Typically requires high dose diuretics Indirect effects of diuretics may be counterproductive Increase neurohormonal activation 1,2 Reflex vasoconstriction, v cardiac output 1 Worsening of renal function 3 1. Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial.
The symptoms and signs of heart failure are neither sensitive nor specific and considerably overlap those of pulmonary disease.
In the largest study to date, the Breathing Not Properly Multinational Study, BNP levels were more accurate than any historical or physical finding or laboratory value in identifying heart failure as the cause of dyspnea.
There is a high negative predictive value of a low level of BNP with respect to the diagnosis of heart failure. It should be noted that in patients with severe renal disease, B-type natriuretic peptide levels are increased.
Remember that either ventricle failing will produce BNP so any patient with cor pulmonale from copd will also have elevated bnps. B-type is so named because it was first isolated from porcine brains, mostly secreted from ventricles.
Knowing the level of B-type natriuretic peptide during initial evaluation in the emergency department is associated with more rapid initiation of appropriate treatment, less needfor hospitalization and intensive care, a shorter length ofstay, and lower costs. Medications. These may include diuretics (“water pills”) to help relieve the body of extra fluid. Use of the copyright symbol on this website does not limit or abridge the rights of Veterans, the general public, or the Government from non-commercial access to, and use of, the information displayed on this website. Visit the Thomas Jefferson University Home Page as a starting point for finding information at Jefferson. The Web site for Thomas Jefferson University, its contents and programs, is provided for informational and educational purposes only and is not intended as medical advice nor, is it intended to create any physician-patient relationship. Cough is the most common single reason for primary care physician visits and is a common source of referrals to pulmonologists.1 In otherwise healthy persons, self-limited cough can occur as part of local irritation due to a viral rhinitis or respiratory infection. Because cough is a symptom that is a common pathway for a variety of diverse conditions and has no reliable objective monitoring tools, physicians' management of cough is actually quite variable. For a symptom such as cough, simply excluding certain serious causes can go a long way to reassuring the patient as well as the clinician and allowing a period of observation.
Cough is a protective physiologic reflex that augments mucociliary clearance of airway secretions. Although physiologic cough has a characteristic acoustic profile and is universally recognizable, there is no clinical test that can document and confirm the presence of cough. Rapidly adapting receptors and C fibers are two afferent nerve subtypes that have been extensively studied and are theorized to play important roles in the regulation of cough.
Cough is the single most common symptom prompting outpatient medical visits in the United States.6 Persistent cough is a common reason for referral to a pulmonologist or allergist. Most patients seek medical attention because of complications of cough, either psychological or physical. Although somewhat arbitrary, it is useful to classify cough by duration as a means of narrowing the differential diagnosis. The most common cause of acute cough, as defined by a time course of less than 3 weeks, is considered to be the common cold. Acute bronchitis, as the term implies, is a lower respiratory tract syndrome and another common source of acute cough. Distinction between the common cold and acute bronchitis is often impossible to make and usually clinically irrelevant in otherwise healthy persons. A common diagnostic challenge encountered in the outpatient setting is determining the need for a chest radiograph.
Several prospective studies have attempted to delineate the causes of chronic persistent cough and have reached the same conclusion.
In January of 2006, the American College of Chest Physicians published a guideline on the diagnosis and management of cough. UACS is the single most common cause of chronic cough, accounting for 8% to 87% of cases, either exclusively or in combination with other factors.2,13 Categories of UACS-induced cough include allergic rhinitis (seasonal or perennial), perennial nonallergic rhinitis (vasomotor or nonallergic rhinitis with eosinophilia), postinfectious UACS, bacterial sinusitis, allergic fungal rhinitis, occupational rhinitis, rhinitis medicamentosa, and pregnancy-associated rhinitis. The pathogenesis of cough in UACS involves stimulation of afferent receptors in the upper airway, rather than run-off of secretions into the lower airway. The presence of copious sputum is associated with an increased likelihood of chronic sinusitis, but neither the clinical examination nor historical features reliably differentiate it from other causes of UACS.11,13 Excessive sputum production, defined as greater than 30 mL per day, can be a manifestation of asthma, GERD, and bronchiectasis.
In most series, asthma is the second most common cause of chronic cough in adult nonsmokers, present in 14% to 55% of cases.16,17 Historical features of wheezing, chest tightness, or exertional dyspnea in response to triggers such as strong odors or perfumes, cold air, or allergens should suggest the diagnosis. The physical examination and spirometry can be entirely normal in patients with chronic cough due to asthma. In some cases, reflux-mediated irritation of laryngeal receptors or episodic microaspiration underlie GERD-induced cough.
The esophageal pH monitoring study will be negative in patients with nonacid reflux, and if this condition is suspected, barium esophagography may be helpful. Most patients with GERD do not have endoscopic findings that suggest acid reflux, such as esophagitis or Barrett's epithelium, and a normal endoscopy does not rule out GERD as a source of cough.
A subset of patients has been recognized with increased sputum eosinophils in the absence of demonstrable bronchial hyperresponsiveness. Chronic bronchitis is characterized by a productive cough on most days for 3 months in 2 consecutive years.
The cause of cough in chronic bronchitis is multifactorial, with bronchial secretions and airway inflammation playing a primary role. Pertussis, or whooping cough, is a severe and debilitating cough illness that can last for weeks to months. Chronic cough may be unexplained despite comprehensive workup and empirical treatment trials in a substantial number of patients. Disorders of any of the locations of cough receptors (external auditory canal, tracheobronchial tree, pleura, pericardium, diaphragm, esophagus, stomach) can cause chronic cough.
