Cough, nonproductive

Cough, nonproductive: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)

A nonproductive cough is a noisy, forceful expulsion of air from the lungs that doesn’t yield sputum or blood. 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.

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.

Someone with a chronic nonproductive cough may downplay or overlook it or accept it as normal. In fact, he generally won’t seek medical attention unless he has other symptoms. A foreign body in a child’s external auditory canal may result in a cough. Always examine the child’s ears.

History and physical examination

Ask the patient when his cough began and whether any 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 any pain associated with coughing, breathing, or activity, when did it begin and 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; recent exposure to irritating fumes, chemicals, or smoke; and recent travel to foreign countries.

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 wheezing or “crowing” noises that 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, or 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 rub, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, or masses, and auscultate it for abnormal bowel sounds.

Medical causes

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.

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 administer an antitussive and a sedative to suppress the cough.

To relieve mucous membrane inflammation and dryness, humidify the air in the patient’s room, or instruct him to use a humidifier at home. Tell him to avoid using aerosols, powders, and other respiratory irritants—especially cigarettes. Make sure that the patient receives adequate fluids and nutrition.

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 ages 6 months and 4 years. Nonproductive coughing can also result from several disorders that commonly affect infants and children. In 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. In bacterial pneumonia, a nonproductive, hacking cough arises suddenly and becomes productive in 2 to 3 days. Acute bronchiolitis, which has a peak incidence at age 6, produces 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.

A child with measles typically 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. Airway hyperactivity causes a chronic nonproductive cough that increases with exercise or exposure to cold air. Psychogenic coughing may occur when a child is under stress, emotionally stimulated, or seeking attention.

Geriatric pointers

Always ask elderly patients about a nonproductive cough because it may be an indication of a 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 in the presence of airway irritants such as paint fumes and dust.

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.

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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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