 1 Chest Pain
 2 coughing

One of the most frightening symptoms you can have. It is also difficult at times to assess the source of chest pain and whether it is life threatening. Each of these parts of the chest can cause chest pain: the heart, the lungs, the esophagus, muscle, bone, and skin. Also, because of the complex nerve distribution in the body, the cause of chest pain may come from sources not located in the chest. The stomach or other organs in the abdomen, for example, can cause chest pain.

Potentially life-threatening causes of chest pain - Heart attack (also known as an acute myocardial infarction): A heart attack occurs when blood flow to the arteries that supply the heart becomes blocked. With decreased blood flow, the muscle of the heart does not receive enough oxygen and begins to deteriorate.

Angina: Angina occurs when there is an imbalance between the oxygen demand of the heart and the amount delivered. Angina is different from a heart attack in that the arteries are not completely blocked. Also, permanent damage has not yet occurred to the heart.

Aortic dissection: The aorta is the main artery that supplies blood to the vital organs of the body (these are the brain, heart, kidneys, lungs, and intestines). An aortic dissection occurs when the inner lining of the aorta tears. Once the aorta is torn, blood flow to the major organs near the tear is disrupted.

Pulmonary embolus: A pulmonary embolus is a blood clot in one of the major blood vessels that supplies the lungs. It is a potentially life-threatening cause of chest pain but is not associated with the heart.

Spontaneous pneumothorax: This condition occurs when air enters the space between the chest wall and the lung tissue. Normally, negative pressure in the chest cavity allows the lungs to expand. When a spontaneous pneumothorax occurs, air enters the chest cavity. When the pressure balance is lost, the lung is unable to re-expand and remains collapsed.

Perforated viscus: Perforated viscus occurs when there is a disruption of the wall of any area of the gastrointestinal tract, which allows air to enter the abdominal cavity. Air in the abdominal cavity irritates the diaphragm, which can cause chest pain. Non?ife-threatening causes of chest pain

Acute pericarditis: This is an inflammation of the pericardium, which is the sac that covers the heart.

Mitral valve prolapse: MVP is an abnormality of one of the heart valves in which the leaves of the mitral valve bulge into the heart chamber during contraction. When this occurs, it is possible for a small amount of blood to flow in the opposite direction thereby causing a heart murmur.

Pneumonia: Pneumonia is an infection of the lung tissue that can cause chest pain, which occurs because of inflammation to the lining of the lungs.

Chest pain originating from the esophagus: Esophageal disorders can cause chest pain, which is an alarming symptom because it often mimics chest pain from a heart attack.

Gastroesophageal reflux disease (GERD) occurs when acidic digestive juices backflow from the stomach into the esophagus.

Esophagitis is an infection of the esophagus.

Esophageal spasm is defined as excessive, intensified, or uncoordinated contractions of the smooth muscle of the esophagus.

CAUSES - A heart attack may be caused by cholesterol build-up in the coronary arteries, blood clots, or spasm of the vessels that supply blood to the heart. Risk factors for a heart attack are high blood pressure, diabetes, smoking, high cholesterol, family history of heart attacks at young ages (younger than 60 years), previous heart attacks, male gender, postmenopausal women who are not taking hormone replacement therapy (estrogen), cocaine use, and obesity.

Angina may be caused by spasm of the arteries that supply the heart or by cholesterol build-up that affects blood flow but does not completely block the blood vessel.

Aortic dissection may be caused by conditions that damage the innermost lining of the aorta, such as uncontrolled high blood pressure, connective tissue diseases, cocaine use, advanced age, pregnancy, congenital heart disease, cardiac catheterization (a medical procedure), and the male gender.

A pulmonary embolus can be caused by use of birth control pills in conjunction with cigarette smoking, sedentary lifestyle, prolonged immobility, fracture of long bones of the legs, obesity, pregnancy, cancer, history or family history of blood clots, irregular heartbeat, heart attack, and congestive heart failure.

A spontaneous pneumothorax occurs when there is a disruption of the pressure balance across the chest wall. Risk factors are trauma to the chest, AIDS-related pneumonia, emphysema, severe asthma, cystic fibrosis, cancer, and marijuana and crack cocaine use.

A perforated viscus may be caused by trauma or indirect injury. Risk factors not related to trauma are untreated ulcers, prolonged or forceful vomiting, swallowing a foreign body, cancer, appendicitis, long-term steroid use, infection of the gallbladder, gallstones, and AIDS.

Pericarditis can be caused by a viral infection, a bacterial infection, cancer, connective tissue diseases, certain medications, radiation treatment, and chronic renal failure. One life-threatening complication of pericarditis is cardiac tamponade. Cardiac tamponade is an accumulation of fluid around the heart. This prevents the heart from effectively pumping blood to the body. Symptoms of cardiac tamponade include sudden onset of shortness of breath, fainting, and chest pain.

Mitral valve prolapse or MVP is thought to be an inherited birth disorder and affects up to 10% of the population, mostly women. People with connective tissue diseases and skeletal abnormalities (such as severe curvature or straightening of the spine or a concave chest) are at increased risk for this disorder. Pneumonia may be caused by viral, bacterial, or fungal infections of the lungs.

Chest pain originating from the esophagus may have several causes.

GERD may be caused by any factors that decrease the pressure on the lower part of the esophagus, decrease movement of the esophagus, or prolong emptying of the stomach. This condition may be brought on by consumption of high-fat foods, nicotine use, alcohol use, caffeine, pregnancy, certain medications (for examples, nitrates, calcium channel blockers, anticholinergics, estrogen, progesterone), diabetes, or scleroderma.

Esophagitis may be caused by yeast, fungi, viruses, bacteria, or irritation from medications.

Esophageal spasm is caused by excessive, intensified, or uncoordinated contractions of the smooth muscle of the esophagus. Spasm may be triggered by emotional upset or swallowing very hot or cold liquids.

SIGNS AND SYMPTOMS - Typical heart attack pain occurs in the mid to left side of the chest and may also extend to the left shoulder, the left arm, the jaw, the stomach, or the back. Other associated symptoms are shortness of breath, increased sweating, nausea, and vomiting.

Angina is classified as chest pain that is similar to that of a heart attack but occurs with increased exercise and is relieved by nitroglycerin taken under the tongue. Angina becomes life-threatening when pain occurs at rest, has increased in frequency or intensity, or is not relieved with at least 3 nitroglycerin tablets each given 5 minutes apart. This is considered to be unstable angina, which may be a warning sign of an impending heart attack.

The chest pain associated with aortic dissection occurs suddenly and is described as "ripping." The pain may radiate to the back or between the shoulder blades. Because the aorta supplies blood to the entire body, people may experience symptoms such as chest pain, shortness of breath, fainting, abdominal pain, or symptoms of stroke.

Symptoms of a pulmonary embolus are sudden onset of shortness of breath, rapid breathing, and sharp mid-chest pain, which increases with deep breaths. Signs and symptoms of pneumothorax are sudden onset of shortness of breath, sharp chest pain, rapid heart rate, and low blood pressure.

Perforated viscus comes on suddenly with severe abdominal, chest, or back pain or pain in both places. Abdominal pain may increase with movement or when breathing in and may be accompanied by a rigid, boardlike abdominal wall. The pain of pericarditis is typically described as a sharp or stabbing pain in the mid-chest area, worsened by deep breaths. This pain may mimic the pain of a heart attack, because it may radiate to the left side of the back or shoulder. One distinguishing factor is that the pain is worsened by lying flat and improved by leaning forward. When lying flat, the inflamed pericardium is in direct contact with the heart and causes pain. However, when leaning forward, there is a space between the pericardium and the heart. Prior to the onset of the chest pain, people may note having a recent cold, fever, shortness of breath, or pain when swallowing.

Although mitral valve prolapse is not usually associated with symptoms, people may epperience palpitations (feeling the heart beat) and chest pain. Chest pain associated with MVP differs from that of typical angina in that it is sharp, does not radiate, and is not related to physical exertion. Other associated symptoms include fatigue, lightheadedness, and shortness of breath. Anxiety also seems to be more common in people with MVP than in the general population. Complications of MVP include infection of the heart valves, migraine headaches, stroke or mini-stroke, and abnormal heart rhythms, which rarely cause sudden death. Pneumonia may cause chest pain from the strain of the chest wall muscles during prolonged or forceful coughing. With chest pain originating from the esophagus, symptoms depend on the source.

Symptoms of gastroesophageal reflux disease (GERD) include heartburn, painful swallowing, excessive salivation, dull chest discomfort, chest pressure, or severe squeezing pain across the mid chest. People may appear comfortable or may experience profuse sweating, pallor, nausea, and vomiting. Pain from GERD is often relieved with antacids.

Symptoms of esophagitis include difficulty swallowing, painful swallowing, or symptoms of GERD. The associated chest pain comes on suddenly and is not relieved by antacids. The pain of esophageal spasm is usually intermittent and dull. It is located in the mid chest and may radiate to the back, neck, or shoulders.

HOME CARE - If you suspect that you may be having a heart attack, call 911 for emergency services or go to the nearest hospital Emergency Department.

If you think you are having a heart attack, it is advisable to chew at least 2 baby aspirin or 1/2 of a regular aspirin?hat's a total of 160 mg. It is important to chew the aspirin as opposed to swallowing it because chewing decreases the time the medicine is delivered to the body. Aspirin chewed in the early stages of a heart attack may reduce the possibility of death by 23%. If you have nitroglycerin tablets available, place one under your tongue. This may aid in increasing blood flow to blocked or narrowed arteries.

If you have been previously diagnosed with angina and your doctor has prescribed nitroglycerin (sublingual, which means you place the tablets under your tongue), try placing one tablet under your tongue.

If your chest pain continues in the next 5 minutes, you should take another tablet under the tongue.

If after 3 sublingual nitroglycerin tablets, you do not have relief of the chest pain, you should immediately call 911 or go to the nearest Emergency Department. Pain from GERD is often relieved with antacids. Even if your pain goes away, you may not safely assume you are not having a heart attack. Esophagitis and esophageal spasm are typically not relieved with antacids.

WHEN TO CALL THE DOCTOR - If you have any symptoms of chest pain, especially if the pain is new, you may call your doctor. However, it may be best to call 911 for emergency services or go to the nearest Emergency Department. Because so many causes of chest pain often mimic a heart attack or other life-threatening illnesses, it is best to seek medical attention as quickly as possible.

