Cough, nonproductive
Cough, nonproductive: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
A nonproductive cough is a noisy, forceful expulsion of air from the lungs that doesn’t yield sputum. It’s one of the most common complaints of patients with respiratory disorders.
Coughing is a necessary protective mechanism that clears airway passages. However, a nonproductive cough is ineffective and can cause damage, such as airway collapse or rupture of alveoli or blebs. A nonproductive cough that later becomes productive is a classic sign of progressive respiratory disease.
The cough reflex generally occurs when mechanical, chemical, thermal, inflammatory, or psychogenic stimuli activate cough receptors. (See Reviewing the cough mechanism.) However, external pressure — for example, from subdiaphragmatic irritation or a mediastinal tumor — can also induce it, as can voluntary expiration of air, which occasionally occurs as a nervous habit. Certain drugs, such as angiotensin-converting enzyme inhibitors, may also cause a nonproductive cough.
A nonproductive cough may occur in paroxysms and can worsen by becoming more frequent. An acute cough has a sudden onset and may be self-limiting; a cough that persists beyond 1 month is considered chronic and commonly results from cigarette smoking.
History
Ask the patient when his cough began and whether body position, time of day, or specific activity affects it. How does the cough sound — harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack years”). Next, ask about the frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or activity, when did it begin? Where is it located?
Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Also, ask about recent changes in his appetite, weight, exercise tolerance, or energy level and recent exposure to irritating fumes, chemicals, or smoke.
Physical assessment
As you’re taking his history, observe the patient’s general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note whether he’s cyanotic or has clubbed fingers or peripheral edema.
CULTURAL CUE:Because of the fear of being known as someone with tuberculosis (TB), the patient may be reluctant to provide information about his signs and symptoms such as cough. Ask the patient at risk for TB — those born in another country, those in contact with acute TB, and those with high-risk behaviors — about potential TB exposure.
Next, perform a physical examination. Start by taking the patient’s vital signs. Check the depth and rhythm of his respirations, and note if wheezing or “crowing” noises occur with breathing. Feel the patient’s skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, and signs of infection. Inspect his neck for distended veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.
Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rubs, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel sounds.
Medical causes
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.
Special considerations
A nonproductive, paroxysmal cough may induce life-threatening bronchospasm. The patient may need a bronchodilator to relieve his bronchospasm and open his airways. Unless he has chronic obstructive pulmonary disease, you may have to give an antitussive and a sedative to suppress the cough. To relieve mucous membrane inflammation and dryness, humidify the air in the patient’s room.
As indicated, prepare the patient for diagnostic tests, such as X-rays, a lung scan, bronchoscopy, and pulmonary function tests.
Pediatric pointers
A nonproductive cough can be difficult to evaluate in infants and young children because it can’t be voluntarily induced and must be observed.
A sudden onset of paroxysmal nonproductive coughing may indicate aspiration of a foreign body — a common danger in children, especially those between 6 months and 4 years old.
Nonproductive coughing can also result from several disorders that affect infants and children. With asthma, a characteristic nonproductive “tight” cough can arise suddenly or insidiously as an attack begins. The cough usually becomes productive toward the end of the attack. With bacterial pneumonia, a nonproductive, hacking cough arises suddenly and becomes productive in 2 to 3 days. Acute bronchiolitis has a peak incidence at age 6, with paroxysms of nonproductive coughing that become more frequent as the disease progresses. Acute otitis media, which is common in infants and young children because of their short eustachian tubes, also produces nonproductive coughing.
Typically, a child with measles has a slight, nonproductive, hacking cough that increases in severity. The earliest sign of cystic fibrosis may be a nonproductive, paroxysmal cough from retained secretions. Life-threatening pertussis produces a cough that becomes paroxysmal, with an inspiratory “whoop” or crowing sound.
In addition, airway hyperactivity causes a chronic nonproductive cough that increases with exercise or exposure to cold air. Psychogenic coughing may occur when the child is under stress, emotionally stimulated, or seeking attention. A foreign body in a child’s external auditory canal may result in a cough, so always examine the child’s ears.
Geriatric pointers
Always ask elderly patients about nonproductive coughing because it may be an indication of serious acute or chronic illness.
Patient counseling
Explain to the patient why nonproductive coughs should be suppressed and productive coughs encouraged. Encourage the patient to use a respirator (protective mask) in the presence of airway irritants such as paint fumes and dust. Instruct him to use a humidifier at home. Tell him to avoid using aerosols, powders, or other respiratory irritants — especially cigarettes. Make sure that the patient receives adequate fluids and nutrition.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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