signs include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and jugular vein distention. The patient may also have pleural friction rub, diffuse wheezing, crackles, chest dullness on percussion, decreased breath sounds, and signs of circulatory collapse.

Pulmonary emphysema.

Pulmonary emphysema causes a chronic productive cough with scant, mucoid, translucent, grayish white sputum that can become mucopurulent. The patient is thin and has the characteristic “pink puffer” appearance with weight loss, increased accessory muscle use, tachypnea, grunting expirations through pursed lips, diminished breath sounds, exertional dyspnea, rhonchi, barrel chest, and anorexia. Clubbing is a late sign.

Pulmonary tuberculosis.

Pulmonary tuberculosis causes a mild to severe productive cough along with some combination of hemoptysis, malaise, dyspnea, and pleuritic chest pain. Sputum may be scant and mucoid or copious and purulent. Typically, the patient experiences night sweats, easy fatigability, and weight loss. His breath sounds are amphoric. He may have chest dullness on percussion and, after coughing, increased tactile fremitus with crackles.

Silicosis.

A productive cough with mucopurulent sputum is the earliest sign of silicosis. The patient also has exertional dyspnea, tachypnea, weight loss, fatigue, general weakness, and recurrent respiratory infections. Auscultation reveals end-inspiratory, fine crackles at the lung bases. Inflammation initially causes a nonproductive cough that later — following the onset of chills, sore throat, slight fever, muscle and back pain, and substernal tightness — becomes productive as secretions increase. Sputum is mucoid, mucopurulent, or purulent. The patient typically has rhonchi and wheezes; he may also develop crackles. Severe tracheobronchitis may cause a fever of 101° to 102° F (38.3° to 38.9° C) and bronchospasm.

Other causes

Bronchoscopy and pulmonary function tests may increase productive coughing.

Drugs.

Expectorants, of course, increase productive coughing. These include ammonium chloride, calcium iodide, guaifenesin, iodinated glycerol, potassium iodide, and terpin hydrate. Intermittent positive-pressure breathing, nebulizer therapy, and incentive spirometry can help loosen secretions and cause or increase productive coughing.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Hoarseness: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Gastroesophageal reflux

Irritation of the larynx by reflux of gastric juices may result in hoarseness as well as sore throat, cough, throat clearing, and a sensation of a lump in the throat. The arytenoid tissue and the vocal cords may appear red and swollen.

Hypothyroidism

Hoarseness may be an early sign of hypothyroidism. Other signs and symptoms include fatigue, cold intolerance, weight gain despite anorexia, and menorrhagia. Assessment may also reveal coarse hair and alopecia as well as dry, flaky skin and thinning nails.

Laryngeal cancer

Hoarseness is an early sign of vocal cord cancer but may not occur until later in cancer of other laryngeal areas. The patient usually has a long history of smoking. Other common findings include a mild, dry cough; minor throat discomfort; otalgia; and, sometimes, hemoptysis.

Laryngeal leukoplakia

Leukoplakia is a common cause of hoarseness, especially in smokers. Histologic examination from direct laryngoscopy usually reveals mild, moderate, or severe dysphagia.

Laryngitis

Persistent hoarseness may be the only sign of chronic laryngitis. With acute laryngitis, hoarseness or a complete loss of voice develops suddenly. Related findings include pain (especially during swallowing or speaking), cough, fever, profuse diaphoresis, sore throat, and rhinorrhea.

Tracheal trauma

Torn tracheal mucosa may cause hoarseness, hemoptysis, dysphagia, neck pain, airway occlusion, and respiratory distress. The patient with tracheal trauma may also have manifestations of cervical spine injuries.

Vocal cord paralysis

Unilateral vocal cord paralysis causes hoarseness and vocal weakness. Paralysis may accompany signs of trauma, such as pain and swelling of the head and neck. The patient may also experience dysphagia.

Vocal cord polyps or nodules

Raspy hoarseness, the chief complaint, accompanies a chronic cough and a crackling voice. Typically, this condition is painless.

Other causes

Inhalation injury

Inhalation injury from a fire or explosion produces hoarseness and coughing, singed nasal hairs, orofacial burns, and soot-stained sputum. Subsequent signs and symptoms include crackles, rhonchi, and wheezing, which rapidly deteriorate to respiratory distress.

Treatments

Occasionally, surgical trauma to the laryngeal nerve results in temporary or permanent unilateral vocal cord paralysis, leading to hoarseness. Prolonged intubation may cause temporary hoarseness.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Stridor: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Airway trauma

Local trauma to the upper airway commonly causes acute obstruction, resulting in the sudden onset of stridor. Accompanying this sign are dysphonia, dysphagia, hemoptysis, cyanosis, accessory muscle use, intercostal retractions, nasal flaring, tachypnea, progressive dyspnea, and shallow respirations. Palpation may reveal subcutaneous crepitation in the neck or upper chest.

Anaphylaxis

With a severe allergic reaction (anaphylaxis), upper airway edema and laryngospasm cause stridor and other signs and symptoms of respiratory distress: nasal flaring, wheezing, accessory muscle use, intercostal retractions, and dyspnea. The patient may also develop nasal congestion and profuse, watery rhinorrhea. Typically, these respiratory effects are preceded by a feeling of impending doom or fear, weakness, diaphoresis, sneezing, nasal pruritus, urticaria, erythema, and angioedema. Common associated findings of anaphylaxis include chest or throat tightness, dysphagia and, possibly, signs of shock, such as hypotension, tachycardia, and cool, clammy skin.

Anthrax (inhalation)

Initial signs and symptoms of inhalation anthrax are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by stridor, fever, dyspnea, and hypotension generally leading to death within 24 hours.

Aspiration of a foreign body

Sudden stridor is characteristic in this life-threatening situation. Related findings include abrupt onset of dry, paroxysmal coughing, gagging or choking, hoarseness, tachycardia, wheezing, dyspnea, tachypnea, intercostal muscle retractions, diminished breath sounds, cyanosis, and shallow respirations. The patient typically appears anxious and distressed.

Epiglottiditis

With epiglottiditis, a life-threatening inflammatory condition, stridor is caused by an erythematous, edematous epiglottis that obstructs the upper airway. Stridor occurs along with fever, sore throat, and a croupy cough. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia.

Hypocalcemia

With hypocalcemia, laryngospasm can cause stridor. Other findings include paresthesia, carpopedal spasm, hyperactive deep tendon reflexes, muscle twitching and cramping, and positive Chvostek’s and Trousseau’s signs.

Inhalation injury

Within 48 hours after inhalation of smoke or noxious fumes, the patient may develop laryngeal edema and bronchospasms, resulting in stridor. Associated signs and symptoms include singed nasal hairs, orofacial burns, coughing, hoarseness, sooty sputum, crackles, rhonchi, wheezes, and other signs and symptoms  of respiratory distress, such as dyspnea, accessory muscle use, intercostal retractions, and nasal flaring.