WHEN TO GO TO THE HOSPITAL - If you suspect that you may be having a heart attack or any symptom of chest pain, call 911 or go to the nearest hospital's Emergency Department. Do not attempt to drive yourself.

When chest pain may be caused by a heart attack, time is muscle. If you are having a heart attack, the longer you wait to receive evaluation and treatment, the more heart muscle is damaged. If there is something serious going on that is causing your chest pain, doctors can choose from many effective early interventions to reduce your chances of dying, of becoming severely ill, and improving the long-term quality of your life.

What if it turns out not to be a heart attack? You won? know until the doctors check out the cause of your chest pain. Give yourself that peace of mind. If your chest pain is not life threatening, the doctor will be pleased that you came for evaluation. Whatever the outcome, you can always make the correct choice by going to the Emergency Department. There is no need to feel awkward or embarrassed.

The symptoms of a heart attack and other life-threatening conditions are similar. So are the symptoms of serious conditions that are not life threatening. Be reassured that you are making the right decision and feel comfortable seeking emergency care whenever you experience chest pain.

PHYSICIAN DIAGNOSIS - Doctors use 3 basic procs to decide if you are having a heart attack. The first is the history of symptoms that you tell the doctor. The second is an ECG, which is an electrical tracing of the heart? activity. On the ECG, it may be possible to tell which vessels in the heart are blocked or narrowed.

The third component is the measurement of enzymes given off by the heart when it does not receive enough oxygen. These enzymes are detectable via blood tests. Angina is diagnosed by the same methods doctors use to diagnose heart attacks. However, the results do not indicate permanent damage. The diagnosis is made only after the possibility of a heart attack has been ruled out, usually by 3 sets of negative cardiac enzymes. Although the EKG may show abnormalities, these changes are often reversible. Another possible way to diagnose angina is by exercise or radionucleotide stress tests to identify any obstructed blood vessels to the heart.

The diagnosis of aortic dissection is based on history, chest x-ray, and other special imaging tests. On a chest x-ray, the aorta will have an abnormal contour or appear widened. Transesophageal echocardiography is a specialized ultrasound of the heart in which a probe is inserted into the esophagus. The technique is performed under sedation or general anesthesia. The dissection may be more specifically determined by a CT scan of the chest or angiography, which is a test that outlines the aorta and its branching vessels.

The diagnosis of pulmonary embolism is made from a variety of indirect sources. History, an arterial blood gas, EKG, chest x-ray, evidence of a clot in the leg, and ventilation-perfusion scans all contribute to the diagnosis of pulmonary embolism. An angiogram offers definitive diagnosis. Spontaneous pneumothorax is diagnosed by physical examination and chest x-ray. A CT scan may be helpful in locating a small pneumothorax.

A chest x-ray with the person upright or an abdominal x-ray while lying on the left side are ways to detect perforated viscus. X-rays in these positions allow air to rise to the diaphragm, where it can be detected. The person? history, physical exam, and other lab tests also assist in diagnosis. The diagnosis of acute pericarditis is usually made by history, serial EKGs, and echocardiography. Certain lab tests may be helpful in diagnosing the cause. Diagnosis of mitral valve prolapse is made by physical exam and an echocardiogram, which is a ultrasound of the heart. Anyone with this condition may also have a variety of abnormal findings on EKG. Pneumonia is diagnosed by history, physical examination, and chest x-ray. Chest pain originating from the esophagus is a diagnosis of exclusion. Diagnosis is made based on prior history, after ruling out heart causes and observing whether you get pain relief from antacids.

PHYSICIAN TREATMENT - The treatment for a heart attack is aimed at increasing blood flow by opening arteries blocked or narrowed by a blood clot. Medicines used to achieve this goal include aspirin, heparin, and thrombolytic agents. Other medications can be used to slow the heart rate, which decreases the workload of the heart. Surgery may be required if medical treatment is unsuccessful. This could include angioplasty or cardiac bypass.

Treatment of angina is directed at relieving chest pain that occurs as the result of reduced blood flow to the heart. This is primarily accomplished by the use of nitroglycerin, which dilates the coronary arteries. People with a known history of angina may be treated with nitroglycerin tablets or spray for 3 doses, each 5 minutes apart. If the pain remains, a continuous infusion of nitroglycerin by IV is used, and the person is admitted to the hospital and monitored to rule out a concurrent heart attack. People with suspected aortic dissection will often require medications that reduce blood pressure. This is accomplished by using medications that slow the heart rate and dilate the arteries. Close monitoring is required to avoid medication-induced hypotension (low blood pressure). Surgical repair is required for any dissection that involves the ascending portion of the aorta. Anyone with the presumed or documented diagnosis of pulmonary embolism (PE) requires admission to the hospital, supplemental oxygen, and medication to prevent the clotting of blood (heparin is often used for this purpose). If the PE is massive, destruction of the clot is achieved with clot-busting medications. For some people, surgery may be done to place an umbrella-like filter in a blood vessel to prevent blood clots from the lower extremities from moving to the lungs.

Treatment of spontaneous pneumothorax without associated symptoms of shortness of breath, rapid breathing, low oxygenation, or chest pain involves 6 hours of hospital observation and repeat chest x-rays. If the size of the pneumothorax remains unchanged, and the person has no symptoms, a follow-up in 24 hours may be arranged. If the symptoms develop, or the pneumothorax enlarges, catheter aspiration or chest tube insertion and hospital admission is indicated.

Any disruption of the intestinal tract, with a perforated viscus, is a potentially life-threatening emergency. Immediate surgery may be required. People with viral pericarditis usually respond to 7-21 days of therapy with nonsteroidal anti-inflammatory agents such as aspirin and ibuprofen. Another illness that may be the cause would be treated.

Treatment for mitral valve prolapse is usually conservative and involves medications to control palpitations and chest pain. When MVP is severe and does not respond to medical treatment, valve replacement is required. In addition, anyone diagnosed with MVP should receive antibiotics prior to any high-risk surgery or dental work. This will reduce the risk of endocarditis, which is an infection of the heart valves. Pneumonia is treated with antibiotics and pain medication for chest wall tenderness. The 3 major esophageal disorders that cause chest pain?ERD, esophagitis, and esophageal spasm?re treated with antacid therapy, antibiotic, antiviral, or antifungal medication, or medicines that relax the muscles of the esophagus or some combination of medications.

PROGNOSIS - Early medical intervention improves survival in potentially life-threatening illnesses involving chest pain.

Heart attack and unstable angina: Heart disease, which includes heart attacks and angina, is the leading cause of death for American adults. Almost 1 million people die each year from this disease. The prognosis for heart attack depends on the time it takes to get medical treatment, the region and extent of injury within the heart, and the presence of any other risk factors. Aortic dissection: Quick action in getting medical treatment is essential with aortic dissection. Death occurs in up to 20% of people who receive medical treatment without surgical intervention. Those who undergo surgery have a 7% death rate. Pulmonary embolism: Even with early treatment, 1 in 10 people with pulmonary embolism will die within the first hour. One-third will be diagnosed and treated with good outcome. Two-thirds go undiagnosed, and one-third of them will die. Spontaneous pneumothorax: 95% fully recover. Other illnesses causing pneumothorax and complications from the chest tube placement may prolong or worsen the course. Perforated viscus: With early detection and intervention, the prognosis for perforated viscus is good. Acute pericarditis: Although the course may vary with each person, an estimated 60% have complete recovery within 1 week while another 20% recover within 3 weeks. Only 3% of people have symptoms more than 3 weeks before resolution. For about 15% of people, symptoms return within a year.

Mitral valve prolapse: Overall, the outlook is good. The complication rate is low. Pneumonia: In young healthy adults, the prognosis for pneumonia is good with appropriate treatment. Prognosis is generally poorer in the elderly, in people with weakened immune systems such as those with AIDS. Chest pain originating from the esophagus: GERD affects approximately one-fourth of the adult population and has a very low death rate. Esophagitis may lead to ulcerations, scarring, or stricture formation. With the exception of possible perforation, which has a high death rate, the overall prognosis is good. Esophageal spasm has a good outcome.

PREVENTION - Prevention of heart attack and angina includes smoking cessation, exercise, diets low in cholesterol and saturated fats, control of diabetes and high blood pressure, and avoidance of obesity. Aortic dissection may be prevented with adequate blood pressure control. Prevention of pulmonary embolism includes smoking cessation in women older than 35 years who take oral contraceptive pills, avoidance of obesity, a physically active lifestyle, and preventive therapy after surgery, especially after orthopedic surgery. Smoking cessation decreases the risk of spontaneous pneumothorax. Risk of perforation with perforated viscus may be decreased with adequate treatment of ulcers and avoidance of foreign body ingestion. There is no true prevention for acute pericarditis and mitral valve prolapse. Effective handwashing and good hygiene will help reduce the transmission of infectious agents that can cause pneumonia. To prevent symptoms of GERD, avoid foods and other substances that aggravate the disease process: Avoid a high-fat diet, stop smoking, and decrease alcohol consumption. Also elevate the head of the bed and avoid eating 3 hours before bedtime.

FOLLOW-UP - No matter what the cause of chest pain, follow-up with your doctor is important to maintain a healthy life. OTHER CAUSES OF CHEST PAIN - Cocaine-induced chest pain: Cocaine causes the blood vessels in the body to constrict. This blood vessel constriction in the heart can cause decreased blood flow to the heart, which causes chest pain. Cocaine also accelerates the progression of atherosclerotic disease, which is a risk factor for a heart attack. Although cocaine can cause these changes in the body, the possibility of a heart attack cannot be ruled out without proper medical evaluation. Go to the nearest hosp Emergency Dept for medical attention.

Costochondritis: This is an inflammation of the cartilage between the ribs. Pain is typically located in the mid chest, with intermittently dull, sharp, and increased pain with deep breaths, movement, and deep touch. The mainstay of treatment is anti-inflammatory medications such as ibuprofen.

Herpes zoster: Herpes zoster is a reactivation of chicken pox (caused by the varicella virus). The pain of a viral herpes infection may precede the rash by 4-7 days. The rash is very painful and may last from months up to years. Symptoms are usually isolated to one side of the body along one nerve area. Risk factors include any condition in which the immune system is compromised such as advanced age, HIV, or cancer. Herpes zoster is highly contagious, especially 5 days prior to and 5 days after the appearance of the rash.

