Cough - Productive

Initial history of cough should include an assessment of the production of sputum, and the quantity, quality, and circumstances of the sputum production and coughing episodes. Additionally, associated history and physical findings, with particular attention to inciting factors such as history of smoking, farm work, allergen exposure, etc., are important in identifying the etiology as well. Culture and Gram stain of the sputum is necessary in all but the most obvious cases of productive cough such as upper respiratory infection.

Differential Diagnosis

• 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

Workup and Diagnosis

• Complete history and physical examination
  –Note acute (<3 weeks) versus chronic or recurrent
• Initial tests may include CBC, pulse oximetry, ESR, peak flow measurements, PPD, chest X-ray, blood cultures, sputum Gram stain and culture, and acid-fast stain for tuberculosis
• Pulmonary function tests with or without methacholine challenge
• Chest CT and/or sputum cytology if patient has concerning symptoms (e.g., weight loss, hemoptysis, fever)
• Initial empiric treatment for postnasal drip (antihistamine, decongestant, nasal steroids)
• Consider CT of sinuses or nasolaryngoscopy to evaluate for sinusitis
• Consider bronchoscopy with possible bronchoalveolar lavage and/or biopsy

Treatment

• Cessation of cigarette smoking
• Administer supplemental O₂ if necessary
• Postnasal drip: Treat underlying etiology (e.g., antibiotics for sinusitis, antihistamines and/or inhaled steroids for allergies)
• Acute bronchitis: Inhaled β₂ agonists (e.g., albuterol); since most cases are of viral origin, antibiotics are usually not indicated; increased fluid intake; antitussive
• Pneumonia: Oral (e.g., macrolide, doxycycline, quinolone) or IV antibiotics (third-generation cephalosporin and a macrolide; or a second-generation quinolone)
• COPD: Inhaled bronchodilator therapy with β₂ agonists (e.g., albuterol) and anticholinergics (e.g., ipratropium); systemic corticosteroids; antibiotics (e.g., azithromycin, doxycycline) should be administered in severe exacerbations or secondary infections; noninvasive mechanical ventilation by CPAP or BiPAP may be necessary

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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