Laryngeal tumor

Stridor is a late sign of laryngeal tumor and may be accompanied by dysphagia, dyspnea, enlarged cervical nodes, and pain that radiates to the ear. Typically, stridor is preceded by hoarseness, minor throat pain, and a mild, dry cough.

Laryngitis (acute)

Acute laryngitis may cause severe laryngeal edema, resulting in stridor and dyspnea. Its chief sign, however, is mild to severe hoarseness, perhaps with transient voice loss. Other findings include sore throat, dysphagia, dry cough, malaise, and fever.

Mediastinal tumor

Commonly producing no symptoms at first, a mediastinal tumor may eventually compress the trachea and bronchi, resulting in stridor. Its other effects include hoarseness, brassy cough, tracheal shift or tug, dilated neck veins, swelling of the face and neck, stertorous respirations, and suprasternal retractions on inspiration. The patient may also report dyspnea, dysphagia, and pain in the chest, shoulder, or arm.

Thoracic aortic aneurysm

If a thoracic aortic aneurysm compresses the trachea, it may cause stridor accompanied by dyspnea, wheezing, and a brassy cough. Other findings include hoarseness or complete voice loss, dysphagia, jugular vein distention, prominent chest veins, tracheal tug, paresthesia or neuralgia, and edema of the face, neck, and arms. The patient may also complain of substernal, lower back, abdominal, or shoulder pain.

Other causes

Diagnostic tests

Bronchoscopy or laryngoscopy may precipitate laryngospasm and stridor.

Treatments

After prolonged intubation, the patient may exhibit laryngeal edema and stridor when the tube is removed. Aerosol therapy with epinephrine may reduce stridor. Reintubation may be necessary in some cases. Neck surgery, such as thyroidectomy, may cause laryngeal paralysis and stridor.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Cough, barking: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Aspiration of foreign body

Partial obstruction of the upper airway caused by aspiration of foreign body first produces sudden hoarseness, then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing and, possibly, cyanosis.

Epiglottiditis

Epiglottiditis, a life-threatening disorder, has become less common since the use of influenza vaccines. It occurs nocturnally, heralded by a barking cough and a high fever. The child is hoarse, dysphagic, dyspneic, and restless and appears extremely ill and panicky. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia. The child will struggle to get sufficient air as epiglottic edema increases. Epiglottiditis is a true medical emergency.

Laryngotracheobronchitis (acute)

Also known as viral croup, acute laryngotracheobronchitis is most common in children between 9 and 18 months old and usually occurs in the fall and early winter. It initially produces low to moderate fever, runny nose, poor appetite, and infrequent cough. When the infection descends into the laryngotracheal area, barking cough, hoarseness, and inspiratory stridor occur.

As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.

Spasmodic croup

Acute spasmodic croup usually occurs during sleep with the abrupt onset of a barking cough that awakens the child. Typically, he doesn’t have a fever but may be hoarse, restless, and dyspneic. As his respiratory distress worsens, the child may exhibit sternal and intercostal retractions, nasal flaring, tachycardia, cyanosis, and an anxious, frantic appearance. The signs usually subside within a few hours, but attacks tend to recur.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Cough, nonproductive: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Airway occlusion

Partial occlusion of the upper airway produces a sudden onset of dry, paroxysmal coughing. The patient is gagging, wheezing, and hoarse, with stridor, tachycardia, and decreased breath sounds. If the patient has aspirated a foreign body he may exhibit the universal sign for choking — a hand clutched to the throat, with thumb and fingers extended.

Anthrax (inhalation)

Inhalation anthrax is caused by inhalation of aerosolized spores of the gram-positive bacterium Bacillus anthracis. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Aortic aneurysm (thoracic)

A thoracic aortic aneurysm causes a brassy cough with dyspnea, hoarseness, wheezing, and a substernal ache in the shoulders, lower back, or abdomen. The patient may also have facial or neck edema, neck vein distention, dysphagia, prominent veins over his chest, stridor and, possibly, paresthesia or neuralgia.

Asthma

Asthma attacks commonly occur at night, starting with a nonproductive cough and mild wheezing; this progresses to severe dyspnea, audible wheezing, chest tightness, and a cough that produces thick mucus. Other signs include apprehension, rhonchi, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis.

Atelectasis

As lung tissue deflates, it stimulates cough receptors, causing a nonproductive cough. The patient with atelectasis may also have pleuritic chest pain, anxiety, dyspnea, tachypnea, and tachycardia. His skin may be cyanotic and diaphoretic, his breath sounds may be decreased, his chest may be dull on percussion, and he may exhibit inspiratory lag, substernal or intercostal retractions, decreased vocal fremitus, and tracheal deviation toward the affected side.

Bronchitis (chronic)

Chronic bronchitis starts with a nonproductive, hacking cough that later becomes productive. Other findings include prolonged expiration, wheezing, dyspnea, accessory muscle use, barrel chest, cyanosis, tachypnea, crackles, and scattered rhonchi. Clubbing can occur in late stages.

Bronchogenic carcinoma

The earliest indicators of bronchogenic carcinoma can be a chronic, nonproductive cough, dyspnea, and vague chest pain. The patient may also have wheezing, hemoptysis, and stridor.

Common cold

The common cold generally starts with a nonproductive, hacking cough and progresses to some mix of sneezing, headache, malaise, fatigue, rhinorrhea, myalgia, arthralgia, nasal congestion, and sore throat.

Esophageal achalasia

With esophageal achalasia, regurgitation and aspiration produce a dry cough. The patient may also have recurrent pulmonary infections and dysphagia. The patient may report weight loss, heartburn, and chest pain that increases after eating.

Esophageal diverticula

The patient with esophageal diverticula has a nocturnal nonproductive cough, regurgitation and aspiration, dyspepsia, and dysphagia. His neck may appear swollen and have a gurgling sound. He may also exhibit halitosis and weight loss.

Esophageal occlusion

Esophageal occlusion is marked by immediate nonproductive coughing and gagging, with a sensation of something stuck in the throat. Other findings include neck or chest pain, dysphagia, and the inability to swallow.

Esophagitis with reflux

Esophagitis with reflux commonly causes a nonproductive nocturnal cough due to regurgitation and aspiration. The patient may experience chest pain that mimics angina pectoris; heartburn that worsens if he lies down after eating; and increased salivation, dysphagia, hematemesis, and melena.

Hodgkin’s disease

Hodgkin’s disease may cause a crowing nonproductive cough. However, the earliest sign is usually painless swelling of one of the cervical lymph nodes or, occasionally, of the axillary, mediastinal, or inguinal lymph nodes. Another early sign is pruritus. Other findings depend on the degree and location of systemic involvement and include dyspnea, dysphagia, hepatosplenomegaly, edema, jaundice, nerve pain, and hyperpigmentation.