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Chest tightness; Chest discomfort; Chest pressure Definition - Pain, heaviness, pressure or discomfort in the chest. See also documents on stable angina, unstable angina, and variant angina.

Considerations - When faced with unexpected chest pain, it is normal for people to fear the worst, since chest pain is a symptom, which, to many people, means "heart attack." Nevertheless, chest pain can have many causes unrelated to the heart. A health care provider should evaluate any chest discomfort that is new or different. Furthermore, it is very important to note the other factors associated with chest pain (exact location, type of pain, radiation of pain, and other associated symptoms).

While it is true that heart disease is the #1 cause of death and disability in the U.S., chest pain caused by a heart condition is very rare in previously healthy men under 30 years of age or women under 40, and is uncommon for either sex before the age of 50. A shooting pain lasting a few seconds is common in a healthy person and is nothing to worry about; however, the sensation of a "catch" at the end of a deep breath is clinically important for, while it usually does not represent heart disease, it may be a symptom of pulmonary embolism (clot to the lung) which requires immediate evaluation by a physician. Yet, there are certain risk factors that can increase the probability of developing early heart disease. Some of these risk factors include: Family history of early heart disease, cigarette smoking, elevated cholesterol, high blood pressure, diabetes, cocaine use.

Chest pain that is caused by a heart problem may be mild or intense. Feelings of pressure or squeezing on the chest are often more prominent than actual pain which is usually located in the center of the chest, under the breastbone. It may also radiate to the back, jaw or shoulder (usually the left) and may be accompanied by nausea, sweating, dizziness, palpitations, or shortness of breath.

Stable angina (chest pain caused by temporary inadequacy of blood flow to the heart muscle) usually lasts 1 to 15 minutes and is provoked by exercise or stress and relieved by rest or nitroglycerin. Unstable angina is angina that either occurs at rest or is an increase in the frequency, severity, or duration of previously stable angina.

Angina and unstable angina can lead to an acute myocardial infarction (heart attack). The chest discomfort of a heart attack often is prolonged (longer than 15 or 20 minutes) and is unrelieved by rest or nitroglycerin; however, some patients, especially diabetics, can have a heart attack without feeling any chest discomfort at all. Their only symptoms might be shortness of breath, dizziness, or sweating.

Chest-wall pain (pain originating in the tissues of the chest-wall rather than the heart) can often be demonstrated by pressing a finger on the chest at the spot of discomfort, which reproduces or aggravates the pain. Heart and chest-wall pain can be present at the same time. Pleurisy (inflammation of the linings of the lungs) worsens with a deep breath or a cough while chest pain related to a heart problem usually does not. Hyperventilation, or panic attack, is a frequent cause of chest pain, especially in young people. Ulcer pain burns with an empty stomach and gets better with food. Conversely, gallbladder pain often becomes more intense after a meal.

Common causes: stable angina unstable angina acute MI (heart attack) pleurisy hyperventilation gastric ulcer cholecystitis cholelithiasis anxiety pneumonia costochondritis cough (especially if long-term) herpes zoster indigestion (heartburn, gastroesophageal reflux disease) mitral valve prolapse trauma with injury to the chest asthma pneumothorax pulmonary embolism (blood clot to the lungs) aortic dissection (a tear in the lining of the aorta)

Chest-wall pain is often associated with muscular strain, such as that resulting from unusual activity, or from coughing. It can be treated with over-the-counter pain medications. Treatments such as mentholated rubs, heat, and rest can help. If symptoms persist for more than 3 to 5 days, see your health care provider and be certain to follow the therapy prescribed by the health care provider for treating the underlying cause.

Call your health care provider if there is sudden onset of discomfort in the chest (in an adult). It is safer to assume that the chest pain has something to do with the heart and call the doctor. If it turns out to be a false alarm, nothing is lost. chest pain is associated with shortness of breath, an irregular pulse, sweating, dizziness, or if the pain is severe. known angina increases in severity, frequency, or duration; begins to occur at rest; or angina pain is unrelieved by nitroglycerin. chest-wall pain persists for longer than 3 to 5 days.

ANY CHEST PAIN THAT IS NEW OR DIFFERENT IS WORTH A VISIT TO YOUR HEALTH CARE PROVIDER!

What to expect - Emergency measures will be taken if necessary. The medical history will be obtained and a physical examination performed. At that time, vital signs (temperature, pulse, rate of breathing, blood pressure) will be monitored. The physical examination will include emphasis on the chest wall, lungs, and heart. Hospitalization will be required in difficult or advanced cases or when the cause of the pain is unclear.

Medical history questions documenting chest pain in detail may include: Location Is the pain between the shoulder blades (interscapular)? Is it under the sternum (breastbone, substernal)? Does the pain change location? Is it on one side only (unilateral)? Which side? Quality How would you describe the pain? Severe Tearing or ripping Sharp or stabbing Burning Squeezing, constricting, tight, pressure-like, or crushing Aching Dull Heavy sensation Time pattern Did the pain begin recently? Does it occur repeatedly (recurrent)? Does the pain occur at the same time each day? Does it come on suddenly? Is it worse or more frequent at night? Is the pain getting worse; increasing in severity? Is the pain more frequent or lasting longer than previous episodes?

How long does the pain last? (The pain is continuous for how long on each episode?) Radiation Does the pain go from your chest into your shoulder? From your chest into your arm? From your chest into your neck? From your chest into your back? From your chest around the lower chest wall? From your chest into your jaw? Aggravating factors Is the pain worse when you are breathing deeply? When you are coughing? When you are eating? When you are bending or stooping? When you are under mental stress? When you are moving around or changing position? When you are exercising? When you have exercised less than in the recent past? Relieving factors Is the pain better after you rest? Is it completely relieved or just less pain? Is the pain better after you take nitroglycerin (NTG) medication? After you drink milk or take antacids? After belching (eructation)? Other

What other symptoms are also present? Diagnostic tests that may be performed include: Blood tests (such as LDH, LDH isoenzymes, CPK, CPK isoenzymes, Troponin, CBC and blood differential) cardiac catheterization ECG Exercise ECG Lung scan X-rays of the chest

After seeing your health care provider, you may want to add a diagnosis related to chest pain to your personal medical record.

Note: More complex tests may be required depending on the difficulty of diagnosis or the suspected cause of the chest pain.

 - Intro - Patients with chest pain are the leading cause of malpractice losses to emergency physicians and internists. Failure to diagnose myocardial infarction (MI) accounts for 10 percent of the cases filed against emergency physicians. Judgments and settlements in these cases total 25 percent of the dollars paid out to claimants. In a recent study, all discharged chest pain patients came back for further testing the next day. Five percent of MI patients had been sent home. What factors lead to inappropriate discharge? Physician inexperience (less than 3 years practice) and atypical presentation. Myocardial infarction may become an even bigger cause of litigation in the future. Because thrombolytics can lower mortality and improve cardiac function, suits will be filed by patients who have lost the opportunity to receive this therapy. Back to Index.

Initial Stabilization - Patients presenting to the emergency department with chest pain should be triaged immediately to the treatment area. Evaluation and stabilization should begin at once. The patient with acute chest pain should be approached in much the same manner as the multiple-trauma patient: Stabilize the patient and treat life-threatening conditions while obtaining the historical and physical exam information. Any patient who presents in obvious distress, has abnormal vital signs, or who volunteers a history of cardiac-compatible chest pain, should be immediately stabilized with oxygen, cardiac monitor, and IV. In most emergency departments, several care-givers will stabilize the patient, simultaneously placing nasal oxygen, cardiac monitor, and IV, and obtaining vital signs. If only one person is available to care for the patient, place oxygen first, to obtain its rapid therapeutic benefits. Most protocols use 4 liters by nasal cannula. Next attach the cardiac monitor (at this point, the most likely urgent need is cardioversion of an evolving arrhythmia such as V-tach). Now start the IV at a keep-open rate. The choice of D5W or normal saline is hotly debated, and probably makes no practical difference. Once the IV is running, take vital signs. Just as with trauma care, act to correct a life-threatening abnormality found during initial stabilization before progressing on with the work-up. For example, if V-tach is seen when placing the cardiac monitor, the physician takes action: he checks skin color, skin temperature, and radial pulse; he decides the patient is unstable, and orders an unsynchronized counter-shock. No vital signs; no 12-lead ECG  when the clinical threshold for action is reached, the physician should act. As a second example, suppose initial vital signs show significant hypotension. The physician immediately obtains the specific information he needs to act: he quickly looks at the neck veins, listens for rales, and checks the heart tones. Then he intervenes. For example, he might order a saline fluid challenge. Acting on information as it is received continues during the history and physical portion of the evaluation. Once the physician knows the pain is cardiac-compatible, he should not wait until after the Babinski reflexes are tested to give nitroglycerin. Nitroglycerin should be ordered as soon as the indications for (and lack of contraindications to) its use are established. Similarly, morphine is given when its determined that the nitroglycerin has been ineffective. These interventions should be considered part of the stabilization process. Back to Index.

