Mucous hypersecretion and relationship to cough.
The relationship between smoking and chronic cough and sputum . between chronic cough and sputum or chronic mucus hypersecretion and frequent .. GmbH, Konstanz, Germany, provided editorial assistance with the preparation of this. Correlation between the function and structure of the lung in smokers. Annesi, I and Kauffmann, F. Is respiratory mucus hypersecretion really an .. German, VF, Corrales, R, Ueki, IF, and Nadel, JA. .. Chapman, RS, Calafiore, DC, and Hasselblad, V. Prevalence of persistent cough and plegm in young adults in relation to. Acute cough is a mechanism to clear the airways of mucus and foreign It impairs social relationships and worsens other symptoms such as pain, Their stimulation may also lead to bronchoconstriction and mucous hypersecretion . non-small cell lung cancer patients in France and Germany.
Neither dyspnea nor tachypnea were observed after recovery from anesthesia. The patient was admitted to the ICU for further close observation. Immediate postoperative chest X-ray in the ICU showed a newly developed, ill-defined hazy infiltration in the left lung Fig.
The patient was transferred to the general ward and experienced no additional complications. Pressures greater than 30 mmHg applied to the tracheal mucosa lead to hypoperfusion of the capillaries and mucosal ischemia.
As a result, the mucosa becomes necrotized and disappears, activating the fibrinolytic pathway and leading to commissural scarring within 3 to 6 weeks, which ultimately causes tracheal stenosis. In addition, appropriate cuff volume was confirmed by chest radiography. Without risk factors for tracheal stenosis other than long-term intubation, including difficult intubation, intubation history, excessive steroid use, old age, female gender, or respiratory disease,[ 6 ] tracheal stenosis was reported in this case.
Description of nighttime cough epochs in patients with stable COPD GOLD II–IV
As shown in this case, follow-up neck radiography until 6 weeks is necessary in long-term intubated ICU patients because tracheal fibrosis progresses until 6 weeks after extubation. To avoid these complications, preoperative interventions such as repeated bougienage, tracheal laser cauterization, stent insertion, and mitomycin C spray are performed.
If edema caused by interventions for upper airway obstruction was the main reason, ventilation of both lungs should be decreased to the same degree; however, our patient had ventilation failure in only one lung, ruling out edema and bronchospasm as possible causes. No active lesion was found on chest radiography done after intubation prior to surgery, so we eliminated pulmonary disease as the cause of respiratory dysfunction.
Under flexible fiberoscopy, we showed that the left main bronchus was completely obstructed by sputum, which led to ventilation failure. We suspect sputum that had collected under the stenotic lesion moved to the left upper and lower lobar bronchi during tracheal bougienage, which resulted in complete obstruction.
Before surgery, the patient complained difficulty of expectoration, so we attempted to aspirate sputum via a catheter; however, the sputum beyond the stenotic lesion could not be removed.
Anatomically, the suction catheter primarily enters to the right bronchus, resulting in difficult removal of sputum in the left lung and subsequent accumulation of sputum. By bougienage bronchoscopy, the accumulated mucus and sputum was accumulated in the bronchus and totally obstructed the left lung.
Pulmonary pathology such as chronic obstructive pulmonary disease, asthma, bronchiectasis, and cystic fibrosis lead to mucus hypersecretion or dysfunction of mucus excretion, which result in bronchiolar obstruction and increased risk of infections. Hyperinflation of the lung with pressures greater than 40 cmH2O for over 2 seconds during the inspiratory period in intubated patient promotes excretion of sputum and mucus and is reported to reduce early pulmonary complications.
Its mechanism involves closure of the vocal cord, which causes approximately cmH2O of intrathoracic pressure. According to Lanefors and Wollmer,[ 15 ] excretion is induced not only by gravity, but also by increased ventilation in dependent regions of the lung, which allows higher airflow.
Because postural drainage is necessary to maintain the same position from at least 3 minutes to more than 15 minutes, it has its limitations in positions such as Trendelenburg reduce tidal volume and functional residual volume, which increases the work of breathing. But if postural drainage is used with other chest physiotherapy techniques, it could be applied to patients effectively. Short-term research confirms that chest physiotherapy helps mobilize airway secretions,[ 18 ] and has a positive impact on pulmonary functional ability, shortening ICU stays.
We experienced a case of acute tracheal obstruction due to accumulated sputum that moved to the lower trachea after tracheal bougienage, which was undertaken in an effort to widen the tracheal diameter.
We suggest chest physiotherapy be applied widely and aggressively to prevent mucus accumulation and tracheal obstruction for patients with respiratory depression in the ICU. A Neck X-ray 25 days after extubation shows segmental narrowing of the upper trachea. B Neck CT shows focal tracheal narrowing with wall thickening around the lower thyroid pole black arrow head.
The narrowest transverse diameter of the trachea is 5. A Preoperative neck X-ray in the intensive care unit shows endotracheal tube is not advanced due to the tracheal stenosis black arrow head. B Preoperative chest X-ray in the intensive care unit shows the endotracheal tube is inserted, and there are no active lesions in the lung.