Hypersensitivity pneumonitis

With hypersensitivity pneumonitis, an acute nonproductive cough, fever, dyspnea, and malaise usually occur 5 to 6 hours after exposure to an antigen. The patient may also report chest tightness and extreme fatigue.

Interstitial lung disease

A patient with interstitial lung disease has a nonproductive cough and progressive dyspnea. He may also be cyanotic and have clubbing, fine crackles, fatigue, variable chest pain, and weight loss. Other findings include dyspnea on exertion and vague chest pain.

Laryngeal tumor

A mild, nonproductive cough is an early sign of a laryngeal tumor, in addition to minor throat discomfort and hoarseness. Later, dysphagia, dyspnea, cervical lymphadenopathy, stridor, and earache may occur.

Laryngitis

In its acute form, laryngitis causes a nonproductive cough with localized pain (especially when the patient is swallowing or speaking) as well as fever and malaise. His hoarseness can range from mild to complete loss of voice.

Legionnaires’ disease

After a prodrome of malaise, headache and, possibly, diarrhea, anorexia, diffuse myalgia, and general weakness, legionnaires’disease causes a nonproductive cough that later produces mucoid, mucopurulent and, possibly, bloody sputum.

Lung abscess

Lung abscess typically begins with nonproductive coughing, weakness, dyspnea, and pleuritic chest pain. The patient may also exhibit diaphoresis, fever, headache, malaise, fatigue, crackles, decreased breath sounds, anorexia, and weight loss. Later, his cough produces large amounts of purulent, foul-smelling, possibly bloody sputum.

Mediastinal tumor

A large mediastinal tumor produces a nonproductive cough, dyspnea, and retrosternal pain. The patient may also develop stertorous respirations with suprasternal retraction on inspiration, hoarseness, dysphagia, tracheal shift or tug, neck vein distention, and facial or neck edema.

Pleural effusion

A nonproductive cough along with dyspnea, pleuritic chest pain, and decreased chest motion are characteristic of pleural effusion. Other findings include pleural friction rub, tachycardia, tachypnea, egophony, flatness on percussion, decreased or absent breath sounds, and decreased tactile fremitus.

Pneumonia

Bacterial pneumonia usually starts with a nonproductive, hacking, painful cough that rapidly becomes productive. Other findings include shaking chills, headache, high fever, dyspnea, pleuritic chest pain, tachypnea, tachycardia, grunting respirations, nasal flaring, decreased breath sounds, fine crackles, rhonchi, and cyanosis. The patient’s chest may be dull on percussion.

With mycoplasma pneumonia, a nonproductive cough arises 2 to 3 days after the onset of malaise, headache, and sore throat. The cough can be paroxysmal, causing substernal chest pain. Fever commonly occurs, but the patient doesn’t appear seriously ill.

Viral pneumonia causes a nonproductive, hacking cough and the gradual onset of malaise, headache, anorexia, and low-grade fever.

Pneumothorax

Pneumothorax, a life-threatening disorder, causes a dry cough and signs of respiratory distress, such as severe dyspnea, tachycardia, tachypnea, and cyanosis. The patient experiences sudden, sharp chest pain that worsens with chest movement as well as subcutaneous crepitation, hyperresonance or tympany, decreased vocal fremitus, and decreased or absent breath sounds on the affected side.

Pulmonary edema

Pulmonary edema initially causes a dry cough, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, tachycardia, tachypnea, dependent crackles, and ventricular gallop. If pulmonary edema is severe, the patient’s respirations become more rapid and labored, with diffuse crackles and coughing that produces frothy, bloody sputum.

Pulmonary embolism

A life-threatening pulmonary embolism may suddenly produce a dry cough along with dyspnea and pleuritic or anginal chest pain. More commonly, though, the cough produces blood-tinged sputum. Tachycardia and low-grade fever are also common; less common signs and symptoms include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and distended neck veins. The patient may also have a pleural friction rub, diffuse wheezing, dullness on percussion, and decreased breath sounds.

Sarcoidosis

With sarcoidosis, a nonproductive cough is accompanied by dyspnea, substernal pain, and malaise. The patient may also develop fatigue, arthralgia, myalgia, weight loss, tachypnea, crackles, lymphadenopathy, hepatosplenomegaly, skin lesions, vision impairment, difficulty swallowing, and arrhythmias.

CULTURAL CUE:The risk of sarcoidosis is greatest in young adult Blacks, especially Black women. Others at high risk include those of Scandinavian, German, Irish, or Puerto Rican descent.

Severe acute respiratory syndrome

The incubation period of this acute infectious disease of unknown etiology is 2 to  7 days, and the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms of severe acute respiratory syndrome (SARS) include headache, malaise, a dry nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

CULTURAL CUE:Most cases of SARS have been reported in Asia (China, Vietnam, Singapore, Thailand), although some cases have appeared in Europe and North America.

Sinusitis (chronic)

Chronic sinusitis can cause a chronic nonproductive cough due to postnasal drip. The patient’s nasal mucosa may appear inflamed, and he may have nasal congestion and profuse drainage. Usually, his breath smells musty.

Tracheobronchitis (acute)

Initially, acute tracheobronchitis produces a dry cough that later becomes productive as secretions increase. Chills, sore throat, slight fever, muscle and back pain, and substernal tightness generally precede the cough’s onset. Rhonchi and wheezes are usually heard. Severe illness causes a fever of 101° F to 102° F (38.3° to 38.9° C) and possibly bronchospasm, with severe wheezing and increased coughing.

Tularemia

Following inhalation of the gram-negative, non-spore-forming bacterium Francisella tularensis, patients with tularemia show signs and symptoms including the abrupt onset of fever, chills, headache, generalized myalgia, nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Diagnostic tests

Pulmonary function tests and bronchoscopy may stimulate cough receptors, triggering coughing.

Treatments

Irritation of the carina during suctioning or deep endotracheal or tracheal tube placement can trigger a paroxysmal or hacking cough. Intermittent positive-pressure breathing or spirometry can also cause a nonproductive cough. Some inhalants, such as pentamidine, may stimulate coughing.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Cough, productive: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Aspiration pneumonitis

Aspiration pneumonitis causes coughing that produces pink, frothy, possibly purulent sputum. The patient also has marked dyspnea, fever, tachypnea, fatigue, chest pain, halitosis, tachycardia, wheezing, and cyanosis.

Asthma (acute)

A severe asthma attack, which can be life-threatening, may produce mucoid, tenacious sputum and mucus plugs. Such an attack typically starts with a dry cough and mild wheezing, then progresses to severe dyspnea, audible wheezing, chest tightness, and a productive cough. Other findings include apprehension, prolonged expirations, intercostal and supraclavicular retraction on inspiration, accessory muscle use, rhonchi, crackles, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis. Attacks commonly occur at night or during sleep.

