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.

See more : 

• Cough - Definition and Mechanisms
• Cough - Causes and Complications

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
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.

Definition
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 System, Pulmonary defence mechanisms

Anesthesia Patients With Asthma

Pre-operation / Pre-anesthesia Assessment
Anamnesis

History about whether patients had received previous anesthesia is very important to know if there are things that need special attention, for example: allergies, nausea, vomiting, itching or shortness of breath after the surgery, so that we can design the next anesthetic well.

Physical examination

State of dentition examination, action open mouth, the tongue is relatively large is very important to know whether the action would make it difficult laryngoscopy intubation. Another routine systemically check about the general course should not be missed such as inspection, palpation, percussion and auscultation of all organ systems of patients. Examination of inspection, palpation, percussion and auscultation on the cardiopulmonary system is a major clinical examination of much help in the assessment of asthma. With this examination can be known frequency of breathing, respiratory pattern, presence of wheezing / ronchi.

ECG examination

In addition to knowing about the state / heart disease, especially the picture ECG can also determine the influence of lung function.

Radiological examination

Includes images of the thorax and CT-scan (if necessary). This examination is not to assess lung function disorders but it is important for supporting the diagnosis of pulmonary disease, signs of lung hyperinflation and congestive heart disease, also to help determine abnormalities in the mediastinal cavity (CT-scan).

Laboratory examination

Include routine blood tests, blood gas analysis of blood sugar.

Pulmonary Physiology Tests

• Without tools: although simple but can provide information on respiratory function and are useful as an assessment of "fronss for operation" such as the ability to climb stairs without shortness of breath while talking. Snider match test: the ability to hold breath for 30 seconds.

• Using a spirometer.

Physical Status Classification

Classification is commonly used to assess a person's physical fitness is derived from The American Society of Anaesthesiologist (ASA). Physical classification is not a forecasting tool ratio of anesthesia, because the side effects of anesthesia can not be separated from the side effects of surgery.

• Class I   : Patients healthy organic, physiological, psychiatric, biochemistry.
• Class II  : Patients with mild or moderate systemic disease.
• Class III : Patients with severe systemic disease, so that routine activities are limited.
• Class IV : Patients with severe systemic disease can not perform routine activities and the disease is life threatening at any moment.
• Class V  : dying patient who is expected with or without surgery her life would not be more than 24 hours
• In Cito or emergency surgery is usually imprinted letter E.

Pre-Operative Preparation
Fasting
Laryngeal reflexes decreased during anesthesia. Regurgitation of gastric contents and impurities contained in the airway is a major risk in patients undergoing anesthesia. To minimize this risk, all patients scheduled for elective surgery should dipantangkan of oral input (fasting) during a certain period before induction of anesthesia.

Perioperative Management
For anesthesia and elective surgery in patients with a history of asthma, then asthma should be controlled and the patient was not suffering from an infection or severe wheezing attacks. If a patient takes medication on a regular basis, then the drug should not be stopped. Particular attention should be given pad of patients who use steroids, systemically or by inhaler.
Bronchospasme may be induced by anxiety, pain, drugs, endotracheal intubation, foreign body or irritation. Drugs that are contraindicated are: tubocurarrine and anticolinesterase, Sodium thiopental (Pentothal™), morphine, papaverin, trimethaphan and beta blockers.
Many drugs that can be used as a premedication such as diazepam, pethidine, promethazine and atropine, an estimated free from bronchospatic activity. Bronchodilator and steroid therapy is continued.

Anesthesia Techniques
Whenever possible, choose regional anesthesia with continuous epidural block with a low of 1% lidocaine (analgesia only) so that the respiratory muscles are not disrupted.
If general anesthesia is required then given premedication with antihistamines such as promethazine together with hydrocortisone 100 mg. What is important to avoid laryngoscopy and intubation with a shallow anesthesia, because it can cause bronchospasm. Ketamine is good enough for intravenous induction, because it is a bronchodilator. For a brief action, you should use a face mask after induction techniques and avoid intubation. Use of oxygen with a concentration of 30% or more for air inspiration. If intubation is required, then deepened with inhalation anesthesia, and then do the intubation without muscle relaxants. In the anesthetized patient in laryngoscopy can be done without causing bronchospasm when intubated. Vecuronium may be administered as a muscle relaxant is good because it does not release histamine. Ether and halothane is bronchodilator good, but ether has the advantage, that is if there is bronchospasm, epinephrine (0.5 mg subcutaneously) can be administered safely (but this is dangerous if given in conjunction with halothane or trichlorethylene, because it can cause heart rhythm disturbances due to effects of catecholamines). As an alternative to epinephrine, aminophylline 250 mg can be administered intravenously slowly to mature; drug is compatible with all inhaled medication.
At the end of the action when using intubation, extubation done on his side and with anesthesia in, because stimulation of the larynx can cause bronchospasm.

Post Operative Care
Provision of adequate analgesia postoperative care is vital. Adequate oxygenation. Maintenance intravenous fluids. Usually anti-asthma drugs are still needed. Form of steroid drugs given intravenously as a temporary substitute for oral medications and inhalers brochodilator nebulizer as a substitute if the patient can not breathe in, or not yet maximal lung function after surgery. In the event of failure of achieving adequate ventilation and oxygenation after surgery, the patient to go to Intensive Care Unit (ICU).

Tags : Anesthesia and Asthma, Anesthesia With Asthma, Ketamine and asthma,