The fiberoptic bronchoscopy is located in the left main bronchus, passing through the carina. Fiberoptic bronchoscopy shows the left main bronchus is completely obstructed by sputum.
A Immediate postoperative chest X-ray in the ICU shows a newly developed, ill-defined hazy infiltration at left lung and insertion of the tracheostomy tube. B Chest X-ray from postoperative day 3 shows no active lesions in the lung.
Tracheal stenosis after tracheostomy or intubation: Tex Heart Inst J ; Flexible bronchoscopic management of benign tracheal stenosis: J Cardiothorac Surg ; 5: Do commonly used ventilator settings for mechanically ventilated adults have the potential to embed secretions or promote clearance?
Respir Care ; Puchalski J, Musani AI. Clin Chest Med ; Occurrence of acquired tracheoesophageal fistula due to excess endotracheal tube cuff volumes - A Case Report.
Korean J Crit Care Med ; Post tracheostomy and post intubation tracheal stenosis: BMC Pulm Med ; 8: Outcome of surgical treatment for proximal long segment post intubation tracheal stenosis. J Cardiothorac Surg ; 8: Dexamethasone to prevent post-extubation airway obstruction in adults: Crit Care ; Cavallone LF, Vannucci A.
Extubation of the difficult airway and extubation failure. To compare the groups, the average of both nights was taken. However, differences in groups should not be generalized due to the small number of patients included in this study.
Mucous hypersecretion and relationship to cough.
Results Cough events were found in all 30 patients ranging from 1 to events over the recording period. Cough epochs could be found in 29 patients ranging from 1 to Of all cough events, Both nights marked as N1, N2 of each patient were divided into two equally sized halves marked as H1, H2. The first half of each night contains a period where the patients are falling asleep followed by a sleeping period, while the second half mostly consists of sleep.
There were no significant differences between the two halves. However, most of the patients had a similar distribution of cough epochs in both halves during each night, although the amount of cough epochs was not equal.
There are also patients with different amounts and different distributions of cough epochs over both nights. Within our COPD subgroups, parameters like median epoch length and median number of cough events in cough epochs do not show significant variations Figures 4 and 5. The mean pack-years for active smokers was Discussion and conclusion Ambulatory cough recording by LEOSound offers a promising opportunity in the objective assessment of cough. More than three-quarters of all cough events occurred in cough epochs.
In active smokers, Several ways of quantifying cough have been published in recent years. It is essential that cough monitoring devices define exactly what is recognized as cough and how cough is quantified. The explosive phase induces the characteristic sound of a single cough event.
However, most cough events occur in bursts or epochs, and single coughs are not the typical pattern for patients with chronic respiratory diseases. Using cough epochs to quantify coughing might represent the amount of cough inducing stimuli in a certain time period. The ERS defines a cough epoch as at least two consecutive cough events with a maximum distance of 2 s. During end-stage disease, breathlessness becomes the more important symptom and cough is less frequent.
A possible explanation for patients suffering from COPD III having the highest amount of coughing could be that their cell metaplasia and hyperplasia have progressed further than in the earlier stages of the disease, whereas the muscle atrophy has not progressed as far as it does in the end-stage COPD. Therefore, further investigations with automated, objective cough monitoring methods are necessary to show if cough causes sleep arousals.
Lack of validated and objective measures of cough frequency and severity has hampered understanding cough and its relationship with different respiratory diseases.
Visual analog scales, questionnaires, and self-report coughing diary cards have been used, but these do not directly correlate with objective methods such as ambulatory cough monitoring. Subjective assessments, such as scales or questionnaires, give physicians a different perspective on the symptom cough, especially when quality of life is affected by a lot more than just the amount of coughing.
Therefore, international experts recommend using both subjective and objective methods when investigating cough. These data should be considered in future studies. Most of the cough periods in our patients were nonproductive during nighttime. This correlates with the fact that productive cough is predominantly found in the morning hours after getting up from bed. To understand the underlying processes, this crucial time in the morning needs to be investigated, with both subjective and objective assessments of cough, in more detail.
Productive cough being strongest both during sleep and the morning hours is highly suggestive of still smoking COPD patients. This was also true for our patients. The groups of smokers and nonsmokers in our study are comparable in terms of pack-years. Because mean pack-years in both groups differed in just a small way, it is very likely that continued tobacco exposure leads to more productive cough. Therefore, we come to a conclusion similar to other researchers that persistent smoking is the most important risk factor for cough and COPD progression.
Total Unilateral Obstruction by Sputum Immediately after Tracheal Bougienage
Nonsmokers with COPD report less chronic cough and sputum and have less impairment in airflow limitation and gas exchange. Parameters like median epoch length and median number of cough events in a cough epoch did not vary in our subgroups, but might also be interesting for future cough studies, especially when acute diseases are investigated.
In summary, LEOSound lung sound monitor offers a good chance to evaluate nighttime cough, which might otherwise stay unnoticed. Cough during sleep is frequent, and most of the cough events occur in cough epochs. The potential drivers for chronic cough in COPD are multifactorial. Cigarette smoke exposure is the most important factor for productive cough.
Systematic hour studies with ambulatory monitoring of chronic cough in larger numbers of well-defined COPD patients are necessary to characterize cough exactly.