Bronchiectasis

The chronic cough of bronchiectasis produces copious, mucopurulent sputum that has characteristic layering (top, frothy; middle, clear; bottom, dense with purulent particles). The patient has halitosis: His sputum may smell foul or sickeningly sweet. Other characteristic findings include hemoptysis, persistent coarse crackles over the affected lung area, occasional wheezing, rhonchi, exertional dyspnea, weight loss, fatigue, malaise, weakness, recurrent fever, and late-stage finger clubbing.

Bronchitis (chronic)

Chronic bronchitis causes a cough that may be nonproductive initially. Eventually, however, it produces mucoid sputum that becomes purulent. Secondary infection can also cause mucopurulent sputum, which may become blood-tinged and foul-smelling. The coughing, which may be paroxysmal during exercise, usually occurs when the patient is recumbent or rises from sleep.

The patient also exhibits prolonged expirations, increased use of accessory muscles for breathing, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea, scattered rhonchi, coarse crackles (which can be precipitated by coughing), and late-stage clubbing.

Chemical pneumonitis

Chemical pneumonitis causes a cough with purulent sputum. It can also cause dyspnea, wheezing, orthopnea, fever, malaise, and crackles; mucous membrane irritation of the conjunctivae, throat, and nose; laryngitis; or rhinitis. Signs and symptoms may increase for 24 to 48 hours after exposure, then resolve; if severe, however, they may recur 2 to 5 weeks later.

Common cold

When a common cold causes productive coughing, the sputum is mucoid or mucopurulent. Early indications of the common cold include a dry, hacking cough, sneezing, headache, malaise, fatigue, rhinorrhea (watery to tenacious, mucopurulent secretions), nasal congestion, sore throat, myalgia, and arthralgia.

Legionnaires’ disease

Legionnaires’ disease causes a cough that produces scant mucoid, nonpurulent, possibly blood-streaked sputum. Prodromal signs and symptoms typically include malaise, fatigue, weakness, anorexia, diffuse myalgia and, possibly, diarrhea. Then, within 48 hours, the patient develops a dry cough and a sudden high fever with chills. Many patients also have pleuritic chest pain, headache, tachypnea, tachycardia, nausea, vomiting, dyspnea, crackles, mild temporary amnesia, disorientation, confusion, flushing, mild diaphoresis, and prostration.

Lung abscess (ruptured)

The cardinal sign of ruptured lung abscess is coughing that produces copious amounts of purulent, foul-smelling, possibly blood-tinged sputum. A ruptured abscess can also cause diaphoresis, anorexia, clubbing, weight loss, weakness, fatigue, fever with chills, dyspnea, headache, malaise, pleuritic chest pain, halitosis, inspiratory crackles, and tubular or amphoric breath sounds. The patient’s chest is dull on percussion on the affected side.

Lung cancer

One of the earliest signs of bronchogenic carcinoma is a chronic cough that produces small amounts of purulent (or mucopurulent), blood-streaked sputum. In a patient with bronchoalveolar cancer, however, coughing produces large amounts of frothy sputum. Other signs and symptoms include dyspnea, anorexia, fatigue, weight loss, chest pain, fever, diaphoresis, wheezing, and clubbing.

Plague

Signs and symptoms of plague, caused by the bacterium Yersinia pestis, include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the flea bite. Septicemic plague develops as a fulminant illness generally with the bubonic form. The onset of the pneumonic form is usually sudden with chills, fever, headache, and myalgia. Pulmonary signs and symptoms include productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pneumonia

Bacterial pneumonia initially produces a dry cough that becomes productive. Associated signs and symptoms develop suddenly and include shaking chills, high fever, myalgia, headache, pleuritic chest pain that increases with chest movement, tachypnea, tachycardia, dyspnea, cyanosis, diaphoresis, decreased breath sounds, fine crackles, and rhonchi.

Pulmonary edema

Severe, pulmonary edema is a life-threatening disorder that causes a cough that produces frothy, bloody sputum. Early signs and symptoms of pulmonary edema include exertional dyspnea; paroxysmal nocturnal dyspnea, followed by orthopnea; and coughing, which may be nonproductive initially. Others include fever, fatigue, tachycardia, tachypnea, dependent crackles, and ventricular gallop. As the patient’s respirations become increasingly rapid and labored, he develops more diffuse crackles and a productive cough, worsening tachycardia and, possibly, arrhythmias. His skin becomes cold, clammy, and cyanotic; his blood pressure falls; and his pulse becomes thready.

Pulmonary embolism

Pulmonary embolism is a life-threatening disorder that causes a cough that may be nonproductive or may produce blood-tinged sputum. Usually, the first symptom of a pulmonary embolism is severe dyspnea, which may be accompanied by angina or pleuritic chest pain. The patient experiences marked anxiety, a low-grade fever, tachycardia, tachypnea, and diaphoresis. Less common signs include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and distended neck veins. The patient may also have a pleural friction rub, diffuse wheezing, crackles, chest dullness on percussion, decreased breath sounds, and signs of circulatory collapse.

Pulmonary emphysema

Pulmonary emphysema causes a chronic productive cough with scant, mucoid, translucent, grayish white sputum that can become mucopurulent. The patient is thin and has the characteristic “pink puffer” appearance with weight loss, increased accessory muscle use, tachypnea, grunting expirations through pursed lips, diminished breath sounds, exertional dyspnea, rhonchi, barrel chest, and anorexia. Clubbing is a late sign.

Pulmonary tuberculosis

Pulmonary tuberculosis causes a mild to severe productive cough along with some combination of hemoptysis, malaise, dyspnea, and pleuritic chest pain. Sputum may be scant and mucoid or copious and purulent. Typically, the patient experiences night sweats, easy fatigability, and weight loss. His breath sounds are amphoric. He may have chest dullness on percussion and, after coughing, increased tactile fremitus with crackles.

Silicosis

A productive cough with mucopurulent sputum is the earliest sign of silicosis. The patient also has exertional dyspnea, tachypnea, weight loss, fatigue, general weakness, and recurrent respiratory infections. Auscultation reveals end-inspiratory, fine crackles at the lung bases.

Tracheobronchitis

With tracheobronchitis, inflammation initially causes a nonproductive cough that later — following the onset of chills, sore throat, slight fever, muscle and back pain, and substernal tightness — becomes productive as secretions increase. Sputum is mucoid, mucopurulent, or purulent. The patient typically has rhonchi and wheezes; he may also develop crackles. Severe tracheobronchitis may cause a fever of 101° to 102° F (38.3° to 38.9° C) and bronchospasm.

Other causes

Diagnostic tests

Bronchoscopy and pulmonary function tests may increase productive coughing.

Drugs

Expectorants, of course, increase productive coughing. These include guaifenesin, potassium iodide, and terpin hydrate.