Obtaining the Chest Pain History - Most of the important decisions the physician must make will be based on the history of the chest pain. When physical findings and lab tests are non-specific, as they often are in chest pain patients, the history alone will decide whether the patient is admitted to the hospital. The history looks for clues to life-threatening causes of chest pain: myocardial infarction, unstable angina, pulmonary embolism, pneumothorax, mediastinitis (esophageal rupture), and aortic dissection. Pertinent negatives (absence of symptoms that would make any of these diagnoses more likely) are an important part of the historical documentation. Obtain an accurate description of the pains onset, duration, severity, nature, location, aggravating or alleviating factors, and prior episodes. Specifically note the presence or absence of radiation of pain and any associated symptoms (nausea, shortness of breath, sweats) and their severity. Have the patient describe how the pain started. The pain of angina or myocardial infarction builds up, while aortic dissection and pulmonary embolism tend to cause instant severe pain. What was the patient doing? Angina at rest has a very different prognosis from angina while running up the stairs. Pain starting as the patient swallows a bolus of food suggests esophageal pain. The duration of the pain also helps establish the cause. Pain that lasts only a second or two, or pain that is constant for many days, is almost never cardiac pain. Angina typically lasts five to 15 minutes  pain for less than a minute is unlikely to be angina. The nature of the pain can suggest the diagnosis. If the patient doesnt volunteer a description, ask him what the pain reminds him of: burning, squeezing, pressure, tearing, stabbing. A description as poking, pinching, or stabbing usually means chest wall pain. Hyperventilation often causes poking pains that are migratory and unrelated to motion. Victims of aortic dissection will often describe a well-localized tearing type pain. However, when the patient has pain from the internal organs (heart, esophagus, gallbladder), the nature of the pain is unhelpful at best, and is often misleading: a victim of myocardial infarction may complain of heartburn, while the patient with esophagitis may complain of a squeezing sensation. Ask about the location of the pain. Pain from the internal organs of the chest tends to be felt over a wide area. But try to make the patient commit to a location and size of the area of pain. If the pain is small in area, located over the chest wall, and corresponds to an area of tenderness, its probably chest wall pain. Work-up of the patient who has several small and migratory locations of pain like tiny pins usually will reveal no organic disease. Question the patient about radiation of the pain. Chest pain from reflux esophagitis, ulcer, or gallbladder will usually have an epigastric component, but rarely radiates to the arms. Aortic dissection usually hurts in the back. And of course, pain radiating to the jaw, shoulders, or arms suggests (but is not diagnostic of) cardiac pain. Ask what things affect the pain. Ask specifically whether breathing makes it worse. Three-fourths of pulmonary embolism victims will have pleuritic pain. Worsening with position or with motion of the arms is expected with chest wall pain, but can occur with any cause of pleuritic pain, such as pericarditis or pleurisy. If resting stops the pain, ask how long it takes to go away. Angina will usually take a minute to ease, while other activity-related pains often stop instantly with rest.

Prior episodes of identical pain are helpful. A history of multiple episodes of the same pain, lasting hours each time, virtually excludes myocardial infarction. Ask about any constant factors for these past episodes, such as: relation to meals or time of day, duration of pain, and factors affecting the pain. Be sure to ask if there has been any previous work-up. When the history seems confusing, you may be dealing with more than one cause of chest pain. A patient with angina on exertion also may have musculoskeletal chest pain with activity, and may have lumped these pains into one. A patient with an MI after a meal may have had past episodes of heartburn or gallbladder pain after meals. Careful questioning about the exact sensations of specific episodes can help you avoid a mistaken diagnosis. Ask for risk factors of cardiovascular disease or pulmonary embolism. Your chart should list them as pertinent negatives. Your decisions wont be based on any single factor in the history. The entire history snapshot is required. For example, hurts on my ribs when I move my arm doesnt automatically mean musculoskeletal chest pain. It must be considered as part of the 42 y.o. female smoker on BCP with fractured leg in cast whos short of breath, hurts to breathe and hurts in ribs when she moves her arm picture. Both absolute and relative contraindications to thrombolytic therapy should be sought. Ask specifically about recent melena, active ulcer disease, recent major surgery, stroke, or brain tumors or vascular malformations. If the patient is diabetic, ask about retinal vascular disease. As you conclude the history, you may already have decided that the patient will be admitted. Back to Index.

The Physical Exam in Chest Pain - As experienced physicians know, the most important part of the physical exam of the chest pain patient is the first lookover. Poor skin color, diaphoresis, tachypnea, and anxious expression alert the physician to a potentially lethal process. The Gestault of the patient serves as a highly accurate severity-O-meter. Evaluate the meaning of the vital signs. Tachycardia is non-specific  it can suggest shock, severe pain, or physical stress  but it serves to alert the physician. Tachycardia is particularly likely with pulmonary embolism. Blood pressure should be checked in both arms. A difference of over 20 mm Hg systolic suggests aortic dissection  and will be present in about two thirds of cases. Hypotension may suggest massive PE or cardiac shock. Fever may suggest pneumonia or mediastinitis as the cause of chest pain. Tachypnea may simply reflect severity, or can suggest pulmonary embolism or hyperventilation. Your exam should seek general evidence of atherosclerosis (or risk factors for ASVD). Note corneal lipid rings, narrowed retinal arteries, and pigment and hair changes in the legs. Evaluate the neck veins for distension. Check the carotids for quality of pulse, and for bruits. The chest wall should be inspected for respiratory motion, respiratory retractions or accessory muscle use, and precordial motion. Identify the apical impulse (PMI). Feel for tender areas. Many older patients will have tenderness. Only if the tender area corresponds to the location of the patients pain, palpation exactly reproduces the pain, and the history suggests chest wall pain, should the physician diagnose musculoskeletal chest pain. Check the lungs for rales, wheezes, and asymmetrical breath sounds. Asymmetry of breath sounds may be found in about half of patients with spontaneous pneumothorax. However, asymmetry also can be due to splinting of the painful side of the chest in other conditions that cause pleuritic pain. Wheezing will most likely be due to underlying COPD, but can occur due to heart failure (cardiac asthma) or pulmonary embolism. Listen to the heart tones. Wide physiologic splitting of the second heart sound (splitting wider with inspiration) can be found in right bundle branch block or in right ventricular infarction. New paradoxical splitting is most often due to left bundle branch block, or anterior or lateral infarction. A new fourth heart sound (preceding the first heart tone) can occur with angina or infarction. An S3 (third heart tone) is more likely due to underlying heart failure. A new murmur may be significant. Aortic regurgitation occurs in over half of patients with aortic dissection. New mitral regurgitation can occur in patients with angina or infarction, and is due to papillary muscle dysfunction.

The extremities should be examined for pulses, edema, calf tenderness, and signs of atherosclerotic vessel disease. Absence of pedal pulses may occur in aortic dissection. Any swelling of the legs, especially if unilateral, raises the odds of pulmonary embolism as the cause of chest pain. Pulmonary embolism often occurs in patients with CHF. Back to Index.

Diagnostic Maneuvers - Trial therapy of chest pain in the emergency department can be misleading. The placebo response may result in improvement of chest pain in about one fourth of chest pain patients, no matter what the intervention. The spontaneous improvement of pain may be attributed to a specific therapeutic trial, resulting in false diagnosis. Patients with cardiac-compatible pain should be given sublingual nitroglycerin. About three fourths of patients with angina will have complete pain relief within two minutes. However, most patients with esophageal spasm also will have pain relief with nitroglycerin. Relief with nitroglycerin is not diagnostic of cardiac pain. A GI Cocktail of antacid and lidocaine can be given for potential pain relief, but should not be relied on for diagnostic purposes. Only 25 percent of emergency patients with reflux esophagitis will have relief of pain with the GI cocktail. More ominously, about 20 percent of MI patients will report some relief of pain with the GI cocktail. The spontaneous resolution of an episode of unstable angina after administering a cocktail may lull the physician into making a mistaken diagnosis  one with potentially fatal consequences for the patient. Back to Index.

Monitoring the Patient During Work-up - The chest pain patient should be kept on continuous cardiac monitor. At first, a nurse should be present at the bedside. If the patient remains stable (no change in pain pattern, no change in vital signs), the patient can later be monitored by telemetry. Blood pressure should be frequently monitored, preferably by automatic bedside equipment that provides a written printout. Pulse oximeters are often misleading (the usual problem is false reassurance  a good oxygen saturation is reported in a patient who later turns out to have horrible blood gases). However, they are useful because they are fast and simple, and can monitor for a change in saturation. The attending nurse should watch for changes in skin color, respiratory rate or effort, sweating, or patient expression. The nurse also should report any change in the patients symptoms. The physician should reevaluate the patient immediately if any significant change occurs. Back to Index.

Lab Evaluation of Chest Pain - Unless the pain is obviously musculoskeletal, all patients with chest pain should have a 12-lead ECG. To speed possible thrombolytic therapy, do the ECG as soon as safe and practical  immediately after initial stabilization and taking of vital signs. If the ECG machine is busy elsewhere, give treatment (if needed) such as nitroglycerin, morphine, or lidocaine while awaiting the ECG. Most patients with myocardial infarction will have an abnormal initial ECG, although the ECG will not necessarily be diagnostic of an MI. About one-fourth of acute MI patients will present with a completely normal ECG. An abnormal ECG can be seen in many non-cardiac conditions. If so, the physician has the duty to demonstrate that the ECG abnormality is either old, unrelated to the chest pain, or caused by a non-cardiac condition. Examples of acute conditions affecting the ECG include pulmonary embolism, electrolyte abnormalities, or CVA. Almost 90 percent of patients with dissection will have an abnormal ECG, often suffering acute MI due to involvement of the roots of the coronary arteries. Obtain a chest x-ray on all patients with chest pain, unless the pain is obviously musculoskeletal. The x-ray may show pneumothorax, pneumomediastinum (such as from esophageal rupture), pleural effusion, or infiltrates. Subtle findings such as loss of lung volume or unilateral decrease in vascular markings may suggest pulmonary embolism. Dissection of the aorta can cause a wide mediastinum or aortic knob contour changes. If the pain is cardiac-compatible, blood tests should include a multichannel survey with electrolytes, complete blood count, clotting studies (PT & PTT), and baseline CPK. If the physician suspects a non-cardiac diagnosis, such as pneumonia or pancreatitis, other tests may be helpful.

The CPK should not be used as a basis for admitting the acute chest pain patient to the hospital. The initial CPK is often normal in acute myocardial infarction. However, if the pain has been present for eight to 12 hours, its reasonable to exclude myocardial infarction in the patient with normal CPK-MB and normal ECG. Draw blood gases for patients in obvious respiratory distress, patients who may have shock or sepsis, patients in whom the diagnosis of PE can be ruled out by normal room air blood gases, and patients with underlying lung disease who must have monitoring of oxygen therapy. A normal arterial-alveolar diffusion gradient on room air gases essentially excludes significant PE. If the pain is cardiac-compatible, its best to await the ECG before ordering blood gases, if the gas analysis is not critical for early management of the patient. If the ECG shows infarction and thrombolytics are given, bleeding may prove problematic at the arterial puncture site. Other studies, such as perfusion scan, arteriogram, and gallbladder ultrasound, are ordered based on clinical suspicion concerning the cause of the chest pain. These studies should NOT be ordered routinely on a Rule-out MI patient to fish for another diagnosis.