The management of chronic cough typically involves some combination of simple screening studies (chest x-ray and spirometry), additional specific diagnostic studies (methacholine provocation, sinus imaging, or a pH probe), and empirical therapy for the three most common entities (rhinitis, asthma, GERD) (see Figure 1). Evaluation and treatment using our algorithm (see Figure 1) assume that failure to remedy the cough using trials of empirical therapy will precipitate appropriate diagnostic testing. Common causes for diagnostic frustration include inadequate diagnosis and inadequate treatment.
Initial therapy for most postnasal drainage syndromes should include an antihistamine-decongestant combination (Table 2). Initial empirical therapy with an antihistamine-decongestant has been shown to be effective in a large percentage of patients who present with chronic cough. The presence of bronchial hyperresponsiveness should be demonstrated by provocation testing or reliable history before initiating oral steroids. The cause of chronic cough may be otherwise clinically silent, and it is not uncommon for there to be more than one contributing factor.
In the absence of smoking and angiotensin-converting enzyme inhibitors, upper airway cough syndrome, asthma, and gastroesophageal reflux disease are the most common causes of chronic cough in patients with a normal chest radiograph.
In most cases, empirical therapy targeted at the most common diagnoses leads to significant improvement or resolution of cough, obviating the need for extensive diagnostic testing.
Inadequate length of treatment, insufficient medication intensity, and patient nonadherence are common reasons for treatment failure. Ultimately, determining the underlying cause of cough is accomplished by demonstrating a response to therapy. February 1, 2014On a chest x-ray lung abnormalities will either present as areas of increased density or as areas of decreased density.Lung abnormalities with an increased density - also called opacities - are the most common. Whenever you see an area of increased density within the lung, it must be the result of one of these four patterns.
Consolidation - any pathologic process that fills the alveoli with fluid, pus, blood, cells (including tumor cells) or other substances resulting in lobar, diffuse or multifocal ill-defined opacities.
Interstitial - involvement of the supporting tissue of the lung parenchyma resulting in fine or coarse reticular opacities or small nodules. Atelectasis - collapse of a part of the lung due to a decrease in the amount of air in the alveoli resulting in volume loss and increased density. Here are the most common examples of these four patterns on a chest x-ray (click image to enlarge).
You have to realize that it is not always possible to divide lung abnormalities into one of these four patterns, but that should not be a problem. Sometimes you are confronted with an abnormality that looks like a mass, but it could also be a consolidation. In such a case information from clinical data, old films or follow-up films and CT-scan will usually solve the problem.
Consolidation is the result of replacement of air in the alveoli by transudate, pus, blood, cells or other substances. For instance a lobar pneumonia caused by streptococcus pneumoniae may become diffuse if the patient does not respond to the treatment. These diseases typically present as multifocal consolidations, but sometimes they may become diffuse.
It is very important to differentiate between acute consolidation and chronic consolidation, because it will limit the differential diagnosis.
Chronic post-infection diseases like organizing pneumonia (OP) or chronic eosinophilic pneumonia, which both present with multiple peripheral consolidations. Sarcoidosis is the great mimicker and sometimes the granulomatous noduli are so small and diffuse that they can present as consolidation.
Alveolar proteinosis is a rare chronic disease that is characterized by filling of the alveoli with proteinaceous material. Lobar consolidation is the result of disease that starts in the periphery and spreads from one alveolus to another through the pores of Kohn. At the borders of the disease some alveoli will be involved, while others are not, thus creating ill-defined borders. As the disease reaches a fissure, this will result in a sharp delineation, since consolidation will not cross a fissure. As the alveoli that surround the bronchi become more dense, the bronchi will become more visible, resulting in an air-bronchogram (arrow). In consolidation there should be no or only minimal volume loss, which differentiates consolidation from atelectasis. Expansion of a consolidated lobe is not so common and is seen in Klebsiella pneumoniae and sometimes in Streptococcus pneumoniae, TB and lung cancer with obstructive pneumonia. On the chest x-ray there is an ill-defined area of increased density in the right upper lobe without volume loss.
However if this patient had weight loss or long standing symptoms, we would include the list of causes of chronic consolidation.
Based on the images alone, it is usually not possible to determine the cause of the consolidation. Other things need to be considered, like acute or chronic illness, clinical data and other non-pulmonary findings.
Infarction - peripheral consolidation in a patient with acute shortness of breath with low oxygen level and high D-dimer. Pumonary cardiogenic edema - filling of the alveoli with transudate in a patient with congestive heart failure. Sarcoidosis - at first glanse this looks like consolidation, but in fact this is nodular interstitial lung disease, that is so wide-spread that it looks like consolidation.
In this case there was a solitary nodule in the right upper lobe and a biopsy was performed. The radiographic features of acute pulmonary thromboembolism are insensitive and nonspecific. The most common radiographic findings in the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study were atelectasis and patchy pulmonary opacity.
The peripheral consolidation is seen in the region of the emboli and can be attributed to hemorrhage in the infarcted area. A nonfunctioning part of the lung lacks communication with the bronchial tree and receives arterial blood supply from the systemic circulation. This is also called cardiogenic edema, to differentiate it from the various causes of non-cardiogenic edema.
The increased heart size is usually what distinguishes between cardiogenic and non-cardiogenic.