Respiratory therapy

Intermittent positive-pressure breathing, nebulizer therapy, and incentive spirometry can help loosen secretions and cause or increase productive coughing.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Cough: Principal Causes of Cough
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Infection/inflammation
   1. Upperrespiratory tract infection
   2. Sinusitis
   3. Laryngitis
   4. Croup
   5. Tracheitis
   6. Bronchitis
   7. Pertussis
   8. Bronchiolitis
   9. Pneumonia
      1. Viral
      2. Bacterial
         1. Tuberculosis
         2. Chlamydia
         3. Legionella
         4. Nocardia
      3. Mycoplasma
      4. Fungal
         1. Histoplasmosis
         2. Coccidioidomycosis
         3. Aspergillosis
         4. Blastomycosis
      5. Protozoa
      6. Chemical pneumonia
      7. Aspiration pneumonia
   10. Cystic fibrosis
   11. Bronchiectasis
   12. Lung abscess
2. Allergic disorders
   1. Allergicrhinitis
   2. Asthma
3. Mechanical or chemical irritation
   1. Environmentalirritants
   2. Foreign body aspiration
4. Bronchopulmonary dysplasia
5. Congenital anomalies
6. Cardiac failure
7. Gastroesophageal reflux
8. Swallowing dysfunction
9. Immotile cilia syndrome
10. Neoplasm
11. Reflex cough
12. Psychogenic, including habitual cough

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Hoarseness: Principal Causes of Hoarseness
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Congenitalanomalies of the larynx
   1. Laryngomalacia
   2. Laryngeal web, cyst, or cleft
   3. Laryngocele
2. Infection/inflammation
   1. Laryngitis
   2. Croup
   3. Supraglottitis
3. Allergic disorders
4. Trauma
   1. Vocal abuse
   2. Intubation
   3. Caustic substances and burns
   4. Blunt neck trauma
   5. Airway suctioning and passing of feedingtubes
   6. Foreign body
5. Vocal cord paralysis
6. Gastroesophageal reflux
7. Neoplasm

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Stertor, Stridor, and Airway Obstruction: Principal Causes of Airway Obstruction
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Noseand nasopharynx
   1. Congenital
      1. Choanal atresia
      2. Craniofacial anomalies
      3. Midline masses
   2. Infection/inflammation
      1. Rhinitis
      2. Adenoid hypertrophy
      3. Polyps
   3. Trauma
   4. Neoplasm
2. Oropharynx and hypopharynx
   1. Congenital
      1. Micrognathiaand other skull base abnormalities
      2. Macroglossia
      3. Decreased pharyngeal muscle tone
   2. Infection/inflammation
      1. Tonsillarhypertrophy
      2. Abscess
   3. Foreign body
   4. Trauma
   5. Neoplasm
3. Supraglottic
   1. Congenital
      1. Laryngomalacia
      2. Laryngeal cyst and laryngocele
   2. Infection/inflammation
      1. Supraglottitis
      2. Gastroesophageal reflux
      3. Hereditary angioedema
   3. Trauma
   4. Neoplasm
4. Glottic
   1. Congenital
      1. Laryngeal web
      2. Laryngeal cleft
      3. Vocal cord paralysis
   2. Infection/inflammation
      1. Laryngitis
      2. Laryngeal spasm
   3. Foreign body
   4. Trauma
   5. Neoplasm
5. Subglottic
   1. Congenital
      1. Subglottic stenosis
      2. Cysts
   2. Infection/inflammation
      1. Croup
      2. Bacterial tracheitis
   3. Trauma
   4. Neoplasm
6. Tracheobronchial
   1. Congenital
      1. Tracheomalacia
      2. Tracheal web
      3. Tracheal cysts
      4. Tracheal stenosis
      5. Vascular anomalies
   2. Infection/inflammation
   3. Foreign body
   4. Trauma
   5. Neoplasm
      1. Tracheal
      2. Thyroid
      3. Mediastinal masses
7. Psychogenic

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Hoarseness: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Gastroesophageal reflux.With gastroesophageal reflux, retrograde flow of gastric juices into the esophagus may then spill into the hypopharynx. This, in turn, irritates the larynx, resulting in hoarseness as well as a sore throat, a cough, throat clearing, and a sensation of a lump in the throat. The arytenoids and the vocal cords may appear red and swollen.

Hypothyroidism.With hypothyroidism, hoarseness may be an early sign. Others include fatigue, cold intolerance, weight gain despite anorexia, and menorrhagia.

Laryngeal cancer.Hoarseness is an early sign of vocal cord cancer, but may not occur until later in cancer of other laryngeal areas. The patient usually has a long history of smoking. Other common findings include a mild, dry cough; minor throat discomfort; otalgia; and, sometimes, hemoptysis.

Laryngeal leukoplakia.Leukoplakia is a common cause of hoarseness, especially in smokers. Histologic examination from direct laryngoscopy usually reveals mild, moderate, or severe dysphagia.

Laryngitis.Persistent hoarseness may be the only sign of chronic laryngitis. With acute laryngitis, hoarseness or a complete loss of voice develops suddenly. Related findings include pain (especially during swallowing or speaking), a cough, a fever, profuse diaphoresis, a sore throat, and rhinorrhea.

Rheumatoid arthritis.Hoarseness may signal laryngeal involvement in reumatoid arthritis. Other findings include pain, dysphagia, a sensation of fullness or tension in the throat, dyspnea on exertion, and stridor.

Thoracic aortic aneurysm.Thoracic aortic aneurysm typically produces no symptoms, but may cause hoarseness. Its most common symptom is penetrating pain that's especially severe when the patient is supine. Other clinical features include a brassy cough; dyspnea; wheezing; a substernal aching in the shoulders, lower back, or abdomen; a tracheal tug; facial and neck edema; jugular vein distention; dysphagia; prominent chest veins; stridor; and, possibly, paresthesia or neuralgia.

Tracheal trauma.Torn tracheal mucosa may cause hoarseness, hemoptysis, dysphagia, neck pain, airway occlusion, and respiratory distress.

Vocal cord paralysis.Unilateral vocal cord paralysis causes hoarseness and vocal weakness. Paralysis may accompany signs of trauma, such as pain and swelling of the head and neck.

Vocal cord polyps or nodules.Raspy hoarseness, the chief complaint, accompanies a chronic cough and a crackling voice.

Other causes

Inhalation injury.Inhalation injury from a fire or explosion produces hoarseness and coughing, singed nasal hairs, orofacial burns, and soot-stained sputum. Subsequent signs and symptoms include crackles, rhonchi, and wheezing, which rapidly deteriorate to respiratory distress.