Disposition of the Chest Pain Patient - The physician must make a decision on admission or outpatient work-up and therapy. Life-threatening causes of chest pain must be eliminated through historical, physical, and laboratory data before the patient can be discharged to out-patient follow-up. These critical diagnoses are unstable angina, myocardial infarction, pulmonary embolism, pneumothorax, mediastinitis, and aortic dissection. Of the above diagnoses, all except pneumothorax require automatic admission. A small pneumothorax can be tapped in the emergency department, or simply observed, with careful outpatient follow-up. Patients with less-lethal causes of chest pain may still require admission if the severity of the disease, underlying poor health, or patient distress warrants it. An unfortunate side effect of recent Medicare regulations is that the physician may have to summon greater investigative skills to find the criteria for admission than was necessary to diagnose the problem. Any patient with cardiac-compatible chest pain should be admitted to the hospital as a Rule-out MI, unless the pain has been proven to have another etiology. Although undiagnosed chest pain patients with normal initial ECG and CPK have only a .01 percent (one-hundredth of a percent) risk of life-threatening complications, todays legal climate does not allow the more cost-effective treatment protocols used in other countries. Back to Index.

Thrombolytics - WHICH thrombolytic is used is infinitely less important than that a thrombolytic IS given, and as early as possible. The physician should usually make the decision to use thrombolytics within 20 minutes of the patients arrival. The physician can obtain the chest pain history while the treatment team places the patient on oxygen, cardiac monitor, and IV. This initial history includes specific questions about contraindications to thrombolytics.

Obtain the ECG when it can be done without getting in the way of basic stabilization, usually within three minutes of arrival. Meantime, the physician is examining the patient. Give nitroglycerin when vital signs have been obtained. By the third nitroglycerin dose, the physician is ready to order the thrombolytic.

\2 coughing

is a common complaint. Almost everyone coughs sometime; some people cough a lot, nearly all the time with many causes. While cough is sometimes just a minor annoyance, it can warn of a more serious problem. It is an important normal protective reflex activity which can become a major sign and symptom of lung disease and a significant clinical problem for a large number of patients.

Cough is an important normal protective reflex activity which can become a major sign and symptom of lung disease and a significant clinical problem for a large number of patients.

The normal mechanism occurs with an inhalation of gas above FRC followed by closure of the glottis and an increase in intrapleural pressure to 100 cm H2O. About 0.2 seconds after glottis closure, it reflexively opens with resulting turbulent expiratory flow.

The cough reflex has 5 components: 1) cough receptors, 2) afferent nerves, 3) a poorly defined cough center, 4) efferent nerves, 5) effector muscles. Key to cough particularly in pathology is the cough receptors. In summary, cough receptors are throughout all the airways and upper G.I. tract. as well as the pericardium and diaphragm.

Four ways to look at cough: Cough helps us clear mucus and foreign material from our airways; in this respect, cough is useful and needs to be as effective as possible. Cough can be a symptom of a disease or of a problem, such as a peanut stuck in the airway. Cough spreads colds and other infections from one person to another. Occasionally, in certain persons with heart trouble, cough can be lifesaving by helping restore normal beating in a heart experiencing abnormal beating or rhythm.

What makes us cough? A cough probably begins with irritation of nerves in the respiratory tract. The irritation may come from a plug of mucus in the airway, for example, or from exposure to a chemical aerosol such as hair spray, or postnasal drip, or from a number of other causes.

What makes cough useful and effective? Normal nerve pathways in the respiratory tract, so cough can be stimulated when needed Normal expiratory muscles such as the diaphragm and abdomen wall, so a strong "push" can be given to air in the lungs Normal mucus stickiness, so mucus can be dislodged and expelled from airways by cough What makes cough less effective? Weakness or paralysis of expiratory muscles makes it difficult or impossible to "push" air from the lungs by coughing. Mucus that is abnormally thick and sticky can be difficult to remove from airways by coughing. Bronchial tubes that are abnormally narrowed and obstructed. Ineffective cough may require medical treatment to keep airways free of mucus and other secretions. Physical therapy can help people whose expiratory muscles have been weakened or paralyzed by disease or spinal cord injury. Some drugs are available that may help some patients cough up and expel abnormally thick mucus. Keeping airways free of mucus is important to prevent invasion of airways by bacteria that can cause serious disease.

Sometimes cough is not useful, just annoying. Cough that persists and serves no apparently useful purpose can be a problem that ranges from annoying to exhausting, depending on the duration and forcefulness of the cough. If a physician determines that a cough serves no useful purpose, medication can be given to stop the cough. An example of cough that is not useful is the cough that some people experience as a side effect when taking certain drugs. Cough can be defined by how long it persists. Acute cough lasts for 3 weeks or less; its most frequent cause is the common cold, but occasionally, acute cough can be due to a more serious illness such as pneumonia or congestive heart failure. Chronic cough lasts for 3 weeks or more; it is sometimes caused by more than one condition (most commonly in nonsmokers by postnasal drip syndrome [PNDS], asthma, or gastroesophageal reflux disease [GERD]) and is very frequent in tobacco smokers whose "smoker's cough" can mask a second, more serious cause of cough.

Causes of Cough

Acute Cough - Two of these causes include bronchopulmonary infection ( ex. bronchitis or pneumonia) and environmental causes such as cigarette smoke or other air pollutants such as ozone. Chronic Cough

Persistent cough for greater than 2 weeks without a recognized etiology presents an important clinical problem. The persistence of cough can be do to stimulation of any of the numerous cough receptors by a wide variety of causes. The approach to a chronic cough requires consideration of the anatomical distribution of the cough receptors and the knowledge of the likely of the various etiologies of chronic cough. Common causes of chronic cough airways hyperactivity post nasal drip gastro-esophageal reflux Less common but important causes of chronic cough lung cancer laryngeal disease drug induced (ACE inhibitors) ear disease psychogenic

Cough is a symptom. Acute cough and chronic cough are symptoms of conditions that may require medical attention. Hundreds of conditions can cause cough; about a dozen conditions are the most frequent causes.

The cause of cough may not be immediately apparent. In the case of chronic cough, more than one cause may simultaneously be at work. A full medical examination and laboratory tests may be necessary to arrive at a correct diagnosis and effective treatment. In the greatest majority of cases, the specific cause of cough can be diagnosed and successfully treated with therapy specific for the cause. Specific therapy is so often successful that there is a limited role for nonspecific medicines.

Postnasal Drip Syndrome PNDS is the most frequent cause of both acute and chronic cough. PNDS plus one or two other conditions, such as GERD, are often involved in chronic cough.

In addition to cough, complaints associated with PNDS are (1) a feeling of something dripping into the throat, (2) a need to constantly clear the throat, (3) nasal congestion or discharge, and (4) hoarseness.

The person with PNDS usually has recently had a cold, or suffers from allergic rhinitis, or suffers from acute or chronic sinusitis. Treatment of cough due to PNDS is determined by the diagnosis, including diagnosis of underlying conditions such as sinusitis.

ASTHMA is a common cause of chronic cough in both children and adults. In some persons, chronic cough is the only symptom of asthma. In other persons, symptoms in addition to cough include wheezing, shortness of breath, and a feeling of tightness in the chest.

Asthma is a serious medical condition that requires monitoring and treatment with carefully selected drugs. When cough is due to asthma, the cough usually goes away when the asthma is effectively treated.

Gastroesophageal Reflux Disease GERD is caused when contents from the stomach reflux (backs up) into the esophagus. GERD is a common cause of chronic cough in adults and children. In addition to cough, serious respiratory complications of GERD include chronic bronchitis, worsening bronchial asthma, and other lung diseases.

GERD is often difficult to diagnose. More than half of the persons with cough due to GERD are unaware of reflux; they do not complain of typical gastrointestinal symptoms such as heartburn, sour taste, or regurgitation. Tests to detect GERD may include 24-h monitoring of acidity in the esophagus with a catheter.

GERD is sometimes one of the other causes of chronic cough when chronic cough is due to more than one cause. GERD and cough also can have a self-perpetuating cycle in conjunction with another cause of cough: cough due to another cause precipitates reflux from the stomach, which in turn causes cough due to GERD, so that the patient ends up with two causes of chronic cough.

Treatment of GERD includes dietary restrictions and antireflux drugs, and occasionally, surgery. Treatment of cough due to GERD also includes treatment of any other conditions causing cough.

Chronic Bronchitis Chronic bronchitis is a frequent cause of chronic cough, especially in smokers. Tobacco smoke causes airway inflammation, excessive mucus secretion, and impairment of normal clearance of mucus. Effective cough is important for the smoker, as it helps clear excessive mucus from the airway.

Smoking cessation is the only fully effective treatment for chronic cough due to chronic bronchitis in a smoker.

Because smokers often expect to cough, they may not seek medical attention for a cough that persists. Smokers should be aware, however, that cough is also an important symptom of lung cancer, which is primarily a disease of smokers.

Bronchiectasis Cough is one of the most important symptoms of bronchiectasis, a lung disease in which the bronchial tree is dilated and chronically colonized by bacteria. Bronchiectasis is most likely to occur in persons with cystic fibrosis and persons who have multiple respiratory infections, especially in childhood.

Effective cough is essential for the person with bronchiectasis. Chest physiotherapy and drugs to stimulate clearance of mucus are accompanied by intermittent courses of antibiotics to keep lung infection in check.

Postinfectious Cough Cough that persists for 3 or more weeks as the only symptom after a viral upper respiratory tract infection may be a postinfectious cough. This cough due to persisting inflammation after infection will usually go away in time, but medical treatment may ease discomfort.

Postinfectious cough is more significant if there was contact with a known case of pertussis (whooping cough). In this case, antibiotic treatment should be given to the persons with this bacterial infection and to all persons who were exposed to pertussis.

Bronchogenic Carcinoma Bronchogenic carcinoma (lung cancer) is an uncommon cause of chronic cough in nonsmokers. The danger for smokers or recent ex-smokers is that they expect to cough, and may overlook a cough that may be symptomatic of lung cancer.

Suspicion of lung cancer is an indication for diagnostic tests including chest x-ray, bronchoscopy, and examination of sputum for presence of cancer cells.

