Procedure, Treatment and Therapy

Definition | Treatment | Management of Disease | Diagnosis | Symptoms | Etiology | Pathophysiology | Procedure


Pertussis (Whooping Cough)

Pertussis (Whooping Cough) is an acute disease of the respiratory tract. Found in children younger than 5 years, especially in children age 2-3 years.

Pertussis is caused by gram-negative Bordetella Pertussis.

Clinical Overview
These symptoms occur 1-2 weeks after contact with the infected person and preceded by an incubation period of 7-14 days. Typically, the disease lasts for 6 weeks or more. That is why the disease is called cough hundred days.
On his way, pertussis includes several stages, namely:

  • Kataralis which marked the onset of a mild cough, especially at night, accompanied by mild fever and runny nose. This stage lasts 1-2 weeks. In the catarrhal stage indistinguishable from that caused by a viral respiratory infection
  • Second is the spasmodic stage lasts 2-4 weeks. Symptoms, cough more often, people with sweat, and blood vessels in the face of wide-neck. Long coughing attack usually ends with a distinctive high-pitched sound (whooping caugh) and accompanied by vomiting. Subconjunctival frequent bleeding and / or epistaxis. Nails and lips become blue because the blood of patients a lack of oxygen. Beyond the attacks, the patient looked healthy.
  • In the next stage, namely convalescence, going for two weeks. Symptoms, cough subsided and the patient gradually began to increase appetite.


  • Increased serum IgA specific Bordatella pertussis
  • Detected Bordatella pertussis from nasopharyngeal specimens
  • Nasopharyngeal swab culture was found Bordatella pertussis


  • Pertussis treatment aimed at infecting with appropriate antibiotics, such as erythromycin 30-50 mg / kg 4 times daily.
  • Codeine for cough may be given 0.5 mg / year / time.
  • Pertussis can be prevented by immunization of DPT (Diphtheria-Pertussis-Tetanus). This immunization is given three times in a row in infants aged three, four, five months.

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Management of Cough

The best management of cough is best to specific drug delivery to the etiology. Three forms of management of cough are:

1. Without the drug delivery
Cases with a cough without the interference caused by acute illness and heal itself usually does not need medication.
2. Specific Treatment
This treatment is given to the causes of cough.
If the cause of cough is known then the treatment should be directed towards the cause. With an integrated diagnostic evaluation, in almost all patients can be a known cause of chronic cough.
Specific treatment depends on the etiology or the cough mechanism. Asthma treated with bronchodilators or corticosteroids. Post nasal drip due to sinusitis treated with antibiotics, nasal spray and antihistamine-decongestant combinations, post nasal drip due to allergies or non allergic rhinitis dealt with avoiding environments that have the precipitating factors and antihistamine-decongestant combinations.
Gastroesophageal reflux treated by elevating the head, dietary modifications, antacids and cimetidine. Cough in chronic bronchitis treated by stopping smoking. Antibiotics are given to pneumonia, sarcoidosis treated with corticosteroids and cough in congestive heart failure with digoxin and furosemide.
Specific treatment also may include surgery such as pulmonary resection in lung cancer, polypectomi, remove hair from the outer ear canal.
Cases with a cough without the interference caused by acute illness and heal itself usually does not need medication.
3. Symptomatic treatment
Given both to patients who can not determined the cause of the cough as well as to patients who cough is a nuisance, not working properly and can potentially cause complications.
Symptomatic treatment is given if:
The cause of cough is certainly not known, so that specific treatment can not be given.
Coughing is not functioning properly and its complications endanger the patient.
Drugs used for symptomatic treatment of two types namely:
a. Antitussive
Antitussive is a medication that suppress the cough reflex, used in respiratory disorders and unproductive coughs due to irritated skin.
In general, based on place of work is divided into antitussive  drug that works in the peripheral and central antitussive who works at. Working in the central antitussive divided into non-narcotic and narcotic.
b. Mucokinesis
A pathologic fluid retention in the airway is called mucostasis. Drugs that are used to handle the situation called mucokinesis.