Look for other signs of heart failure like redistribution of pulmonary blood flow, Kerley B-lines and pleural fluid. However some patients, who have an acute cardiac infarction, may still have a normal heart size, while other patients who have a large heart due to a chronic heart disease, may have non-cardiac pulmonary edema due to a superimposed pulmonay infection, ARDS, near-drowning etc.
All these findings indicate, that we are dealing with pulmonary edema due to heart failure. Unlike lobar pneumonia, which starts in the alveoli, bronchopneumonia starts in the airways as acute bronchitis. The chest x-ray shows diffuse consolidation with 'white out' of the left lung with an air-bronchogram.
The disease started as a persitent consolidation in the left lung and finally spread to the right lung.
It demonstrates, that based on the x-ray alone, it is not certain which pattern we are looking at. On the other hand this also could be areas of consolidation with hypodense areas due to necrosis.
BatwingA bilateral perihilar distribution of consolidation is also called a Batwing distribution.
The sparing of the periphery of the lung is attributed to a better lymphatic drainage in this area. Reverse BatwingPeripheral or subpleural consolidation is called reverse Batwing distribution.
Multifocal consolidations are also described as multifocal ill-defined opacities or densities. As mentioned before bronchopneumonia starts in the bronchi and then spreads into the lungparenchyma.
In some cases however the underlying pathology of multiple ill-defined densities is interstitial disease, like in the alveolar form of sarcoidosis in which the granulomas are very small and fill up the alveoli. The larger ones are ill-defined and maybe there is an air-bronchogram in the right lower lobe.
Probably we are dealing with multifocal consolidations, but one might also consider the possibility of multiple ill-defined masses. This patient had a several month history of chronic non-productive cough, that did not respond to antibiotics. The lab-findings were normal which makes bronchoalveolar carcinoma and lymphoma less likely.
Wegener's is a collagen vascular disease with vasculitis involving the lung, kidney and sinuses.
In the lung the vasculitis causes infarcts which first present as ill-defined areas of consolidation. In a later stage these infarcts become more circumscribed and can be seen as multiple nodules or masses, sometimes with cavitation. There are ill-defined densities in the right lung, which proved to be a manifestation of Wegener's. On a Chest X-Ray it can be very difficult to determine whether there is interstitial lung disease and what kind of pattern we are dealing with. When the cysts have thick walls like in Langerhans cell histiocytosis or honeycombing, it frequently presents as a reticular pattern on a CXR.
However sometimes an interstitial pattern can be seen and in many cases UIP can be suspected based on the x-ray findings. It can be difficult to determine whether we are dealing with a reticular pattern or a cystic pattern. This creates a reticular pattern on the chest x-ray, because the cysts in honeycombing have thick walls. Here another chest x-ray with interstitial edema and Kerley B lines in a patient with congestive heart failure.
In this case the chest x-ray shows subtle findings that could be described as fine reticulation. The differential diagnosis includes chronic hypersensitivity pneumonitis, which also results in fibrosis with upper lobe predominance. This pattern was first attributed to chronic congestive heart failure, but persisted on follow-up CXR's despite therapy.
An acute reticular pattern is most frequently caused by interstitial edema due to cardiac heart failure. On a CXR sarcoidosis usually first presents with hilar and mediastinal lymphadenopathy (example). Parenchymal disease can present as consolidation or even as masses, but the most common presentation is a fine nodules.


Atelectasis or lung-collapse is the result of loss of air in a lung or part of the lung with subsequent volume loss due to airway obstruction or compression of the lung by pleural fluid or a pneumothorax. Evidently it is very important to recognize the various presentations of atelectasis, since some of them can be easily misinterpretated. Lobar atelectasis or lobar collaps is an important finding on a chest x-ray and has a limited differential diagnosis.
Sometimes lobar atelectasis produces only mild volume loss due to overinflation of the other lungparts. On the PET-CT a lungneoplasm is seen with subsequent atelectasis of the right upper lobe due to obstruction of the upper lobe bronchus. A common finding in atelectasis of the right upper lobe is 'tenting' of the diafphragm (blue arrow). This patient had a centrally located lungcarcinoma with metastases in both lungs (red arrows). Usually right middle lobe atelectasis does not result in noticable elevation of the right diaphragm. A pectus excavatum can mimick a middle lobe atelectasis on a frontal view, but the lateral view should solve this problem. Chest x-rays of a 70-year old male who fell from the stairs and has severe pain on the right flank. The right interlobar artery is not visible, because it is not surrounded by aerated lung but by the collapsed lower lobe, which is adjacent to the right atrium. Notice the reappearance of the right interlobar artery (red arrow) and the normal right heart border (blue arrow).
There is a centrally located mass which obstructs the left upper lobe bronchus (red arrow). You would not expect the apical region to be this dark, but in fact this is caused by overinflation of the lower lobe, which causes the superior segment to creep all the way up to the apical region. Singapore health authorities are reporting an increased number of hand, foot and mouth disease (HFMD) so far in 2015, according to local media sources. Since the beginning of the year, health officials have reported 609 HFMD cases, approximate double 2014 numbers for the same period. The contagious virus has affected several child care facilities in the city prompting the Department of Health to stress the importance of maintaining high standards of personal and environmental hygiene to minimize the risk of HFMD.
Parents should consult a doctor early if their child has fever, mouth ulcers and rashes on the palms, soles or buttocks. In Okinawa, health officials at Kadena AB say they have reported several cases of HFMD in the military and dependent population. Hand, foot, and mouth disease is caused by viruses that belong to the Enterovirus genus (group).