ACE Inhibitor-Induced Cough Angiotensin-converting enzyme (ACE) inhibitors are blood pressure-lowering drugs that cause chronic cough as a side effect in about 10% of persons who take the drugs. The cough is typically dry and hacking. Discontinuance of the drug causes the cough to improve or resolve within a month.

Habit Cough Habit or nervous cough is a throat-clearing noise made by a person who is nervous and self-conscious. Medical treatment is not necessary. Occasionally, habit cough overlaps with postnasal drip syndrome, which can be treated.

Psychogenic Cough Psychogenic cough has no apparent physical cause. Emotional and psychological problems are likely causes. However, other illnesses have to be ruled out before a firm diagnosis is made.

Psychogenic cough is thought to be more common in children than in adults. A possible scenario: psychogenic cough develops in a child who has a chronically ill brother or sister.

Chronic Interstitial Pulmonary Disease This group of lung diseases that includes idiopathic pulmonary fibrosis is characterized more by shortness of breath than by cough. Before cough is assumed to be due to interstitial pulmonary disease, the most common causes of chronic cough, such as PNDS, need to be ruled out since they may be contributing factors. Then, if cough persists despite specific treatment for the interstitial lung disease, nonspecific medication, such as codeine, may be needed to suppress coughing and ease discomfort.

Other Causes of Cough in Infants and Children Asthma, sinusitis, and GERD are the most frequent causes of chronic cough in children.

Other causes can be hard to diagnose, especially in infants and small children who cannot describe symptoms and are difficult to examine. Some of these other causes of chronic cough include:

Congenital diseases or anomalies of the heart and lungs-that is, diseases or anatomic problems that were present at birth A foreign body (a peanut or a small toy, for example) lodged in the airway Chronic aspiration of milk into the airway while bottle feeding; in some infants this can be a chronic problem that needs medical attention Exposure to tobacco smoke from parents or family members who smoke Cough medicines There are medicines to help you stop coughing (antitussives) and others to help you cough more effectively (protussives). Some medicines are available without prescription, while others must be prescribed by a physician. No cough medicine should be taken for long periods of time (3 weeks or more) without a medical examination. You could be taking the wrong medicine without realizing it, or you could be inadvertently using cough medicine to cover up a serious problem such as asthma or lung cancer.

For tobacco smokers, the most effective way to stop coughing is to stop smoking.

Don't spread infection. Remember that coughing spreads disease by dispersing germs through the air and on skin. You should always

cover your mouth and nose while coughing, and if you cough into your hands or blow your nose, wash your hands immediately to remove germs deposited on the skin. If you have been covering your mouth while coughing, do not handle or prepare food until you have washed your hands.

How to cure a cough Stop. Don't reach for the cough medicine until you know what you're doing. And certainly don't give it to children or people with addictions until you understand exactly what those ingredients mean.

The first thing to find out is whether your cough mixture is an antitussive or an expectorant. It cannot be both. One cough mixture does not treat all coughs. If your cough mixture claims to contain both ingredients (and there are some which do), put it back on the shelf immediately.

An antitussive is a cough mixture which stops the coughing reflex. It is intended for the kind of cough we commonly call dry: that itchy, persistent scratch in the throat. It's often caused by an irritation in the throat, and coughing just makes the irritation worse. So the best remedy is to suppress the body's natural reaction to cough. Antitussives may be addictive, because they work on the cough reflex in the brain. If you are concerned about addiction, look for an antitussive called dextromethorphan, which is considered safe.

An expectorant is a cough mixture which assists the coughing reflex. Yes, that's right, it helps you cough more. It is intended for the kind of cough we commonly call wet, or productive: you cough up mucus. Where is that mucus coming from? It's coming from your lungs. What happens if you don't cough it out? You can answer that one yourself.

Your lungs normally produce a certain amount of mucus, which is carried out of the lungs by little hair-like cilia lining the air pipes. It's so natural you don't even notice it. However, if you have an infection, or sometimes just an allergic reaction to something, this can result in a buildup of mucus. Your body's natural reaction is to clear the lungs by coughing. Once the infection has cleared, and the mucus buildup has gone, the coughing will stop by itself and you'll be able to breathe again.

That's step one. Identify what kind of cough you want to treat, and buy the right kind of formulation. Anti-tussives for dry coughs, expectorants for wet coughs. If you want to keep cough mixture in your first aid cupboard, make sure you have one of each.

Step two is to find out more about the other ingredients in a cough mixture. Very few cough mixtures have just one ingredient. Often, the ingredients fight each other instead of working together.

Some cough mixtures have ingredients to help stop pain. This can be useful with both an antitussive and an expectorant. If your throat is sore, you want to soothe the pain. If your lungs are painful from a tight chest caused by inflammation, some pain relief is always welcome. Codeine is often added to cough mixture to help soothe the pain. That's fine - but be aware that codeine is potentially very addictive. It is a derivative of morphine, which is a powerful narcotic painkiller. If you're buying a cough mixture for children or people with addictions, avoid the codeine.

Another ingredient often added to cough mixtures is an antihistamine, which helps fight allergic reactions. It is probably a good combination with an antitussive, where coughing may result from an allergic reaction in the throat. It can happen that lungs fill up with phlegm caused by an allergic post-nasal drip, for example, so don't be surprised to see it in an expectorant.

Some cough mixtures have a bronchodilator added. This is an ingredient that helps widen the air passages in the lungs. It can be a very helpful ingredient when your lungs are filled with mucus, because it gives the mucus room to move so that it can be coughed out more easily. It is completely useless in an antitussive and serves only to increase the price.

Decongestants help soften the phlegm, so that it can move out of the lungs more easily. Once again, these are only appropriate in an expectorant. Your doctor will often advise you to breathe steam when you have a cold or cough: this is a natural way to help decongest a tight chest. Some chemical decongestants, such as ephedrine, also have a natural bronchilatory effect.

Many cough mixtures contain high amounts of sugar. If you are treating a diabetic or someone who has problems with sugar, you should look for a sugar-free product. Cough mixtures may also contain alcohol, often as a preservative. Whether you are naturally pro or anti alcohol, you certainly don't want to give it to a child or an alcoholic.

As you can see, a cough mixture is not as innocent as it seems. Find out what ingredients are in any cough mixture you consider buying, and what exactly they do. The right cough mixture can help solve a coughing problem remarkably quickly. You may even want to ask your doctor to recommend an expectorant and an antitussive for your first-aid needs.

One last word. The cough mixture should help clear the cough quickly. Consult your doctor

1)If the cough lasts for more than a few days

2)If there is blood in the mucus

3)If the mucus stops being clear, ie. it turns yellow or green

4)If a fever develops or any of these symptoms develop, your infection has gone beyond the stage of a cough and needs some expert intervention.

CHRONIC COUGH

by ELIZABETH B. PHILP, M.B., CH.B. Univ of Alabama School of Med Tuscaloosa, AL.

Chronic cough is defined as a cough that lasts for more than three weeks. More than 90% of cases of chronic cough result from five common causes: smoking, postnasal drip, asthma, gastroesophageal reflux and chronic bronchitis. Although in most patients chronic cough has a single cause, in up to one fourth of patients, multiple disorders contribute to the cough. A stepwise evaluation in patients with chronic cough can minimize the invasiveness and expense of the work-up.

Initial screening of patients with chronic cough should search for smoking, occupational exposure to an airway irritant, cough-inducing medications, airway hyperrespon-siveness following upper respiratory infection, chronic bronchitis or any systemic symptoms suspicious for serious disease. Patients who are not diagnosed after an initial screening are evaluated or empirically treated in a stepwise fashion for postnasal drip, asthma and reflux. Bronchoscopy is reserved for use in the few patients still without a diagnosis after the previous steps have been completed.

Cough is a defense mechanism for clearing secretions and inhaled and noxious substances from the tracheobronchial tree. Coughing may be voluntary but is more often the result of an involuntary reflex response to stimulation of cough receptors in the airways. The cough reflex is quite complex and as yet is not completely understood. A variety of peripheral sites are connected to the cough center in the medulla, including the nose, auditory canal, nasopharynx, larynx, trachea, intrapulmonary bronchi and pleural surfaces. Stimulation of receptors in these sites can result in cough.1

Definition and Prevalence A chronic cough may be defined as one of greater than three weeks duration.2 In the nonsmoking population, persistent cough is reported to occur in 14 to 23% of adults 3,4 and is a frequent reason for visits to primary care physicians.5 From 17 to 24 percent of adults smoke, and the incidence of chronic cough caused by smoking is directly related to the number of cigarettes smoked per day. Approximately 25 percent of those who smoke one half pack per day report a chronic cough, while over 50 percent who smoke more than two packs per day have a chronic cough. Many smokers will not report their cough to their physicians or seek medical attention for it.

Common causes Smoking and other environmental irritants Postnasal drip Asthma Gastroesophageal reflux Chronic bronchitis Transient airway hyperresponsiveness (e.g., after viral upper respiratory infection) Medication-related (ACE inhibitors, beta blockers)

Less common causes Congestive heart failure Cancer (bronchogenic or esophageal) Interstitial lung disease (emphysema or sarcoidosis) Bronchiectasis Tuberculosis and other chronic lung infections (e.g., fungal) Cystic fibrosis Recurrent aspiration (e.g., post-stroke, frequent vomiting [bulimia], alcoholism) Pressure from an intrathoracic mass (e.g., thoracic aneurysm, thyromegaly, mediastinal lymphadenopathy) Irritation of cough receptors in ear (e.g., impacted cerumen, hair, foreign body) Opportunistic infections in immunosuppressed patients Lymphangitis carciomatosis Foreign body Chronic inhalation of bronchial irritants (occupational) Psychogenic

ACE = angiotensis-converting enzyme.

 -- Chronic cough may be caused by multiple factors in addition to smoking (Table 1).6 In patients referred to a pulmonary clinic for chronic cough, a study2 concluded that in 94 percent of patients, chronic cough was caused by four conditions: postnasal drip, asthma, chronic bronchitis or gastroesophageal reflux. In 82 percent of patients, cough had a single cause, and in 18 percent of cases, multiple causes were found. Tailoring treatment to specific causes of chronic cough resulted in sustained resolution of the cough in 97 percent of patients.

