Cough

Causes:

• Infections- Pharyngitis, bronchitis, pneumonia, bronchiectasis, Pulmonary tuberculosis, lung abscess, pertussis, viruses (Respiratory syncytial virus, influenza, parainfluenza, human metapneumovirus, rhinovirus etc)
• Tumors- Bronchogenic carcinoma, carcinoma larynx
• Airway irritation- Smoking, dust, fumes, post nasal drip, foreign body
• Drugs- ACE inhibitors, beta blockers, NSAIDs
• Stimulation in the territory of cranial nerves V, IX and X. Ex: Wax in ear
• Pressure on trachea/bronchus- aortic aneurysm, cardiomegaly, lymphadenopathy, mediastinal mass
• Others- Interstitial lung disease, lung GVHD, asthma, pulmonary edema, reflux esophagitis, psychogenic

Investigations:

• Chest X ray
• Sputum for AFB
• CT thorax (Plain and with contrast)
• Bronchoscopy- cytology, microbiological tests, biopsy, PCR for various viral infections

Symptomatic treatment:

• Dry cough
  • Tab. Montelukast 10mg- (Montair)- 0-0-1 (2-6yrs- 4mg- OD, 6-14yrs- 5mg- OD, >14yrs- 10mg- OD)
  • Syp. Levodropropizine + Chlorpheniramine (Reswas) 5ml- 1-1-1
  • Tab. Pantaprazole + Domperidone (Pan-D)- 1-0-0
• Productive cough
  • Syp. Ambroxol + Levosalbutamol (Ascoril-LS/ Kofarest)- 10ml- 1-1-1
• If bronchospasm: 
  • Nebulization with Salbutamol (Ashthalin)/ Budesonide (Budecort)/ Ipratropium + Levosalbutamol (Duolin)
  • Cap. AbPhylline- 100mg- BD
• T. Azithromycin- 500mg- OD for 3 days

Dyspnea, Hypoxia and Respiratory Failure

Introduction:

• Hypoxia is SpO2 <90%, PaO2- <60mmHg, PaCO2- >40mmHg
• SpO2 and blood gas levels do not correlate with patient's subjective report of dyspnea. One must believe patient's report and manage accordingly.
  
   

Causes:

• Severe anemia
• Pneumonia
• LVF
• Asthma
• COPD
• Pneumothorax
• Pleural effusion
• Pulmonary embolism
• Pulmonary edema
• ARDS
• Interstitial lung disease
• Pulmonary hypertension
• Foreign body in bronchus
• Bronchogenic carcinoma
• Pericardial effusion
• IHD
• Diabetic ketoacidosis
• Neuromuscular paralysis
• Anxiety neurosis

Investigations:

• Hemogram
• Chest X Ray
• CT Thorax
• 2D Echo
• RBS
• Bronchoscopy
• ECG
• ABG

Treatment:

• Check airway and neck position. Jaw thrust and chin lift. Clear throat of secretions and foreign body. 
• O2 delivery with nasal prongs/ facemask- Initial high flow rate, then adjust as per SpO2
• Treatment of cause- Antibiotics/ Transfusions/ Bronchoscopic therapy/ anticoagulation
• Bronchodilators
• Diuretics
• Steroids

If no improvement with above measures:

• If DNI/DNR status: Morphine- 2.5-10mg- PO- 3-6hrly
• If active management: Shift to ICU for mechanical ventilation (NIV ;  CPAP/BiPAP or Intubation with mechanical ventilation)
• Initial ventilator settings in general (These settings differ in various indications for mechanical ventilation)
  • Mode: Assist control mode
  • FIO2: Begin with 100%O2
  • Tidal volume: 10ml/kg
  • Respiratory rate: 12 breaths/min
  • Inspiratory flow rate: 60L/min
  • Inspiratory : expiratory ratio: 1:2 
  • PEEP: Start With 5cm of H2O
• Goals:
  • PaO2: 60-90 mm Hg
  • PaCO2: 40 mm Hg
  • pH: 7.35- 7.45
  • FiO2: 40-60%
  • Inspiratory peak pressure: <35 cm H2O