Treatments.Occasionally, surgical trauma to the recurrent laryngeal nerve results in temporary or permanent unilateral vocal cord paralysis, leading to hoarseness. Prolonged intubation may cause temporary hoarseness.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Stridor: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Airway trauma.Local trauma to the upper airway commonly causes acute obstruction, resulting in the sudden onset of stridor. Accompanying this sign are dysphonia, dysphagia, hemoptysis, cyanosis, accessory muscle use, intercostal retractions, nasal flaring, tachypnea, progressive dyspnea, and shallow respirations. Palpation may reveal subcutaneous crepitation in the neck or upper chest.

Anaphylaxis.With a severe allergic reaction, upper airway edema and laryngospasm cause stridor and other signs and symptoms of respiratory distress: nasal flaring, wheezing, accessory muscle use, intercostal retractions, and dyspnea. The patient may also develop nasal congestion and profuse, watery rhinorrhea. Typically, these respiratory effects are preceded by a feeling of impending doom or fear, weakness, diaphoresis, sneezing, nasal pruritus, urticaria, erythema, and angioedema. Common associated findings include chest or throat tightness, dysphagia and, possibly, signs of shock, such as hypotension, tachycardia, and cool, clammy skin.

Anthrax (inhalation).Initial signs and symptoms of anthrax are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by stridor, fever, dyspnea, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Hypocalcemia.With hypocalcemia, laryngospasm can cause stridor. Other findings include paresthesia, carpopedal spasm, and positive Chvostek's and Trousseau's signs.

Inhalation injury.Within 48 hours after inhalation of smoke or noxious fumes, the patient may develop laryngeal edema and bronchospasms, resulting in stridor. Associated signs and symptoms include singed nasal hairs, orofacial burns, coughing, hoarseness, sooty sputum, crackles, rhonchi, wheezes, and other signs and symptoms of respiratory distress, such as dyspnea, accessory muscle use, intercostal retractions, and nasal flaring.

Mediastinal tumor.Commonly producing no symptoms at first, a mediastinal tumor may eventually compress the trachea and bronchi, resulting in stridor. Its other effects include hoarseness, a brassy cough, a tracheal shift or tug, dilated neck veins, swelling of the face and neck, stertorous respirations, and suprasternal retractions on inspiration. The patient may also report dyspnea, dysphagia, and pain in the chest, shoulder, or arm.

Retrosternal thyroid.Retrosternal thyroid causes stridor, dysphagia, cough, hoarseness, and tracheal deviation. It can also cause signs of thyrotoxicosis.

Other causes

Diagnostic tests.Bronchoscopy or laryngoscopy may precipitate laryngospasm and stridor.

Foreign body aspiration.Sudden stridor is characteristic in foreign body aspiration, a life-threatening situation. Related findings include an abrupt onset of dry, paroxysmal coughing; gagging or choking; hoarseness; tachycardia; wheezing; dyspnea; tachypnea; intercostal muscle retractions; diminished breath sounds; cyanosis; and shallow respirations. The patient typically appears anxious and distressed.

Treatments.After prolonged intubation, the patient may exhibit laryngeal edema and stridor when the tube is removed. Aerosol therapy with epinephrine may reduce stridor. Reintubation may be necessary in some cases. Neck surgery, such as thyroidectomy, may cause laryngeal paralysis and stridor.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Cough, barking: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Aspiration of foreign body.Partial obstruction of the upper airway first produces sudden hoarseness, and then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing and, possibly, cyanosis.

Epiglottiditis.Epiglottiditis is a life-threatening disorder that has become less common since the use of influenza vaccines. It occurs nocturnally, heralded by a barking cough and a high fever. The child is hoarse, dysphagic, dyspneic, and restless and appears extremely ill and panicky. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia. The child will struggle to get sufficient air as epiglottic edema increases. Epiglottiditis is a true medical emergency.

Laryngotracheobronchitis (acute).Also known as viral croup, laryngotracheobronchitisinitially produces a low to moderate fever, a runny nose, a poor appetite, and an infrequent cough. When the infection descends into the laryngotracheal area, a barking cough, hoarseness, and inspiratory stridor occur.

As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.

Spasmodic croup.Acute spasmodic croup usually occurs during sleep with the abrupt onset of a barking cough that awakens the child. Typically, he doesn't have a fever, but may be hoarse, restless, and dyspneic. As his respiratory distress worsens, the child may exhibit sternal and intercostal retractions, nasal flaring, tachycardia, cyanosis, and an anxious, frantic appearance. The signs usually subside within a few hours, but attacks tend to recur.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Cough, nonproductive: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Airway occlusion.Partial occlusion of the upper airway produces a sudden onset of dry, paroxysmal coughing. The patient is gagging, wheezing, and hoarse, with stridor, tachycardia, and decreased breath sounds.

Anthrax (inhalation).Inhalation anthrax is caused by inhaling aerosolized spores. Initial signs and symptoms are flulike and include a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages, with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Aortic aneurysm (thoracic).Aortic aneurysm causes a brassy cough with dyspnea, hoarseness, wheezing, and a substernal ache in the shoulders, lower back, or abdomen. The patient may also have facial or neck edema, jugular vein distention, dysphagia, prominent veins over his chest, stridor and, possibly, paresthesia or neuralgia.

Asthma.Asthma attacks typically occur at night, starting with a nonproductive cough and mild wheezing; this progresses to severe dyspnea, audible wheezing, chest tightness, and a cough that produces thick mucus. Other signs include apprehension, rhonchi, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis.

Atelectasis.As lung tissue deflates, it stimulates cough receptors, causing a nonproductive cough. The patient may also have pleuritic chest pain, anxiety, dyspnea, tachypnea, and tachycardia. His skin may be cyanotic and diaphoretic, his breath sounds may be decreased, his chest may be dull on percussion, and he may exhibit inspiratory lag, substernal or intercostal retractions, decreased vocal fremitus, and tracheal deviation toward the affected side.

Avian influenza.Individuals infected with avian influenza may initially have symptoms of conventional influenza, including a nonproductive cough, fever, sore throat, and muscle aches. The most virulent avian virus, influenza A (H5N1), may lead to severe and life-threatening complications, such as acute respiratory distress and pneumonia.

Bronchitis (chronic).Bronchitis starts with a nonproductive, hacking cough that later becomes productive. Other findings include prolonged expiration, wheezing, dyspnea, accessory muscle use, barrel chest, cyanosis, tachypnea, crackles, and scattered rhonchi. Clubbing can occur in late stages.

Bronchogenic carcinoma.The earliest indicators of bronchogenic carcinoma can be a chronic, nonproductive cough; dyspnea; and vague chest pain. The patient may also be wheezing.

Common cold.The common cold generally starts with a nonproductive, hacking cough and progresses to some mix of sneezing, headaches, malaise, fatigue, rhinorrhea, myalgia, arthralgia, nasal congestion, and a sore throat.

Esophageal achalasia.In esophageal achalasia, regurgitation and aspiration produce a dry cough. The patient may also have recurrent pulmonary infections and dysphagia.