Based on this protocol, an algorithm has been developed for investigating and managing chronic cough.7 A modification of this algorithm has been proposed8 to identify patients with extrathoracic airway disease before embarking on more invasive investigations (Figure 1). The authors suggest a trial of omeprazole (Prilosec) for gastroesophageal reflux disease (GERD) before embarking on esophageal pH monitoring.

As the pathophysiology of the four major disease entities implicated in chronic cough is better understood, further modifications to this algorithm will be forthcoming. For example, it has been suggested that patients who have had a recent upper respiratory infection should only be evaluated if their cough persists for more than eight weeks.9

We recommend that evaluation and treatment progress side by side as an effective method of managing patients with chronic cough. The use of nonspecific antitussives is avoided and invasive procedures are reduced to a minimum.7

TABLE 2 - Checklist for Use in Determining Common Causes of Chronic Cough Management of Chronic Cough Evaluation of chronic cough should begin with a careful history focused on eliciting symptoms associated with the most common causes of chronic cough (Tables 1 and 2). The physical examination should focus on readily accessible anatomic locations known to contain receptor sites for the cough reflex (e.g., the nose, the nasopharynx, the lungs).

By proceeding in a stepwise fashion from common causes of chronic cough to less common causes, the invasiveness and expense of the work-up can be minimized (Figure 1). While the history and physical examination can often identify the cause of chronic cough, empiric treatment for common etiologies is frequently necessary.

Avoid Lung 'Toxins' CIGARETTE SMOKING Cigarette smoking is the leading cause of chronic cough, and cessation of smoking usually leads to a dramatic decrease in cough within one month. Physicians should take every opportunity to advise their patients to stop smoking and can use target symptoms, such as chronic cough, to motivate these patients to quit smoking. Family physicians can increase their success rate in smoking cessation by providing time for patient counseling and by educating patients about the use of nicotine patches or nicotine gum to help them stop smoking.10

OCCUPATIONAL EXPOSURE In patients who note an improvement in their cough during vacations or other time away from their workplace, an occupational exposure (e.g., dust, fumes, other irritants) may be playing a role in their chronic cough. These patients should be counseled to inquire about available engineering controls at their workplace to reduce their exposure. This may mean improving air circulation, or wearing a face mask or other protective clothing. In extreme circumstances, a change of job may be necessary.

Discontinue Medications Causing Cough ANGIOTENSIN-CONVERTING ENZYME INHIBITORS Angiotensin-converting enzyme (ACE) inhibitors are useful in the treatment of hypertension or congestive heart failure because of their minimal side effects. Cough was first described as a side effect of ACE inhibitor therapy in 1985,11 and since then numerous case reports and studies describing this condition have been published. A recent review12 of the literature concludes that cough occurs in 5 to 20 percent of patients treated with an ACE inhibitor. The cough resolves rapidly when the drug is withdrawn. If the cough resolves, the patient should be given an alternate class of medication, because cough would recur with reintroduction of the same or another ACE inhibitor.

BETA BLOCKERS Beta blockers are used in the management of hypertension, angina, cardiac arrhythmias, hyperthyroidism, prophylaxis of migraine and glaucoma. Blockade of beta-adrenergic receptors in the bronchi and bronchioles can cause increased airway resistance resulting from unopposed parasympathetic activity, especially in patients who already have obstructive lung disease (e.g., asthma, emphysema). Cough provoked by this class of drugs will resolve when the drug is withdrawn, and a drug from a different class should be substituted for treatment of the primary disease.

Identify Post&horbar;Upper Respiratory Infection Airway Hyperresponsiveness Acute cough is frequent in upper respiratory infections. Most patients will have total resolution of all symptoms within three weeks. However, a subgroup of patients develop airway hyperresponsiveness with a persistent cough that can last two months or so.9,13 Studies suggest that airway epithelial damage that follows an upper respiratory infection can lead to hypersensitivity of the airway receptors to inhaled irritants. In these patients, the cough, if unresponsive to treatment with an antihistamine, should be treated with inhaled steroids.9

Identify Chronic Bronchitis Chronic bronchitis is associated with excessive mucus produced in the tracheobronchial tree. Patients who have an expectorant cough for three or more months of the year for more than two consecutive years fit the clinical definition of chronic bronchitis.14,15 Patients with longstanding disease may also have overlapping asthma or emphysema. Although cigarette smoking is the single most important etiologic factor, the physician should also inquire about environmental and occupational exposure to dusts, fumes and other air pollutants. Inhaled ipratropium (Atrovent), an anticholinergic bronchodilator, has theoretic advantages, including decreased mucus production and peripheral antitussive effect, and may be more effective than standard beta-agonist bronchodilator treatment.16,17

Patients should be evaluated with chest radiographs and a pulmonary function test. A tuberculosis skin test should be administered in high-risk patients (e.g., patients with human immunodeficiency virus [HIV] infection, intravenous drug users, prison inmates, homeless persons, immigrants from endemic areas).

Management must start with discontinuation of smoking and avoidance of environmental irritants and toxins. An exercise program will increase exercise tolerance and provide an improved sense of well-being. Immunizations with pneumococcal vaccine, as well as annual influenza vaccinations, are important preventive health measures. Treatment of community-acquired respiratory infections with an appropriate antibiotic for seven to 10 days should be promptly instituted. Optimum bronchodilator therapy, postural drainage and hydration are the basics of good management. Patients who fail to improve with these measures may require the addition of oral steroid therapy.18 In some cases, correction of malnutrition is an important adjunctive therapy because of the higher incidence of poor nutritional status in patients with chronic lung disease.

Identify Weight Loss or Other Symptoms of Serious Disease - Patients with serious underlying disease seldom present with only one symptom, such as chronic cough. Inquiry should be made about such symptoms as fever, chills or night sweats (suggesting pulmonary tuberculosis), hemoptysis or recent weight loss (suggesting lung cancer), and dyspnea, orthopnea or pedal edema (suggesting congestive heart failure). If any of these symptoms are acknowledged, appropriate diagnostic evaluation should be undertaken.

In patients with chronic cough as the only presenting symptom, and having excluded the etiologies already discussed, the physician can move to step 1 in the algorithm for management of chronic cough (Figure 1).

Empiric Treatment Algorithm

STEP ONE - For one week, give all patients empiric treatment for postnasal drip using an older-generation antihistamine-decongestant combination.19 Evidence indicates that the newer generation histamine1 antagonists are inferior in treating cough caused by postnasal drip,17 and their use should be avoided unless sedation is a major side effect with the older agents. If the cough improves, the antihistamine-decongestant combination should be continued until the cough is resolved or until there is no further improvement. Nasal steroids should be added in patients whose cough is not controlled by antihistamine-decongestant medications.

If symptoms persist after one to two weeks of nasal steroid use, a computed tomographic (CT) examination of the sinuses should be performed. If chronic sinusitis is identified, the patient should be treated with an empiric trial of antibiotics such as amoxicillin-clavulanate potassium (Augmentin) or trimethoprim-sulfamethoxazole (Bactrim, Septra), or a second- or third-generation oral cephalosporin. In addition, some data indicate that patients may benefit from a short (three-day) course of treatment with an over-the-counter nasal oxymetazoline decongestant spray (Afrin, Allerest, Dristan) plus an oral antihistamine-decongestant combination drug. When all of these measures fail, the patient may require aspiration or irrigation of the sinuses and may benefit from a consultation with an ear, nose and throat specialist.

STEP TWO - Patients who continue to cough despite the treatments in step 1 should be evaluated for asthma. Asthma is a disease characterized by reversible airflow obstruction caused by airway inflammation, edema, mucus production and smooth muscle constriction.14 Clinically, asthma presents as acute, recurrent episodes of dyspnea, coughing or wheezing. Physicians should bear in mind that patients with asthma may present with only a chronic, usually nonproductive cough. This is often termed "cough-variant asthma." Physical examination of asthma patients outside periods of acute symptoms is essentially normal. In one study of nonsmoking patients with chronic cough, asthma was found to be the cause of cough in 24% of patients, and more than one fourth of these patients had so-called cough-variant asthma.

The expert panel of the National Asthma Education Program21 has suggested a sequence for assessing a patient suspected of having asthma, and an algorithm for diagnosing asthma has been developed. The algorithm suggests that airflow obstruction should be objectively evaluated by spirometry.22-24 A reduced peak expiratory flow rate and a reduced ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) is diagnostic of obstructive lung disease. Following bronchodilator therapy, an increase of at least 15 percent in the FEV1 may be expected in the patient with asthma.

When the results of spirometry are equivocal, a bronchoprovocation test using methacholine (Provocholine) may be helpful in evaluating airway hyperresponsiveness.25,26 Patients diagnosed with asthma should be counseled about avoidance of allergens, treated prophylactically with intranasal and inhaled cromolyn (Intal, Nasalcrom), and with beta-agonist and/or steroid inhalers and oral corticosteroids, as required.

STEP THREE - Chest and sinus radiographs should be obtained at this point, if they are not already available. Any clinically significant abnormality should be evaluated and treated.

STEP FOUR - Patients in whom a diagnosis has not been reached by this time and who remain symptomatic should be given an empiric gastric-acid suppression test, along with antireflux measures for treatment of possible GERD.

Patients with GERD usually complain of heartburn or chest discomfort. However, some patients may have chronic cough as their only presenting symptom.27 Mild degrees of GERD, involving only the distal esophagus, can still irritate the nerve fibers that initiate the cough reflex. Actual aspiration of gastric contents causing cough is uncommon.

GERD can be ruled out in most patients if symptoms do not improve during a limited period of gastric-acid suppression therapy. High doses of proton-pump inhibitors (e.g., omeprazole, in a dosage of 80 mg per day) are used to ensure complete suppression. This test has a sensitivity of 83 to 90 percent.28,29 Discontinuing certain medications that can exacerbate GERD (e.g., anticholinergic drugs, calcium channel blockers, theophylline, other smooth muscle relaxants) may be necessary. A protective agent, such as sucralfate (Carafate), in a dosage of 1 g taken one hour before meals, may be helpful, as may the addition of a prokinetic agent, such as metoclopramide (Reglan) or cisapride (Propulsid), before meals and at bedtime.

Nonresponding patients should be further evaluated using 24-hour esophageal pH monitoring, which is the most sensitive and specific test for the diagnosis of GERD.30,31 Patients with abnormal results should receive aggressive therapy with a proton-pump inhibitor for at least eight weeks.