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Cough - Causes and Complications

Cough Reflex
Cough reflex consists of five main components, ie, cough receptors, afferent nerve fibers, central cough, nervous system and efferent effectors. A cough begins with a stimulus on cough receptor. These receptors are non-myelinated nerve fibers in the form of finely located both inside and outside the thoracic cavity. Located within the thoracic cavity, among others, contained in the larynx, trachea, bronchi and the pleura. Will decrease the number of receptors on the branches of a small bronchus, and a large number of receptors found in the larynx, trachea, carina and bronchus branching region. The receptors are also found even in the ear canal, stomach, hilum, paranasalis sinus, pericardial and diaphragm.
The most important afferents exist in the branch of the vagus, which excitatory flow of the larynx, trachea, bronchus, pleura, stomach, and also stimulate the ear through the Arnold branch of n. Vagus. Trigeminal nerve stimulation of the sinus paranasalis channeling, channeling glosofaringeus nerve stimulation of the pharynx and channel phrenic nerve stimulation of the pericardium and diaphragm.

Causes of Cough
Cough in outline can be caused by excitatory as follows:
Inflammatory stimuli such as mucosal edema with a lot of tracheobronchial secretions.
Mechanical stimuli such as foreign body in airway foreign body such as the respiratory tract, post nasal drip, retention of bronchopulmonary secretions.
Temperature stimuli such as cigarette smoke (an oxidant), heat / cold, gas inhalation.
Psychogenic stimuli.

Some causes of cough
  • Irritant
- Cigarettes
- Smoke
- SO2
- Gas in the workplace
  • Mechanical
- Retention of bronchopulmonary secretions
- Foreign body in respiratory tract
- Post nasal drip
- Aspiration
  • Obstructive Pulmonary Disease
- Chronic Bronchitis
- Asthma
- Emphysema
- Firbrosis cystic
- Bronchiectasis

  • Restrictive Lung Disease
- Pneumoconiosis
- Diseases of collagen
- Granulomatous Disease
  • Infection
- Acute Laryngitis
- Acute Brochitis
- Pneumonia
- Pleurisy
- Pericarditis

  • Tumor
- Laryngeal tumors
- Lung Tumors

  • Psychogenic
  • Other

Complications of Cough
At the time of coughing intrathoracic pressure rises to 300 mmHg. Pressure elevation is required to produce an effective cough, but this can lead to complications in the lungs, musculoskeletal, cardiovascular system and central nervous system.

Pneumomediastinum may arise in the lung, may also occur pneumoperitonium and pneumoretropritonium but this is very rare. Another complication was pneumothorax and emphysema, complications muskuloskletal, broken ribs, ruptured abdominal rectus muscle. Cardiovascular complications may include bradycardia, subconjungtiva vein laceration, nose and anus as well as cardiac arrest.

In the central nervous system can occur cough syncope, due to increased intrathoracic pressure occurs reflex vasodilation of systemic arteries and veins. This leads to decreased cardiac output and sometimes berkibat low arterial pressure resulting in loss of consciousness. Syncope occurred a few seconds after the paroxysmal cough.

Can also occur among other constitutional symptoms of insomnia, fatigue, decreased appetite, vomiting, elevated body temperature and headaches. Another complication is urinary incontinence, hernias and prolapse of the vagina.

Cough - Definition and Mechanisms

Cough is a symptom of the most common disease in which the prevalence was found in about 15% in children and 20% in adults. One out of ten patients who visited the doctor's office each year has a chief complaint of cough. Coughing can cause bad feelings, sleep disorders, affecting daily activities and reduce quality of life.