Coxsackievirus A16 is the most common cause of hand, foot, and mouth disease in the United States, but other coxsackieviruses have been associated with the illness. Enterovirus 71 has also been associated with hand, foot, and mouth disease and outbreaks of this disease. Complications associated with HFMD caused by the more pathogenic EV-71 strain include encephalitis, aseptic meningitis, acute flaccid paralysis, pulmonary edema or hemorrhage and myocarditis. According to the US Centers for Disease Control and Prevention (CDC), there is no vaccine to protect against the viruses that cause hand, foot, and mouth disease. Washing hands often with soap and water, especially after changing diapers and using the toilet. Avoiding close contact such as kissing, hugging, or sharing eating utensils or cups with people with hand, foot, and mouth disease. The drugs most commonly connected with drug-induced lupus are hydralazine (used to treat high blood pressure or hypertension), procainamide (used to treat irregular heart rhythms), and isoniazid (used to treat tuberculosis). Neonatal lupus is a rare condition that affects infants of women who have lupus and is caused by antibodies from the mother acting upon the infant in the womb. Although previous studies have demonstrated improved outcomes, the effect of adding bolus intravenous nitroglycerin to standard American Heart Association (AHA) treatment of severe ADHF has not been defined. B-type natriuretic peptide (BNP) is a polypeptide secreted by the cardiac ventricles in response to myocyte stretch, resulting from ventricular volume expansion and pressure overload.
Therefore, higher cutoff values need to be identified for this important patient population. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. B-type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure: analysis from Breathing Not Properly (BNP) Multinational Study. The next question is whether the BNPcan replace other tests like the chest x ray or echocardiogramfor some patients. The fluid buildup makes it hard for the lungs to do their job, including getting oxygen from the air you breathe. For instance, if it’s due to heart failure, treating the heart condition will treat the edema. The link you followed may have moved in the recent site reorganization, it may be inaccurate, or access to the file may be restricted. Please remember that this information should not substitute for a visit or a consultation with a healthcare provider.
Chronic or persistent cough, defined as lasting more than 8 weeks, is usually not caused by a life-threatening disorder.
An optimal, cost-effective approach to the management of chronic cough remains controversial. The cough reflex is characterized by the generation of high intrathoracic pressures against a closed glottis, followed by forceful expulsion of air and secretions on glottic opening. This has hampered progress in the study of cough, and most of our understanding of the neuronal regulation of cough is derived from animal studies. Rapidly adapting receptors are activated by mechanical forces such as lung inflation and deflation, whereas C fibers are much more sensitive to chemical stimuli, primarily bradykinin. The population point-prevalence of chronic cough depends on smoking status, ranging from 5% to 40%. The most common complications include feeling that something is wrong (98%), exhaustion (57%), feeling self-conscious (55%), insomnia (45%), lifestyle change (45%), musculoskeletal pain (45%), hoarseness (43%), excessive perspiration (42%), and urinary incontinence (39%).2 A host of other physiologic symptoms occur occasionally due to the high intrathoracic and intra-abdominal pressures achieved. Acute cough has been defined as one with a duration of less than 3 weeks at presentation.1 Some clinicians have proposed a category of subacute cough, with a duration of 3 to 8 weeks. Although there are no case series addressing the frequency of the common cold as a cause of acute cough, epidemiologic data support the relation. It manifests as a persistent cough, with or without sputum production, in patients with a normal chest radiograph.
Pneumonia can also manifest with acute cough, and its manifestation can be more subtle in the elderly. In the presence of a compatible history and examination, further diagnostic testing is usually not necessary. As a general principle, the positive and negative predictive values of tests for the cause of chronic cough are poor, implying that attribution of cause depends on a response to specific therapy. All patients should undergo evaluation for exposure to common allergens or chemical irritants. Associated symptoms include rhinorrhea, nasal congestion, a sensation of drainage or tickle in the oropharynx, and throat clearing. Patients with chronic sinusitis can present with a nonproductive cough as their sole symptom. The presence of air-fluid levels on four-view sinus x-rays is more specific for diagnosing sinusitis, and one report documented a 100% PPV.15 Due to the poor PPV, CT scan of the sinuses is not encouraged routinely for the diagnosis of UACS1.
In a subset of asthmatic patients, cough is the primary or sole symptom, a condition termed cough-variant asthma (CVA).
The most useful test to support the diagnosis is a bronchoprovocation test with inhaled methacholine. Patients with GERD are commonly asymptomatic, and it can be assumed that the condition is therefore underrecognized. It is important to include a temporal symptom log when conducting pH monitoring so as to document the causality of reflux events vis-à-vis cough.
Esophageal intraluminal impedance plethysmography may also be able to identify patients with nonacid reflux.
It is reasonable to empirically treat patients who fit the clinical profile before testing. These patients are typically nonsmokers and have a chronic cough that responds to inhaled corticosteroids.
It may be caused by irritant-induced inflammation or by the need to mobilize excessive secretions. Cough completely resolves or significantly decreases in 90% of patients after smoking cessation. Postinfectious cough is a diagnosis of exclusion, and by definition it eventually resolves, but its duration may be prolonged. In referral centers, the prevalence has been reported to be as high as 42% of cases.32 A heightened sensitivity to cough challenge with capsaicin has been demonstrated in these patients.
