Cough, productive
Productive coughing is the body’s mechanism for clearing airway passages of accumulated secretions that normal mucociliary action doesn’t remove. It’s a sudden, forceful, noisy expulsion of air (from the lungs) that contains sputum or blood (or both). The sputum’s color, consistency, and odor provide important clues about the patient’s condition. A productive cough can occur as a single cough or as paroxysmal coughing, and it can be voluntarily induced but is usually a reflexive response to stimulation of the airway mucosa.
Usually due to a cardiovascular or respiratory disorder, a productive cough commonly results from an acute or chronic infection that causes inflammation, edema, and increased mucus production in the airways. However, this sign can also result from acquired immunodeficiency syndrome. Inhalation of antigenic or irritating substances or foreign bodies also can cause a productive cough. In fact, the most common cause of chronic productive coughing is cigarette smoking, which produces mucoid sputum ranging in color from clear to yellow to brown.
Many patients minimize or overlook a chronic productive cough or accept it as normal. Such patients may not seek medical attention until an associated problem—such as dyspnea, hemoptysis, chest pain, weight loss, or recurrent respiratory tract infections—develops. The delay can have serious consequences because productive coughing is associated with several life-threatening disorders and can also herald airway occlusion from excessive secretions.
Emergency interventions
A patient with a productive cough can develop acute respiratory distress from thick or excessive secretions, bronchospasm, or fatigue, so examine him before you take his history. Take vital signs and check the rate, depth, and rhythm of respirations. Keep his airway patent, and be prepared to provide supplemental oxygen if he becomes restless or confused, or if his respirations become shallow, irregular, rapid, or slow. Look for stridor, wheezing, choking, or gurgling. Be alert for nasal flaring and cyanosis.
A productive cough may signal a life-threatening disorder. For example, coughing due to pulmonary edema produces thin, frothy, pink sputum, and coughing due to an asthma attack produces thick, mucoid sputum.
History and physical examination
When the patient’s condition permits, ask when the cough began and how much sputum he’s coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Is his sputum production affected by what or when he eats, his activities, or his environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.
How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel any pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?
Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants such as silicone?
Examine the patient’s mouth and nose for congestion, drainage, or inflammation. Note his breath odor: Halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate it for tenderness, masses, and enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss it for dullness, tympany, or flatness. Finally, auscultate for pleural friction rub and abnormal breath sounds, including rhonchi, crackles, or wheezing. (See Productive cough: Causes and associated findings, pages 206 and 207.)
Medical causes
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.
Special considerations
Avoid taking measures to suppress a productive cough because retention of sputum may interfere with alveolar aeration or impair pulmonary resistance to infection. Expect to give a mucolytic and an expectorant, and increase the patient’s intake of oral fluids to thin his secretions and increase their flow. In addition, you may give a bronchodilator to relieve bronchospasms and open airways. An antibiotic may be ordered to treat underlying infection.
Humidify the air around the patient; this will relieve mucous membrane inflammation and help loosen dried secretions. Provide pulmonary physiotherapy, such as postural drainage with vibration and percussion, to loosen secretions. Aerosol therapy may be necessary.
Provide the patient with uninterrupted rest periods. Keep him from using respiratory irritants. If he’s confined to bed rest, change his position often to promote the drainage of secretions.
Prepare the patient for diagnostic tests, such as chest X-rays, bronchoscopy, a lung scan, and pulmonary function tests. Collect sputum specimens for culture and sensitivity testing.
Pediatric pointers
Because his airway is narrow, a child with a productive cough can quickly develop airway occlusion and respiratory distress from thick or excessive secretions. Causes of a productive cough in children include asthma, bronchiectasis, bronchitis, acute bronchiolitis, cystic fibrosis, and pertussis.
When caring for a child with a productive cough, expect to administer an expectorant, but not a cough suppressant. To soothe inflamed mucous membranes and prevent drying of secretions, provide humidified air or oxygen. Remember, high humidity can induce bronchospasm in a hyperactive child or produce overhydration in an infant.
Geriatric pointers
Always ask elderly patients about a productive cough because this sign may indicate a serious acute or chronic illness.
Patient counseling
Encourage the patient not to smoke because doing so can aggravate his condition. Explain that quitting even after decades of smoking is helpful. Teach him how to breathe deeply, to cough effectively and, if appropriate, to splint his incision when he coughs. Tell him to sit or stand upright when coughing, if possible, to maximize chest expansion. Teach the patient and his family how to use chest percussion to loosen secretions.
Tell the patient to cover his mouth and nose with a tissue when he coughs and to dispose of contaminated tissues properly, to protect himself and others from the cough and secretions. Be sure to provide a container for tissues and sputum.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Persistent cough
Read excerpts from these other book chapters related to Persistent cough:
Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Persistent cough
» Next page: Hemoptysis (Professional Guide to Signs & Symptoms (Fifth Edition))
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