Esophageal diverticula.The patient with esophageal diverticula has a nocturnal nonproductive cough, regurgitation and aspiration, dyspepsia, and dysphagia. His neck may appear swollen and have a gurgling sound. He may also exhibit halitosis and weight loss.

Esophageal occlusion.Esophageal occlusion is marked by immediate nonproductive coughing and gagging, with a sensation of something stuck in the throat. Other findings include neck or chest pain, dysphagia, and the inability to swallow.

Hantavirus pulmonary syndrome.A nonproductive cough is common in patients with Hantavirus pulmonary syndrome, which is marked by noncardiogenic pulmonary edema. Other findings include a headache, myalgia, fever, nausea, and vomiting.

Hypersensitivity pneumonitis.With hypersensitivity pneumonitis, an acute nonproductive cough, a fever, dyspnea, and malaise usually occur 5 or 6 hours after exposure to an antigen.

Interstitial lung disease.A patient with interstitial lung disease has a nonproductive cough and progressive dyspnea. He may also be cyanotic and have clubbing, fine crackles, fatigue, variable chest pain, and weight loss.

Laryngeal tumor.A mild, nonproductive cough is an early sign of a laryngeal tumor, in addition to minor throat discomfort and hoarseness. Later, dysphagia, dyspnea, cervical lymphadenopathy, stridor, and an earache may occur.

Laryngitis.In its acute form, laryngitis causes a nonproductive cough with localized pain (especially when the patient is swallowing or speaking) as well as fever and malaise. His hoarseness can range from mild to complete loss of voice.

Lung abscess.Lung abscess typically begins with a nonproductive cough, weakness, dyspnea, and pleuritic chest pain. The patient may also exhibit diaphoresis, a fever, a headache, malaise, fatigue, crackles, decreased breath sounds, anorexia, and weight loss. Later, his cough produces large amounts of purulent, foul-smelling and, possibly, bloody sputum.

Pleural effusion.A nonproductive cough along with dyspnea, pleuritic chest pain, and decreased chest motion are characteristic of pleural effusion. Other findings include a pleural friction rub, tachycardia, tachypnea, egophony, flatness on percussion, decreased or absent breath sounds, and decreased tactile fremitus.

Pneumonia.Bacterial pneumonia usually starts with a nonproductive, hacking, painful cough that rapidly becomes productive. Other findings include shaking chills, a headache, a high fever, dyspnea, pleuritic chest pain, tachypnea, tachycardia, grunting respirations, nasal flaring, decreased breath sounds, fine crackles, rhonchi, and cyanosis. The patient's chest may be dull on percussion.

With mycoplasma pneumonia, a nonproductive cough arises 2 or 3 days after the onset of malaise, a headache, and a sore throat. The cough can be paroxysmal, causing substernal chest pain. Fever commonly occurs, but the patient doesn't appear seriously ill.

Viral pneumonia causes a nonproductive, hacking cough and the gradual onset of malaise, headache, anorexia, and a low-grade fever.

Pneumothorax.Pneumothorax is a life-threatening disorder that causes a dry cough and signs of respiratory distress, such as severe dyspnea, tachycardia, tachypnea, and cyanosis. The patient experiences sudden, sharp chest pain that worsens with chest movement as well as subcutaneous crepitation, hyperresonance or tympany, decreased vocal fremitus, and decreased or absent breath sounds on the affected side.

Pulmonary edema.Pulmonary edema initially causes a dry cough, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, tachycardia, tachypnea, dependent crackles, a ventricular gallop, and anxiety and restlessness. If pulmonary edema is severe, the patient's respirations become more rapid and labored, with diffuse crackles and coughing that produces frothy, bloody sputum.

Pulmonary embolism.A life-threatening pulmonary embolism may suddenly produce a dry cough along with dyspnea and pleuritic or anginal chest pain. Typically, however, the cough produces blood-tinged sputum. Tachycardia and a low-grade fever are also common; less common signs and symptoms include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and jugular vein distention. The patient may also have a pleural friction rub, diffuse wheezing, dullness on percussion, and decreased breath sounds.

Sarcoidosis.With sarcoidosis, a nonproductive cough is accompanied by dyspnea, substernal pain, and malaise. The patient may also develop fatigue, arthralgia, myalgia, weight loss, tachypnea, crackles, lymphadenopathy, hepatosplenomegaly, skin lesions, visual impairment, difficulty swallowing, and arrhythmias.

Severe acute respiratory syndrome (SARS).SARS generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include a headache; malaise; a dry, nonproductive cough; and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Tracheobronchitis (acute).Initially, tracheobronchitis produces a dry cough that later becomes productive as secretions increase. Chills, a sore throat, a slight fever, muscle and back pain, and substernal tightness generally precede the cough's onset. Rhonchi and wheezes are usually heard. Severe illness causes a fever of 101° to 102° F (38.3° to 38.9° C) and, possibly, bronchospasm, with severe wheezing and increased coughing.

Tularemia.Signs and symptoms of tularemia following inhalation of the organism include the abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Diagnostic tests.Pulmonary function tests (PFTs) and bronchoscopy may stimulate cough receptors and trigger coughing.

Treatments.Irritation of the carina during suctioning or deep endotracheal or tracheal tube placement can trigger a paroxysmal or hacking cough. Intermittent positive-pressure breathing or spirometry can also cause a nonproductive cough. Some inhalants, such as pentamidine, may stimulate coughing.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Cough, productive: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Actinomycosis.Actinomycosis begins with a cough that produces purulent sputum. A fever, weight loss, fatigue, weakness, dyspnea, night sweats, pleuritic chest pain, and hemoptysis may also occur.

Aspiration pneumonitis.Aspiration pneumonitis causes coughing that produces pink, frothy and, possibly, purulent sputum. The patient also has marked dyspnea, a fever, tachypnea, tachycardia, wheezing, and cyanosis.

Bronchiectasis.The chronic cough of bronchiectasis produces copious, mucopurulent sputum that has characteristic layering (top, frothy; middle, clear; bottom, dense with purulent particles). The patient has halitosis; his sputum may smell foul or sickeningly sweet. Other characteristic findings include hemoptysis, persistent coarse crackles over the affected lung area, occasional wheezing, rhonchi, exertional dyspnea, weight loss, fatigue, malaise, weakness, a recurrent fever, and late-stage finger clubbing.

Bronchitis (chronic).Bronchitis causes a cough that may be nonproductive initially. Eventually, however, it produces mucoid sputum that becomes purulent. Secondary infection can also cause mucopurulent sputum, which may become blood-tinged and foul-smelling. The coughing, which may be paroxysmal during exercise, usually occurs when the patient is recumbent or rises from sleep.

The patient also exhibits prolonged expirations, increased use of accessory muscles for breathing, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea, scattered rhonchi, coarse crackles (which can be precipitated by coughing), and late-stage clubbing.