It is a diagnosis of exclusion and should not be entertained until all other potential causes have been investigated, with therapeutic trials of adequate intensity and duration.
Recently, obstructive sleep apnea and chronic tonsillar hypertrophy have been recognized as associations with chronic cough. Patients who lack specific clues by history and examination and who have a normal chest x-ray and spirogram represent the most common management dilemma for the clinician. Cough may be the sole manifestation of disorders such as asthma, GERD, or UACS, with a paucity of other historical features to suggest the correct diagnosis.
A significant fraction of nonresponders fail treatment due to inadequate intensity or duration of treatment. First- generation antihistamines, such as dexbrompheniramine maleate or azatadine maleate, have been demonstrated to be superior to second-generation (nonsedating) drugs, due to their additional anticholinergic activity.2 If drowsiness is problematic, therapy may be initiated with bedtime dosing before instituting twice-daily dosing. Using a pressurized MDI can aggravate cough which may be alleviated by the addition of a spacer. Caution is warranted when interpreting the results of empirical therapeutic success with asthma therapy; NAEB and postinfectious cough might respond similarly. Patients should avoid reflux-predisposing foods (fatty foods, chocolate, caffeine, alcohol), give up tobacco, elevate the head of the bed, and not eat within 2 or 3 hours before lying down. Cough frequency and sputum production are most effectively decreased by ipratropium MDI (2 puffs qid).
Narcotics (morphine, codeine and dextromethorphan) have traditionally been used for cough suppression but have well known and prohibitive side effects with chronic use. The balance between empiricism and testing is often dictated by the patient's clinical course and quality of life. An empiric integrative approach to the management of cough: ACCP evidence-based clinical practice guidelines.
Introduction to the diagnosis and management of cough: ACCP evidence-based clinical practice guidelines. Managing cough as a defense mechanism and as a symptom: a consensus panel report of the American College of Chest Physicians.
Global physiology and pathophysiology of cough: ACCP evidence-based clinical practice guidelines. Anatomy and neurophysiology of the cough reflex: ACCP evidence-based clinical practice guidelines. Chronic cough: the spectrum and frequency of causes, key components of the diagnostic evaluation, and outcome of specific therapy. Chronic persistent cough in the adult: the spectrum and frequency of causes and successful outcome of specific therapy. Chronic cough with a history of excessive sputum production: the spectrum and frequency of causes, key components of the diagnostic evaluation, and outcome of specific therapy. Overview of common causes of chronic cough: ACCP evidence-based clinical practice guidelines. From a prospective study of chronic cough: diagnostic and therapeutic aspects in older adults.
Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Predictive values of the character, timing, and complications of chronic cough in diagnosing its cause.
Chronic persistent cough: experience in diagnosis and outcome using an anatomic diagnostic protocol. Evaluation and outcome of patients with chronic non-productive cough using a comprehensive diagnostic protocol. Chronic cough due to gastroesophageal reflux disease: ACCP evidence-based clinical practice guidelines. A prospective evaluation of esophageal testing and a double-blind, randomized study of omeprazole in a diagnostic and therapeutic algorithm for chronic cough. Randomized clinical trial: high-dose acid suppression for chronic cougha€”a double-blind, placebo-controlled study [published online ahead of print November 17, 2010]. Chronic cough due to nonasthmatic eosinophilic bronchitis: ACCP evidence-based clinical practice guidelines.
Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. Serum immunoglobulin G analysis to establish a delayed diagnosis of chronic cough due to Bordetella pertussis [published online ahead of print October 10, 2011]. Controversies in the evaluation and management of chronic cough [published online ahead of print December 10, 2010]. Cough reflex sensitivity improves with speech language pathology management of refractory chronic cough. Pharmacological and clinical overview of cloperastine in treatment of cough [published online ahead of print March 7, 2011]. Levodropropizine in the management of cough associated with cancer or nonmalignant chronic disease: a systematic review [published online ahead of print August 1, 2011]. We assume that the atelectasis was a result of post-traumatic poor ventilation with mucus plugging. Most common in young children, it presents as fever, oral lesions and rash on the hands, feet and buttocks.
This group of viruses includes polioviruses, coxsackieviruses, echoviruses, and enteroviruses.
Although there are many types of rashes and lesions (sores) caused by cutaneous lupus, the most common rash is raised, scaly and red, but not itchy.
The symptoms of drug-induced lupus are similar to those of systemic lupus, but only rarely will any major organs be affected. Drug-induced lupus is more common in men because they are given these drugs more often; however, not everyone who takes these drugs will develop drug-induced lupus.
At birth, the infant may have a skin rash, liver problems, or low blood cell counts, but these symptoms disappear completely after several months with no lasting effects. Our primary objective is to evaluate the feasibility of using this novel therapeutic approach in the management of severe ADHF. CONTEXT: Decompensated congestive heart failure (CHF) is the leading hospital discharge diagnosis in patients older than 65 years. BNP levels are elevated in patients with left ventricular dysfunction, and the levels correlate with both the severity of symptoms and the prognosis. For intermediate levels, use of clinical judgment and adjunctive testing are encouraged (4).
