Broken Tube, The Cause of Chronic Wet Cough
Written By:
Felma Ungson – Garcia, MD, FPPS, DPAPP
Cough is the most common reason of consult both at the Out Patient Department (OPD) as well as at the Emergency Room (ER). Parents have extreme reactions with a coughing child. Some will bring their children on the first day of cough while others will take some time before they bring their children for a consult.
What is cough?
Cough is a reflex that helps clear the airways of secretions and protects airway of foreign bodies.[1] It is a manifestation of several kinds of diseases. According to the British Thoracic Society, cough can be classified as acute, or those lasting less than 4 weeks or chronic, those that usually lasts for more than 4 weeks.[1] Acute cough is caused by viruses and usually affects the Upper Respiratory Tract (URT). Examples of which are, Common Colds, Influenza, Acute Bronchitis. Chronic cough on the other hand maybe due to Bronchial Asthma, Gastro Esophageal Reflux Disease (GERD), Protracted Bacterial Bronchitis and Pulmonary Tuberculosis.
How do clinicians diagnose patients with cough?
A good and reliable history of present illness and an accurate Physical Examination will lead to a right diagnosis. The clinician will ask the associated signs and symptoms such as fever, sore throat, poor appetite, weight loss, night sweats and effects of cough on the patient’s daily activities.
The chronicity of the cough will also be asked as well as the timing of coughing, is it nocturnal? All day cough? post prandial coughing? For chronic cough, it is essential to review the past medical history of the patients like previous admissions due to pneumonia, or a recurrent admissions due to the pulmonary diseases.
Previous diagnosis of congenital anomalies involving the respiratory tract such as, tracheomalacia, tracheoesophageal fistula, vocal cord paralysis, congenital cystic adenomatoid malformation, to name some may lead to recurrent pulmonary infection. Family History of Allergy, Bronchial Asthma, Allergic Rhinitis, Chronic Rhinosinusitis will help reveal the cause of recurrent cough. Exposure to Environmental Tobacco Smoking maybe a culprit for asthma exacerbation.
On Physical Examination, the clinician might be able to observe flaring of nostrils, fast breathing, cyanosis or the bluish discoloration of lips or nailbeds, intercostal retractions. On auscultation, the examiner may hear adventitious sounds like crackles, wheezing, rhonchi or may not be able to appreciate breath sounds at all as in the cases pleural effusion or lung masses. Chest Radiography or Lung Ultrasound maybe requested to aid the physician in diagnosing the disease.
How do physicians treat cough?
Treatment will depend on the diagnosis derived from the history gathered and the physical examination done. Acute upper respiratory tract infections are usually given supportive management, it is important to emphasize that post viral cough may last for 2-3 weeks after the infection. Bacterial causes should be treated with appropriate antibiotics while Bronchial Asthma and Pulmonary Tuberculosis must be given treatment accordingly and monitored until the disease is controlled or completely treated.
What will happen if the chronic cough is not given proper treatment and the wet cough persists resulting to destruction of the respiratory tubules?
The bronchi will have an irreversible damage called bronchiectasis. Bronchiectasis should be considered when children have chronic “wet” sounding or productive cough with or without exertional dyspnea, recurrent wheezing and chest infections, hemoptysis, growth failure, clubbing or hyperinflation.[2]
In the Philippines, Tuberculosis remains one of the most common cause of Bronchiectasis, and of note also are measles pneumonia, foreign body aspiration and chronic micro aspiration. According to Paul King who published an article in International Journal of Chronic Pulmonary Disease which discussed Pathophysiology of Bronchiectasis, he described the disease as a permanent and abnormal widening of the bronchi. The process occurs in the context of chronic airway infection and inflammation characterized by mild to moderate airflow obstruction.[3]
Reid categorized bronchiectasis as having three main phenotypes: 1) tubular, characterized by smooth dilation of the bronchi; 2) varicose in which the bronchi are dilated with multiple indentations; and 3) cystic in which dilated bronchi terminate in blind ending sacs. The current major form seen on High Resolution Chest Tomography (HRCT) is the tubular form of bronchiectasis.[3]
A study performed by Whitwell demonstrated marked inflammation of the bronchial wall principally in smaller airways. Bronchial dilatation was characterized by deficiency or loss of elastin and destruction of muscle cartilage. Whitwell classified bronchiectasis into three different types: follicular, saccular, and atelectatic.[4] The follicular type is the more common type which corresponds to the tubular type described by Reid. With progression of the disease, lymphoid follicles enlarged in size and caused airflow obstruction to the small airways.
Other causes of obstruction are the presence of cells, predominantly by the neutrophils which releases mediators called proteases that causes dilatation of the lumen. The presence of inflammatory cells as well as proteases will result to copious secretions which leads to further obstruction hence resulting to difficulty of breathing, hypoxemia and easy fatigability among patients suffering from bronchiectasis.[4]
Are there any over the counter medications we can give to Patients diagnosed with bronchiectasis? How do we manage patients with bronchiectasis at home?
Treatment of bronchiectasis include monitoring of exacerbations, aggressive management of infection with the use of antibiotics, regular use of airway clearance method, attention to nutrition, use of secretagogues and mucoactive agents.[2]
A review done by Ahmad Karta on the safety and efficacy of Ambroxol for the treatment of acute and chronic respiratory diseases showed that Ambroxol act as secretolytic therapy in chronic bronchopulmonary disorder associated with abnormal mucus secretion and impaired mucus transport. Ambroxol helps transport the mucus by its secretogogue property. It was also noted to stimulate surfactant synthesis making it an effective mucokinetic and sectretogogue properties.[5]
The European Respiratory Society (ERS) Guidelines, recommend the use of mucoactive treatment for 3 or more months in adult patients with Bronchiectasis who have difficulty expectorating sputum and who has poor quality of life and when standard airway clearance have failed. Mucolytic therefore serve as an adjunct to airway clearance.[6]
Bronchiectasis can happen even to pediatric patients, early diagnosis and treatment of the causes of chronic cough will save these children’s lungs from irreversible destruction. Immunization with measles vaccine is highly recommended to prevent measles pneumonia. Parents’ education with every clinic visit will help them recognize early health problems of their children hence early consult and management can be provided.
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