STEP FIVE - Patients who still continue to cough at this stage should receive bronchoscopic examination. If this procedure does not produce a diagnosis, a repeat course of antiasthmatic therapy with a beta agonist and steroids should be tried.

Final Comment - In following this protocol, patients whose cough improves with one therapy but does not resolve completely should continue with the initial therapy and proceed to the next step in the management algorithm, because in some patients, two or three diseases may be contributing to their cough.

If cough still persists, the physician should institute a careful search for less common causes (Table 1). Less than 6 percent of patients with chronic cough have one of these less common diagnoses, and it would be unusual for cough to be the only presenting symptom in patients with serious underlying disease. Patients with lung cancer, interstitial lung disease, chronic lung infections or aneurysm could be expected to be identified by chest radiographs and/or bronchoscopy. A CT scan of the chest would be appropriate in these patients, and lymph-node biopsy may be necessary in diagnosing sarcoidosis or bronchogenic carcinoma. In the absence of clinical signs of congestive heart failure, two-dimensional echocardiography may aid in diagnosis.

Any child who coughs and has a history of recurrent pneumonia and/or failure to thrive should have a sweat chloride test for cystic fibrosis. Finally, an evaluation for immunosuppression caused by HIV infection or IgA deficiency may be indicated. If all of this evaluation and treatment fails, a careful history should be repeated, with emphasis on occupational or home exposure to an airway irritant.

If no pathology can be found, psychogenic cough must be considered. A careful psychosocial history may elicit the abnormal family dynamics that led to this attention-seeking symptom. A harmless subset of this group of patients includes those whose cough is a nervous tic, occurring when they become upset or nervous.

 -Chronic Cough: Causes and Cures - A chonic cough is one that lasts for at least several weeks. If you have had a cough for more than three weeks, here are some questions to help you decide if you should see your doctor:

Are you coughing up thick yellow or green phlegm? Are you running a temperature higher than 101F? Are you losing weight without trying? Are you having drenching sweats in bed at night (the sheets and your pajamas get soaking wet)?

Are you coughing up blood? If you answered "yes" to any of these questions, your doctor will want to find out if you have an illness that is causing the cough. If you answered "no" to all of these questions, you might try to figure out what could be causing your cough.

What are possible causes of chronic cough? Do you smoke? If you do, you need to stop. Talk to your doctor about using nicotine patches or nicotine gum, or another method of stopping smoking.

Do you have postnasal drip caused by allergies? Postnasal drip is mucus that runs down your throat from the back of your nose. If you have this, try to avoid the things you are allergic to, such as the following:

In the home: smoke, dust, molds, pets, certain plants, cleaning agents and room deodorizers. Outdoors: pollen and freshly cut grass. At work: smoke, dust and chemical fumes. An over-the-counter antihistamine-decongestant combination may help stop your allergies and your cough. Ask your doctor or pharmacist to help you choose one.

Can a medicine cause a cough? Some medicines can cause chronic cough in some people. Some examples of medicines that may cause cough are the following:

ACE inhibitors for high blood pressure - Beta blockers for high blood pressure, migraines or glaucoma. Call your doctor's office to find out if any of the medicines you use could cause you to cough. If you are taking a medicine that can cause you to cough, your doctor might be able to prescribe another medicine for you. Don't stop taking a prescribed medicine until after you have talked to your doctor.

Could the cough be caused by asthma? In some people with mild asthma, a cough is the only symptom. This condition is called "cough-variant asthma." Your doctor may ask you to try using some asthma medicine to see if your cough goes away. If it does, you probably have mild asthma. Regular treatment for asthma will help the cough go away.

Could heartburn be the cause? Acid from your stomach may back up into your throat. This is called "acid reflux." It can cause heartburn or cough. Acid reflux is more common when you're lying down. If you have this problem, try raising the head of your bed about 4 inches. It might help to avoid eating or drinking for two hours before you lie down. You shouldn't drink alcoholic beverages or drinks with caffeine in them, or eat chocolate or spicy or greasy foods before you lie down.

An antacid (such as Tums) or one of the over-the-counter acid blocking preparations (such as Axid, Pepcid, Tagamet or Zantax) may also be helpful.

 - This handout provides a general overview on this topic and may not apply to everyone. To find out if this handout applies to you and to get more info on this subject, talk to your family doctor.

  Considerations: The cough reflex is one of the body's best defense mechanisms. Irritation or obstruction in the breathing tubes activates this reflex, and the strong rush of air helps clear material from the breathing tubes.

A cough is more helpful if it is producing and expelling something, such as phlegm (sputum). Such a cough is termed "productive" and usually should not be suppressed by drugs. Minor irritations in the throat can start the cough reflex even though normal mucus is the only material to be expelled. (This is called a "dry" cough.)

Mucus from the nasal passages can drain into the throat and lungs (postnasal drip) and trigger the cough reflex. Such coughs are not helpful and may be treated with cough suppressants. In infants, coughing is unusual and may indicate a serious lung problem. In diagnosing the cause of a cough, it is important to notice details about the cough, such as the type of cough, does it bring up mucus or phlegm, and so on.

A cough that is caused by bronchitis or similar infection commonly lasts for up to 2 weeks. However, a cough that persists longer than this should be evaluated by the health care provider. A cough may occasionally indicate a serious condition: when blood is coughed up when it is accompanied by chest pain when there is difficulty breathing or shortness of breath if there is also an unintentional weight loss

Common Causes: smoking (smoke destroys the cells in the lining of the breathing tubes so that mucus cannot be expelled normally, leading to a chronic cough) including passive or secondhand smoke common cold , influenza , and other viral infections (with yellow or white mucus) are the most common causes drugs (such as ACE inhibitors or expectorants) cause persistent, dry, nonproductive coughs stress (if the cough disappears during sleep, then stress may be the cause) allergies aspiration (see foreign object aspiration or ingestion ) atelectasis bacterial infection ( bronchiectasis , bronchitis , pneumonia , sinusitis , or tracheitis) often with rusty or green mucus congestive heart failure environmental pollution gastroesophageal reflux infections (such as Chlamydia , Mycoplasma , pertussis ) postnasal drip asthma viral infection ( bronchiolitis , croup , pneumonia , upper respiratory infection ) diagnostic tests (such as bronchoscopy , chest X-ray , or pulmonary function tests ) medical treatments (such as intermittent positive pressure breathing, or incentive spirometry ) lung cancer emphysema

Note: There are other causes of a cough. This list is not all inclusive, and the causes are not presented in order of likelihood. The causes of this symptom can include unlikely diseases and medications. Furthermore, the causes may vary based on age and gender of the affected person, as well as on the specific characteristics of the symptom such as quality, time course, aggravating factors, relieving factors, and associated complaints.

Home Care: Increasing humidity in the air may help. A vaporizer and a steamy shower are two ways to increase the humidity. Drink extra fluids to help thin secretions and make them easier to cough up. Glyceryl guaiacolate (guaifenesin, such as in Robitussin) is available without prescription and may help liquefy the mucus. Drink lots of fluids if taking this medication.

When a cold and a stuffy, runny nose accompany the cough, it is often caused by mucus dripping down the back of the throat. A decongestant that opens the nasal passages will relieve this postnasal drip and is the best treatment for that type of cough. Decongestants such as phenylephrine, pseudoephedrine, phenylpropanolamine, or combinations of all three are available as over-the-counter cold medications. Don't give decongestants to a child under six years of age unless prescribed by the doctor. If hypertensive , consult your doctor before taking decongestants.

Coughs due to chronic postnasal drip are probably caused by either sinus infection or allergy . If allergy is the cause, avoid whatever is causing the allergy and take antihistamines.

Dry, tickling coughs can be relieved by sucking on cough lozenges or hard candy.

Codeine is a very effective cough suppressant but has some negative side effects and requires a prescription. Dextromethorphan (such as in Vick's Formula 44) is an effective cough suppressant that is available without prescription.

Call Your Healthcare Provider If: a violent cough begins suddenly or there is a high-pitched sound (stridor) when inhaling. (The person might have inhaled a small object.) there is a cough producing blood in any form. This should be treated as an emergency. There is a cough in an infant less than 3 months old. There is shortness of breath or difficulty breathing . coughing is accompanied by other symptoms such as fever or abdominal swelling . a cough is accompanied by unintentional weight loss . the cough is producing thick, foul-smelling, rusty, or greenish mucus. There is a cough lasting for more than 10 days.

What to Expect: In emergency cases, the patient will be treated first to stabilize the condition. After the condition is stable the medical history will be obtained and a respiratory assessment performed.

Med hist questions documenting your cough in detail may incl: type, Are you coughing up blood (hemoptysis)? Is visible blood coughed up (gross hemoptysis)? Is there blood streaked sputum (phlegm)? Are you coughing up large amounts of blood (massive hemoptysis)? Are there repeated episodes of coughing up blood (hemoptysis)?

Do you bring up any mucus when you cough (sputum, phlegm)? Does the sputum contain pus (purulent sputum)? Does the sputum contain pus and have a foul odor? Does the sputum look like clear, sticky mucus (mucoid sputum)? Is the sputum white and frothy? Is pink, frothy material coughed up? Is the sputum adhesive, thick, hard to cough up (tenacious)? Are you coughing up brownish plugs? How much sputum is produced (about how many cups per day)?

quality - Is the cough severe? Is the cough dry? Does the cough sound like a seal barking?

time pattern - Is the cough worse at night? Did it begin suddenly? Has it been increasing recently? How long has the cough lasted (for how many weeks?) Has the cough been chronic and has it changed pattern recently?

Do spells of coughing occur repeatedly (recurrent)? Are coughing spells composed of a sequence of separate episodes?

Does the cough change? Is it variable over hours?

Aggravating factors Is the cough worse when you are lying on one side? Is it worse when first arising from sleep?

Associated complaints - Are there sudden periodic attacks of coughing with gagging and vomiting ?

other - What other symptoms are also present? The physical examination will include emphasis on the ears, nose, throat, and chest. Do not expect antibiotics to be prescribed for a routine viral or allergic cough because they will not help.

Diag tests that may be performed incl: bronchoscopy, lung scan, pulmonary function tests, sputum analysis (if the cough produces sputum) X-ray of the chest
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