The views or opinions expressed in the resources provided do not necessarily reflect those of Thomas Jefferson University Hospitals, Thomas Jefferson University or their staffs. However, the frequency of this complaint, its effect on quality of life, and concern about a serious underlying cause make chronic cough an important problem. A common situation that clinicians face is the presence of a cough of unclear cause in the setting of a normal chest x-ray and normal spirometry, which is the focus of this section. Because chronic cough is usually due to a benign cause, we recommend a stepwise approach employing empirical therapy targeted at the most common diagnoses, without extensive initial diagnostic testing (Figure 1). The role of vagal afferent nerves in initiating the cough reflex is undisputed; however, the function of the various afferent neuronal subtypes in the regulation of cough is not well understood. Signals from the receptors are carried by vagal afferents to a medullary cough center, which then trigger cough activation via efferents mediated by the vagal, phrenic, and spinal motor nerves. Although cough can cause a variety of anatomic and physiologic complications, 98% of patients in one series listed the suspicion of underlying disease to be the major factor prompting them to seek medical attention.
The most prevalent symptoms include cough syncope, cardiac dysrhythmias, headache, subconjuctival hemorrhage, inguinal herniation, and gastroesophageal reflux. Although this classification system is widely used and accepted by most experts, there are no case series assessing the relative frequency of causes in either the acute or subacute categories. Although it is much less prevalent than the common cold, acute bronchitis is the most common diagnosis given to patients presenting to a physician with acute cough.
Despite this, reports have indicated that more than two thirds of patients receive antibiotic therapy for acute bronchitis.


Prospective studies have shown that the history and physical examination alone can predict the likelihood of pneumonia and therefore the need for a chest radiograph. Underrecognized causes of acute or subacute cough include pertussis and mycoplasma infection.
Additionally, in 18% to 62% of patients, there are two significant causes, and in up to 42% there are three.9a€“11 In studies from cough clinics, the data suggest that there is little or no diagnostic value in descriptive features such as cough frequency, character, or sputum production. Even in immunocompromised hosts and areas where tuberculosis is endemic, UACS, asthma, GERD, and NAEB are the most common causes reported. Given the lack of understanding about whether PND is the cause of cough or a consequence of airway inflammation that is producing cough, the term upper airway cough syndrome was adopted as a more accurate descriptor.
Physical examination can reveal nasal congestion or discharge, nasal mucosal bogginess, mucous in the oropharynx, or a cobblestone appearance of the oropharyngeal mucosa.
The methacholine challenge test (MCT) is highly sensitive, and a negative test virtually excludes the diagnosis of asthma. Nevertheless, GERD-induced cough is frequently attributable to a reflex loop involving vagal afferents in the distal esophagus, and proximal reflux is unnecessary in the pathogenesis.21 Reflux into the distal esophagus alone can stimulate the esophageal-bronchial cough reflex.
However, there are no published data to suggest that outcomes are improved with this device.
However, recent data indicate that empirical treatment of patients with chronic cough who have rare or no heartburn may not improve cough related quality of life or symptoms.24 Similar to other causes of chronic cough, a diagnosis is suggested only when the cough resolves with treatment. Although chronic bronchitis is a common cause of cough in the population, it is present in only 5% of those seeking medical attention for cough.9,10 Cigarette smoke is the most common irritant associated with chronic bronchitis. In contrast to acute bronchitis, exacerbation of chronic bronchitis should be treated with antibiotics. For this reason, 8 weeks is a more clinically useful working definition of chronic cough than 3 weeks. Active pertussis infection in adolescents and adults is an underrecognized cause of chronic cough.
Cough due to ACE inhibitors is a class effect and has been documented with all ACE inhibitors.
There are no distinguishing historical features to reliably differentiate it from other etiologies.16 Habit cough is a syndrome of persistent, habitual throat clearing that might respond to biofeedback.
In addition to ACE inhibitors, drugs such as sitagliptin, inhaled corticosteroids, topiramate, erythromycin, ribavirin and methotrexate have been associated with chronic cough.
A major decision involves the extent of specific diagnostic testing as opposed to trials of empirical therapy.
One study found that the diagnosis was correct in 14% of referred patients, but the treatment regimens were insufficient.10 In these cases, diagnostic testing facilitates appropriate narrowing and intensification of treatment. Over-reliance on historical features or cough characteristics can thwart accurate diagnosis because these are often misleading. Benzonatate is a valuable option for cough suppression; however, side-effect profile includes seizures and cardiac arrhythmias. Complete resolution of chronic cough can take weeks to months, and both the physician and patient need to set realistic treatment goals. During this period, contact with other children should be avoided until the child recovers. The oral lesions consist of rapidly-ulcerating vesicles on the buccal mucosa, tongue, palate and gums. It is commonly known as a discoid rash, because the areas of rash are shaped like disks, or circles.
The lupus-like symptoms usually disappear within six months after these medications are stopped. Secondary objectives include an assessment of the safety and efficacy of bolus intravenous nitroglycerin. OBJECTIVE: To compare the efficacy and safety of intravenous nesiritide, intravenous nitroglycerin, and placebo. When looking at direct effects of drugs, disease specific mortality may have a case for preference.  For example, screening mammography may effectively and significantly lower mortality from breast cancer without altering all cause mortality, simply because most women do not die from breast cancer.
Although our lab reports the results with a cut-off of 100 between normal and abnormal, I consider values between 100 and 500 to be indeterminate. Conclusions For dyspneic adult emergency department patients, a directed history, physical examination, chest radiograph, and electrocardiography should be performed. These can help improve how the heart functions, which helps reduce fluid buildup in the lungs.
