3-14
lung disease, or a non-pulmonary cause (congestive heart failure) or an idiosyncratic effect (medications like
an ACE inhibitor). Most acute coughs, divided equally between upper airway (ENT) and lower airway (lung)
causes, are related to infections (viral upper respiratory tract infections, bronchitis, or laryngitis), allergies
(often seasonal) and postnasal drip. Most chronic coughs are due to underlying lung disease such as
emphysema, chronic bronchitis (especially in smokers) or asthma. Environmental irritants, perennial allergies,
and gastroesophageal (GE) reux/aspiration can also cause chronic cough. Cough due to heart failure,
tuberculosis or lung cancer may be more likely, depending on patient history.
Subjective: Symptoms
Focused History: Quality: Does anything come up when you cough? (indicates secretions and inflamma-
tion in the airway, which are common in infections) What color is the stuff you cough up? (green sputum:
associated with bacterial infection; blood: generally associated with infection or underlying lung disease; clear
or white sputum or non-productive cough: asthma or pneumonia from mycoplasma) Do cough at night?
(CHF, asthma, GE reflux)...while lying flat? (GE reflux) ...after exercise? (asthma) Have you had a cough that
changed? How? (COPD may have a chronic cough that increases and becomes productive with an infection).
Duration: How long have you been coughing? (viral URTI or viral bronchitis usually lasts 7-10 days; if >
14 days, consider underlying lung disease or a more serious type of infection, such as atypical pneumonia).
Alleviating or Aggravating Factors: What makes the cough better, and what makes it worse? (cough that
worsens with talking is usually due to infection or allergy; cough that improves by sitting up, gets worse after
eating or when lying down suggests GE reflux; cough that only occurs after exercise, and is worse in cold
weather [below 32°F the airway is devoid of moisture] is highly suggestive of asthma; cough that improves
with cold medications suggests allergy and post-nasal drip.) Do you smoke? (Morning cough is common,
due to chronic bronchitis.) Did you stop smoking recently? (After stoping, the clearance mechanisms of the
lung begin to recover and mobilize secretions from the lower airways. This type of cough is beneficial to the
lungs and improves over several months if they do not resume smoking).
Sputum Acute cough (< 24 hrs) Subacute (> 24 < 96 hrs) Chronic (Over 5 days)
Non-productive Viral or Mycoplasma or Asthma/COPD
Productive-Clear Viral or Asthma Viral or Asthma Asthma and/or Allergic
Purulent Bacterial Bacterial and/or Chronic Bronchitis
Thick/dark Bacteria and/or Chronic Bronchitis and/or underlying lung
disease
Bloody Bacterial Bacterial Bacterial/Tuberculosis/
Cancer
Pearls:
- Cough associated with eating suggests a mechanical swallowing problem causing aspiration, or a
tracheoesophageal fistula (connection between trachea and esophagus), or gastroesophageal reflux
(associated with heartburn or a sour taste). - Persistent morning cough that improves after expectorating sputum is typical of chronic bronchitis.
- Nighttime cough associated with SOB may suggest congestive heart failure (especially in elderly patients)
or asthma (if wheezing). Nighttime cough without SOB indicates a sinus infection or an allergic origin
such as post-nasal drip.
Objective: Signs
Using Basic Tools: Vital Signs: Low-grade fever (99–100.5°F): viral or mycoplasma infection; high-grade
fever (>102°F): bacterial infection; <14 breath/min: allergies, post-nasal drip, bronchitis, GE reux; >14
breaths/min: asthma, pneumonia, acute exacerbation of chronic bronchitis
Lungs: Resonant: normal – think upper airway cause (sinusitis, etc.); wheeze: asthma or emphysema (rarely
foreign body aspiration); rhonchi: secretions in the airway - bronchitis, pneumonia; rales: inflammation or
fluid in the alveoli – pneumonia; dull: parapneumonia effusion, pneumonia or collapsed lung; barrel chest:
COPD/chronic bronchitis; splinting respiration: pleurisy or pneumonia.
Using Advanced Tools Labs: Gram stain and culture of sputum: >15 white cells/high power field indicates
bacterial infection