Cough, productive

Cough, productive: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses

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, although it’s usually a reflexive response to stimulation of the airway mucosa.

Usually due to a cardiovascular or respiratory disorder, productive coughing 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 is an additional cause. The most common cause of chronic productive coughing is cigarette smoking, which produces mucoid sputum ranging in color from clear to yellow to brown.

Emergency Actions

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 severe 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

When the patient’s condition permits, ask when the cough began, and find out how much sputum he’s coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [88.7 ml] of sputum per day.) At what time of day does he cough up the most sputum? Does his sputum production have any relationship to what or when he eats, or to his activities or 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 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 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?

Physical assessment

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 for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for pleural friction rub and abnormal breath sounds — rhonchi, crackles, or wheezes.

Medical causes

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.

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-ray, 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, administer expectorants, but don’t expect to give 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 use 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 facilitate maximum 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: 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.

More About This Book: Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1

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