The aggregate cost of treatment for cough exceeds several billion dollars in the United States alone. It is important to elicit which specific cough-related symptoms are bothersome for the patient as a guide to the pace and scope of diagnostic testing. Cough that lasts longer than 3 weeks but does not become chronic falls into the subacute category. Elderly patients are more likely to receive broad-spectrum antibiotics, and nine out of ten smokers receive antibiotics despite the lack of evidence that smoking itself is a risk factor for bacterial infection.
A diagnosis of pneumonia is unlikely in the absence of tachycardia, tachypnea, fever, and evidence of focal consolidation on chest examination. In addition, the most common causes of chronic cough can manifest with cough as the sole presenting symptom. Chronic bronchitis, usually resulting from cigarette smoking, is believed to be the most common overall cause of chronic cough, but most smokers with cough typically do not seek medical attention. The examination findings are nonspecific, however, and may be present in any of the other major causes of chronic cough.
A 20% decrement in forced expiratory volume in 1 second (FEV1) after methacholine inhalation, although indicating bronchial hyperresponsiveness, can have a PPV as low as 74% for diagnosing the cause of cough.19 More recently, measurement of exhaled nitric oxide has proved useful in the evaluation of chronic cough, presumably by identifying cases due to CVA. It is important to recognize that nonacid reflux can cause chronic cough, and these patients do not respond to acid-suppression therapy. A temporal symptom log can also substantiate GERD as a cause of cough even when pH probe scores lie within the normal range. If induced sputum cannot be obtained or is nondiagnostic, bronchoscopy with bronchial wash can provide useful information. There is a direct relation between the incidence of chronic bronchitis and the number of cigarettes smoked. Acute respiratory infections, whether viral or bacterial, are a common cause of exacerbations in chronic bronchitis. Particular vigilance is warranted when there is a change in the character of the cough or sputum, because this may be the manifesting feature of a superimposed bronchogenic carcinoma. Postinfectious cough is usually caused by respiratory viruses, Mycoplasma spp, Chlamydia pneumoniae (strain TWAR), or Bordatella pertussis.
One investigation found a 21% incidence of pertussis in a group of patients with a cough duration of 2 weeks to 3 months.29 In recent years, the incidence of pertussis has increased, most likely due to a combination of waning immunity and increased detection of the illness. The syndrome appears to have a predilection for females who have onset of cough around menopause.
Randomized clinical trials do not provide adequate guidance to help the clinician choose between these two strategies. Finally, there are no diagnostic tests with a sufficiently high PPV to reliably implicate any particular cause of cough. Because the overwhelming majority of patients have UACS, asthma, or GERD, it is crucial to assiduously investigate the roles of each before further investigations.
The cause of cough may be otherwise clinically silent, and 18% to 62% of chronic coughs are due to two or more causes.
The role of bacteria in perpetuating chronic sinusitis is controversial, and treatment regimens are not well defined. Steroids should also be tapered in patients whose MCT was obtained in the setting of a postinfectious cough. Intensive treatment for at least several months should be attempted before referral for further diagnostic testing. A chest radiograph and spirometry are recommended before referring a patient to a specialist. The rash consists of papulovesicular lesions on the palms, fingers and soles, which generally persist for seven to 10 days, and maculopapular lesions on the buttocks. Another common example of cutaneous lupus is a rash over the cheeks and across the bridge of the nose, known as the butterfly rash. With proper testing, physicians can now identify most at-risk mothers, and the infant can be treated at or before birth. Methods: This study was designed as an unblinded pilot intervention trial of the addition of bolus intravenous nitroglycerin to standard AHA treatment for ADHF. DESIGN, SETTING, AND PATIENTS: Randomized, double-blind trial of 489 inpatients with dyspnea at rest from decompensated CHF, including 246 who received pulmonary artery catheterization, that was conducted at 55 community and academic hospitals between October 1999 and July 2000.
If the suspicion of heart failure remains, obtaining a serum BNP level may be helpful, especially for excluding heart failure.
When the heart doesn’t work properly, it can cause pressure to rise in the veins (blood vessels) of the lungs. Thus, it remains unclear whether most patients should undergo a trial of empirical therapy (either sequential or concurrent) or an aggressive and targeted diagnostic evaluation. For instance, in patients with a normal chest x-ray who have persistent cough and hemoptysis after antibiotic treatment, a fiberoptic bronchoscopic examination may be indicated to exclude endobronchial malignancy. Afferent nerves are most concentrated in the epithelia of the upper and lower respiratory tracts, but they are also located in the external auditory meatus, tympanic membrane, esophagus, stomach, pericardium, and diaphragm.
Most of the attention by clinicians is devoted to chronic or persistent cough because this is the variety that usually prompts patients to seek medical care. Postinfectious cough due to irritation of cough receptors accounts for most of these cases.
Viral cultures and serologic assays are not routinely ordered; hence, the organism responsible is rarely identified. Treatment of self-limited bronchitis with antibiotics is often fueled by public expectation. All of these data are derived from studies of patients referred to pulmonologists or cough clinics; however, it is likely that a similar spectrum of causes accounts for most patients seen by primary care providers. Although most patients have at least one symptom or sign, UACS can manifest as cough alone up to 20% of the time.12 Because it is highly prevalent and may be otherwise clinically unapparent, it is reasonable to employ a brief trial of empirical treatment in the approach to diagnosis.