Cough is a complex physiological reflex that protects the lung from mechanical trauma, chemical and temperature. Coughing is also a natural defense mechanism of lung airway to keep it clean and open to the street:
Prevent the entry of foreign objects into the respiratory tract.
Remove foreign objects or abnormal secretions from the respiratory tract.
Coughing becomes physiologically when perceived as a nuisance. Such a cough is often a sign of a disease within or outside the lungs and sometimes are the early symptoms of a disease. Cough may be very significant on the transmission of disease through the air (air-borne infection). Cough is one of the symptoms of respiratory tract diseases in addition to tightness, wheezing, and chest pain. Often the cough is a problem faced by physicians in their daily work. The reason is very diverse and the introduction of the pathophysiology of cough would be very helpful in establishing the diagnosis and prevention of people with coughs. Research shows that in patients with acquired chronic cough 628 cough up to 761 times / day. Patients with pulmonary TB coughs number about 327 times / day and patients with influenza-even up to 154.4 times / day.
Epidemiological studies have shown that many chronic cough associated with smoking. Twenty-five percent of those who smoked 1 / 2 pack / day will have to cough, while the patients who smoked one pack per day will be found to be approximately 50% of chronic cough. Most of the heavy smokers who smoked 2 packs / day will complain of chronic cough. Large-scale research in the U.S. also found that 22% of non-smokers also suffer from cough, among others, caused by chronic diseases, air pollution and others. Coughing can also cause various complications such as pneumothorax, pneumomediastinum, headache, fainting, disc herniation, inguinal hernia, broken ribs, bleeding subkonjungtiva, and urinary incontinence.

Cough in Latin called tussis is a reflex that can occur suddenly and often repeated that aims to help clear mucus from the respiratory tract of, irritants, foreign particles and microbes. Coughing can happen voluntarily or involuntarily.
Coughing is a reflex action in the respiratory tract that is used to clean the upper airways. Chronic cough lasts more than 8 weeks are common in the community. Causes include smoking, exposure to cigarette smoke, and exposure to environmental pollutants, especially particulates.

Mechanism of Occurrence of Cough
Cough starts from a cough receptor stimulation. These receptors are non-myelinated nerve fibers in the form of finely located both inside and outside the thoracic cavity. Located within the thoracic cavity, among others, contained in the larynx, trachea, bronchus, and pleura. Will decrease the number of receptors on the branches of a small bronchus, and a large number of receptors in the can in the larynx, trachea, carina and bronchus branching region. The receptors are also found even in the ear canal, stomach, hilum, paranasalis sinus, pericardial, and diaphragm.
Mechanism Of Cough
Afferent fibers are the most important branch of the vagus on the drain stimuli from larynx, trachea, bronchus, pleura, stomach, and also stimulation of the ear through the Arnold branch of the vagus. Trigeminal nerve stimulation of the sinus paranasalis channel, glosofaringeus nerve, excitatory channel of the pharynx and channel phrenic nerve stimulation of the pericardium and diaphragm.

By excitatory afferent fibers was taken to the cough center located in the medulla, near the center of the respiratory and vomiting centers. Then from here by afferent fibers of the vagus, phrenic nerve, intercostal and lumbar nerves, the trigeminal nerve, facial nerve, nerve hipoglosus, and others headed to the effector. These effector standing of the muscles of the larynx, trachea, bronchi, diaphragm, intercostal muscles, and others. In the area of ​​this effector mechanism of cough ensued.

Phase of Cough
Basically the mechanism of cough can be divided into four phases, namely:

1. Phase irritation
Irritation of one sensory vagus nerve in the larynx, trachea, large bronchi, or afferent fibers from the pharyngeal branch glosofaringeus nerve can cause coughing. Coughing also arise when the cough receptors in the lining of the pharynx and esophagus, pleural cavity and external ear canal is stimulated.

2. Phase of inspiration
In the inspiration phase of the glottis is wide open due to reflex muscle contraction abduktor aritenoidea cartilage. Inspiration occurs in and quickly, so the air quickly and in large quantities into the lungs. This is accompanied terfiksirnya rib due to muscle contraction under the thorax, abdomen and diaphragm, so that the lateral dimension enlarged breasts lead to increased lung volume. The entry of air into the lungs by the number of lots of benefits that will strengthen the expiratory phase resulting in faster and stronger and reduce the air cavity is closed so as to produce a potential cleaning mechanism.

3. Compression phase
This phase begins with the closing of the glottis due to contraction of the adductor muscle aritenoidea cartilage, glottis closed for 0.2 seconds. In this phase the intrathoracic pressure rises to 300 cmH2O to place an effective cough. Pleural pressure remained elevated for 0.5 seconds after the glottis open. Coughing can occur without glottis closure because of expiratory muscles to increase intrathoracic pressure although the glottis remains open.