Chemical pneumonitis.Chemical pneumonitis causes a cough with purulent sputum. It can also cause dyspnea, wheezing, orthopnea, a fever, malaise, and crackles; mucous membrane irritation of the conjunctivae, throat, and nose; laryngitis; or rhinitis. Signs and symptoms may increase for 24 to 48 hours after exposure, then resolve; if severe, however, they may recur 2 to 5 weeks later.

Common cold.When the common cold causes productive coughing, the sputum is mucoid or mucopurulent. Early indications include a dry hacking cough, sneezing, a headache, malaise, fatigue, rhinorrhea (watery to tenacious, mucopurulent secretions), nasal congestion, a sore throat, myalgia, and arthralgia.

Lung abscess (ruptured).The cardinal sign of a ruptured lung abscess is coughing that produces copious amounts of purulent, foul-smelling and, possibly, blood-tinged sputum. A ruptured abscess can also cause diaphoresis, anorexia, clubbing, weight loss, weakness, fatigue, a fever with chills, dyspnea, a headache, malaise, pleuritic chest pain, halitosis, inspiratory crackles, and tubular or amphoric breath sounds. The patient's chest is dull on percussion on the affected side.

Lung cancer.One of the earliest signs of bronchogenic carcinoma is a chronic cough that produces small amounts of purulent (or mucopurulent), blood-streaked sputum. In a patient with bronchoalveolar cancer, however, coughing produces large amounts of frothy sputum. Other signs and symptoms include dyspnea, anorexia, fatigue, weight loss, chest pain, a fever, diaphoresis, wheezing, and clubbing.

Nocardiosis.Nocardiosis causes a productive cough (with purulent, thick, tenacious, and possibly blood-tinged sputum) and fever that may last several months. Other findings include night sweats, pleuritic pain, anorexia, malaise, fatigue, weight loss, and diminished or absent breath sounds. The patient's chest is dull on percussion.

North American blastomycosis.North American blastomycosis is a chronic disorder that produces coughing that's dry and hacking or produces bloody or purulent sputum. Other findings include pleuritic chest pain, a fever, chills, anorexia, weight loss, malaise, fatigue, night sweats, cutaneous lesions (small, painless, nonpruritic macules or papules), and prostration.

Plague(Yersinia pestis).The pneumonic form of plague may be contracted from person-to-person through direct contact via the respiratory system or through biological warfare from aerosolization and inhalation of the organism. The onset is usually sudden with chills, a fever, a headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pneumonia.Bacterial pneumonia initially produces a dry cough that becomes productive. Associated signs and symptoms develop suddenly and include shaking chills, a high fever, myalgia, headache, pleuritic chest pain that increases with chest movement, tachypnea, tachycardia, dyspnea, cyanosis, diaphoresis, decreased breath sounds, fine crackles, and rhonchi.

Mycoplasma pneumonia may cause a cough that produces scant blood-flecked sputum. Typically, however, a nonproductive cough starts 2 or 3 days after the onset of malaise, a headache, a fever, and a sore throat. Paroxysmal coughing causes substernal chest pain. Patients may develop crackles, but generally don't appear seriously ill.

Psittacosis.As psittacosis progresses, the characteristic hacking cough, nonproductive at first, may later produce a small amount of mucoid, blood-streaked sputum. The infection may begin abruptly, with chills, a fever, a headache, myalgia, and prostration. Other signs and symptoms include tachypnea, fine crackles, chest pain (rare), epistaxis, photophobia, abdominal distention and tenderness, nausea, vomiting, and a faint macular rash. Severe infection may produce stupor, delirium, and coma.

Pulmonary coccidioidomycosis.Pulmonary coccidioidomycosis causes a nonproductive or slightly productive cough with a fever, occasional chills, pleuritic chest pain, a sore throat, a headache, backache, malaise, marked weakness, anorexia, hemoptysis, and an itchy macular rash. Rhonchi and wheezing may be heard. The disease may spread to other areas, causing arthralgia, swelling of the knees and ankles, and erythema nodosum or erythema multiforme.

Pulmonary edema.Severe, pulmonary edema, which is a life-threatening disorder, causes a cough that produces frothy, bloody sputum. Early signs and symptoms include exertional dyspnea; paroxysmal nocturnal dyspnea, followed by orthopnea; and coughing, which may be nonproductive initially. Others include a fever, fatigue, tachycardia, tachypnea, dependent crackles, and a ventricular gallop. As the patient's respirations become increasingly rapid and labored, he develops more diffuse crackles and a productive cough, anxiety, restlessness, worsening tachycardia and, possibly, arrhythmias. His skin becomes cold, clammy, and cyanotic; his blood pressure falls; and his pulse becomes thready.

Pulmonary embolism.Pulmonary embolism is a life-threatening disorder that causes a cough that may be nonproductive or may produce blood-tinged sputum. Usually, the first symptom of a pulmonary embolism is severe dyspnea, which may be accompanied by angina or pleuritic chest pain. The patient experiences marked anxiety, a low-grade fever, tachycardia, tachypnea, and diaphoresis. Less-common signs include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and jugular vein distention. The patient may also have a pleural friction rub, diffuse wheezing, crackles, chest dullness on percussion, decreased breath sounds, and signs of circulatory collapse.

Pulmonary tuberculosis (TB).Pulmonary TB causes a mild to severe productive cough along with some combination of hemoptysis, malaise, dyspnea, and pleuritic chest pain. Sputum may be scant and mucoid or copious and purulent. Typically, the patient experiences night sweats, easy fatigability, and weight loss. His breath sounds are amphoric. He may have chest dullness on percussion and, after coughing, increased tactile fremitus with crackles.

Silicosis.A productive cough with mucopurulent sputum is the earliest sign of silicosis. The patient also has exertional dyspnea, tachypnea, weight loss, fatigue, general weakness, and recurrent respiratory infections. Auscultation reveals end-inspiratory, fine crackles at the lung bases.

Tracheobronchitis.Inflammation initially causes a nonproductive cough that later—following the onset of chills, a sore throat, a slight fever, muscle and back pain, and substernal tightness—becomes productive as secretions increase. Sputum is mucoid, mucopurulent, or purulent. The patient typically has rhonchi and wheezes; he may also develop crackles. Severe tracheobronchitis may cause a fever of 101° to 102° F (38.3° to 38.9° C) and bronchospasm.

Other causes

Diagnostic tests.Bronchoscopy and pulmonary function tests (PFTs) may increase productive coughing.

Drugs.Expectorants increase productive coughing. These include ammonium chloride, calcium iodide, guaifenesin, iodinated glycerol, potassium iodide, and terpin hydrate.

Respiratory therapy.Intermittent positive-pressure breathing, nebulizer therapy, and incentive spirometry can help loosen secretions and cause or increase productive coughing.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

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