The pathogenesis of NAEB is not well understood, although, similar to asthma, an inhaled allergen or environmental agent is theorized to play a role. Patients experience periodic episodes of violent coughing, and post-tussive emesis is common. Usually, cough begins within 1 week of starting the medication, but it can begin as late as 1 year later. Most patients with psychogenic cough harbor an intractable fear of a serious underlying medical disease. Vitamin B12 deficiency has been associated with chronic cough via induction of cough reflex hypersensitivity. The approach is usually negotiated with the patient, partly based on the level of subjective distress and on the level of exasperation by the patient and the clinician. Diagnostic testing that suggests an underlying cause does not ensure that cough is caused by that etiology. Occupational and environmental exposures should be considered as exacerbating factors in all patients who present with cough. Zafirlukast, a leukotriene inhibitor, has been shown to have an antitussive effect in patients with CVA. Documentation of persistent symptomatic acid reflux should prompt referral to a specialist. Recent introduction of central cough suppressants such as cloperastin37 and peripheral cough suppressants such as levodrpropizine38 and moguisteine39 have been welcome additions although not yet available in the United States. For this reason, a combination of systematic empiricism and limited adjunctive diagnostic testing are appropriate for most patients. Proper hygiene should also be practiced at home so as to prevent transmission to other family members. Other rashes or sores may appear on the face, neck, or scalp (areas of the skin that are exposed to sunlight or fluorescent light), or in the mouth, nose, or vagina. INTERVENTIONS: Intravenous nesiritide (n = 204), intravenous nitroglycerin (n = 143), or placebo (n = 142) added to standard medications for 3 hours, followed by nesiritide (n = 278) or nitroglycerin (n = 216) added to standard medication for 24 hours.
Similarly, new cough or a persistent change in the character of cough in a patient with heavy smoking history may necessitate airway examination. Most commonly, persistent bronchial or sinonasal inflammation caused by a preceding viral upper respiratory infection is the culprit. Ultimately, UACS is a syndrome without a clear definition, and its role in chronic cough is best proven by a response to therapy.
Persistent eosinophilic airway inflammation can lead to progressive airflow obstruction, and NAEB may be implicated as a causative factor in chronic obstructive pulmonary disease (COPD).26 The frequency and significance of NAEB remain incompletely understood.
Clinicians should also inquire about passive smoke exposure because it is linked to chronic productive cough.
Inadequate treatment regimens are a common reason for failure to alleviate symptoms, and eradication of related symptoms (heartburn, nasal congestion) does not ensure that an underlying cause is sufficiently treated. Long-term use of topical decongestants should be discouraged to avoid rebound nasal congestion (rhinitis medicamentosa). Surgical correction with esophageal fundoplication is controversial and can result in significant comorbidity. The discovery of upregulation of the transient receptor potential (TRP) nociceptors in patients with cough reflex hypersensitivity promises new peripherally active agents (TRP receptor antagonists) in the treatment of stubborn cough. Hair loss and changes in the pigment, or color, of the skin are also symptoms of cutaneous lupus.
MAIN OUTCOME MEASURES: Change in pulmonary capillary wedge pressure (PCWP) among catheterized patients and patient self-evaluation of dyspnea at 3 hours after initiation of study drug among all patients. Newer generation nonsedating antihistamines are not as effective in reducing cough compared with the older, first-generation antihistamine-plus-decongestant preparations. Because the recommended therapy (older generation antihistaminics) can suppress the cough reflex centrally and peripherally, response to therapy may not necessarily confirm that the diagnosis is accurate.
The role of nonacid reflux in cough pathogenesis is also currently unknown, but it probably accounts for some of the nonresponders.
The main inclusion criterion was a systolic blood pressure of 160 mm Hg or greater or a mean arterial pressure of 120 mm Hg or greater. Secondary outcomes included comparisons of hemodynamic and clinical effects between nesiritide and nitroglycerin at 24 hours.
Bronchodilators are not recommended as adjunctive treatment unless baseline airflow obstruction is present. Central cough suppressants, such as dextromethorphan and codeine, should generally be avoided; they might serve as a temporizing measure but can distract from the search for a specific cause.
Patients with a suspected or proven right ventricular infarction, known or suspected pregnancy, or a history of intolerance to nitroglycerin and those requiring immediate intubation or cardiopulmonary resuscitation were excluded. Angiotensin II receptor blockers do not cause cough and therefore are useful therapeutic alternatives. The study was approved by the institutional review board of Wayne State University, and written informed consent was obtained from all patients (or proxy) before initiation of the protocol. At 3 hours, nesiritide resulted in improvement in dyspnea compared with placebo (P =.03), but there was no significant difference in dyspnea or global clinical status with nesiritide compared with nitroglycerin. And in some cases, living or exercising at high altitudes can lead to fluid buildup in the lungs. On enrollment, baseline hemodynamic values and a serum brain natriuretic peptide level were obtained. Initial treatment of all patients consisted of 100% oxygen (by nonrebreather), 3 doses of sublingual nitroglycerin (0.4 mg), and intravenous furosemide (60 to 100 mg). CONCLUSION: When added to standard care in patients hospitalized with acutely decompensated CHF, nesiritide improves hemodynamic function and some self-reported symptoms more effectively than intravenous nitroglycerin or placebo. Ventilatory assistance with endotracheal intubation or biphasic positive airway pressure and administration of additional pharmacologic therapy was permitted at any point at the discretion of the treating physician. Secondary efficacy endpoints included the need for ICU admission and total hospital length of stay. Primary safety endpoints included the incidence of cardiac or neurovascular complications and symptomatic hypotension. Other administered medications included morphine (11 patients), angiotensin-converting enzyme inhibitors (10 patients), and b-blockers (3 patients).



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