4. Expiratory phase / expulsion
In this phase the glottis opens suddenly due to active contraction of expiratory muscles, so there was spending large amounts of air at high speed accompanied by spending foreign objects and other materials. Movement glottis, respiratory muscles and the branches of the bronchus is important in the mechanism of cough phase and this phase of cough is actually happening. Cough sound varies greatly due to vibration secretions in the respiratory tract or the vibration of vocal cords

Cough - Causes and Complications
Management of Cough

Lung Defense Mechanism

Lung defense mechanisms are very important in explaining the occurrence of respiratory infections. lung has defense mechanisms to prevent bacteria from entering into the lungs. cleaning mechanism are:
1. Cleaning mechanism in the conductive airways, including:
• Reepitelisasi airway
• The flow of mucus on the surface epithelium
• Bacteria naturally or "epithelial-cell binding site analogue"
• Local humoral factors (IgG and IgA)
• Components of the local microbial
• Mucosilliar transport system
• Sneezing and coughing reflexes

Upper respiratory tract (nasopharynx and oropharynx) is a defense mechanism through the barrier against the entry of the anatomy and mechanism of pathogenic microorganisms. Cilia and mucus push microorganisms out of the way coughed or swallowed.
If there is dysfunction of cilia as in Kartagener's syndrome, the use of nasogastric tube and pipe nasotracheal long can disrupt the flow of secretions that have been contaminated with pathogenic bacteria. In these circumstances may occur nosocomial infection or "Hospital Acquired Pneumonia".

2. Cleaning mechanism in "Respiratory airway exchange", include:
• The fluid lining the alveolar surfactant include
• The system of local humoral immunity (IgG)
• Alveolar Macrophages and inflammatory mediators
• Withdrawal of neutrophils
Humoral immune system plays an important role in lung defense mechanisms (upper airway). IgA is one part of the nasal secretions (10% of the total protein nasal secretions). Patients with IgA deficiency have an increased risk for upper respiratory tract infection recurring yan. Colonization of bacteria that often hold the upper airway often removing and damaging IgA proteolytic enzymes. Gram-negative bacteria (Pseudomonas aeruginosa, E.colli, Serratia spp, Proteus spp, and Klebsiella pneumoniae) has the ability to destroy IgA. Deficiencies and damage to any component of upper airway defense led to the colonization of pathogenic bacteria as facilities for lower respiratory tract infection.

3. Cleaning mechanism in the subglottic airways
Subglottic airway defense mechanisms composed of anatomic, mechanical, humoral and cellular components. Mechanism of closure of the glottis and cough reflex is the main defense against the aspirate from the oropharynx. In case of malfunctioning of the glottis it dangerous for lower respiratory tract that are normally sterile. Nasogastric tube mounting action, tool tracheostomy facilitate the entry of bacterial pathogens directly into the lower respiratory tract. Impaired mucociliary function may facilitate the entry of pathogenic bacteria into the lower respiratory tract, even acute infection by Mycoplasma pneumoniae, Haemophilus influenzae and viruses can damage the cilia movement.

4. Cleaning mechanism in the "respiratory airway gas exchange"
Bronchioles and alveol have a defense mechanism as follows:
• The liquid that coats alveol:
a. Surfactants
A fat-rich glycoprotein, consists of several components of SP-A, SP-B, SP-C, SP-D that serves to strengthen phagocytosis and killing of bacteria by macrophages.
b. Anti-bacterial Activity (non specific) : FFA, lysozyme, iron binding protein.
• IgG (IgG1 and IgG2 subset that serves as an opsonin)
• alveolar macrophages that act as the first defense mechanism
• Serves to attract PMN leucocytes into the alveoli (there GNB infections, Pseudomonas aeruginosa)
• Mediator biology
Ability to attract PMN to the airway, including C5a, the production of alveolar macrophages, cytokines, leucotrienes
Tags : Defense Mechanism of lung, Defense Mechanisms of the Respiratory SystemPulmonary defence mechanisms

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