cough
TRANSCRIPT
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cough
I’m Coughing my lungs up Doc
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Impact of cough
an important defense mechanism that helps clear excessive secretions and foreign material from the airways
an important factor in the spread of infection
most common symptoms for which patients seek medical attention and spend health-care dollars
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Definition of cough
deep inspiration followed by a strong expiration against a closed glottis, which then opens with an expulsive flow of air, followed by a restorative inspiration
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Acute InfectionsTracheobronchitisBronchopneumoniaViral pneumoniaExacerbation of COPD bronchitisPertussis
Chronic InfectionsBronchiectasisTuberculosisCystic fibrosis
Airway DiseasesAsthmaChronic bronchitisChronic postnasal drip
Parenchymal DiseasesChronic interstitial lung fibrosisEmphysemaSarcoidosis
-- Common Causes of Cough
TumorsBronchogenic carcinomaAlveolar cell carcinomaBenign airway tumorsMediastinal tumors
Foreign BodiesMiddle Ear PathologyCardiovascular DiseasesLeft ventricular failurePulmonary infarctionAortic aneurysm (thoracic)
Other DiseasesReflux esophagitisRecurrent aspirationEndobronchial sutures
DrugsACE inhibitorsCOPD,
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Cough reflexcough
Cough reflex
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Stages of cough
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Coughy names
Brazy cough- Trachitis Bovine cough- R.L.N palsy Bubbly cough- sputum in the airways Prolonged wheezy cough- Emphysema Paroxysoms of cough without sputum
production - airway reactivity Paroxysoms of cough foll,. by
prolonged stridulous inspiration - pertussis
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Hacking- dry irritable cough in URI Staccato- whooping cough or
chlamydial inf Nocturnal-
asthma,GERD,UACS,pul.edema. Croupy- harsh ,hoarse cough in
laryngeal inf. Suppressed- pleurisy Barking- hysteria
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Classification of Cough
Three Categories of Cough Acute Cough = < 3 Weeks Duration Subacute Cough = 3 – 8 Weeks Duration Chronic Cough = > 8 Weeks Duration
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Acute Cough
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Acute Cough <3/52 DurationDifferential Diagnosis
Upper Respiratory Tract infections:Viral syndromes, sinusitis viral / bacterial
URTI triggering exacerbations of Chronic Lung Disease eg Asthma/ COPD
Pneumonia Left Ventricular Heart Failure Foreign Body, Aspiration pieural
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Managing Acute CoughIdentify High Risk groups
Acute Cough Can be 1st Indicator of
Serious Disease eg Lung ca, TB, Foreign Body, Allergy, Interstitial Lung disease
‘Chronic cough always preceded by acute cough’.
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Red Flags in Acute Cough
Symptoms Haemoptysis Breathlessness Fever Chest Pain Weight Loss
SignsTachypnoea
CyanosisDull chest
Bronchial BreathingCrackles
THINK pneumonia, lung cancer, LVF
GET a CHEST X-Ray
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Treatment of Simple Acute Cough
Benign course -reassure Cough can distress Voluntary cough
suppression -linctuses/ drinks
Suppression of cough -dextromethorphan, menthol, sedating antihistamines & codeine
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Sub-Acute Cough
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Sub-acute Cough 3-8 weeks
Likely Diagnoses Postinfectious Bacterial Sinusitis Asthma Start of Chronic Cough
Don’t want to miss lung cancer
ACTIONS
•Examine Chest
•Chest X-Ray if signs or smoker
•Measure of airflow obstruction
ie peak flow -one off
peak flow -serial
spirometry
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Post Infectious Cough
A cough that begins with an acuterespiratory tract infection and is not
complicated* by pneumonia
*Not complicated = Normal lung exam and normal chest X-ray
Post Infectious cough will resolve without treatment
Cause = Postnasal drip or Tracheobronchitis
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Postinfectious Cough Following an acute respiratory infection, at least 3 weeks- 8weeks, consider the diagnosis of postinfectious cough.– Chest radiograph must be normal– If > 8weeks, consider other – Always consider the possibility of B. pertussis infection paroxysms of coughing associated with post-tussive vomiting, and/oran inspiratory whooping sound judge other factors < considering therapy– UACS– lower airway– GERD Except for bacterial sinusitis or early in B. pertussisinfection, antibiotics have no role.
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Chronic Cough
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Chronic Upper Airway
It is unclear whether the mechanism(s) of cough is
postnasal drip or
direct irritation or inflammationof the cough receptors in the upper airway
Cough Syndrome
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Post-Nasal Drip
Symptoms: ‘something
dripping’ frequent throat
clearing nasal congestion /
discharge posture
Causes Allergic rhinitis Non-allergic
rhinitis Vasomotor rhinitis Chronic bacterial
sinusiits
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Post Nasal Drip Treatment
Options:1. Exclude /treat
infection2. Nasal steroid for 8wks3. Sedating
antihistamines4. Antileukotrienes eg
montelukast5. Saline lavage6. ENT opinion
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Cough +dyspnea + wheezing (Cough-variant asthma) When nondiagnostic,methacholine challenge performed – If methacholine challenge cannot be performed,empiric therapy given;[ exclude NAEB.] However, a diagnosis of asthma as the cause of coughis established only after resolution of cough withspecific therapy
Asthma
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initially treated with a standard antiasthmaregimen of inhaled bronchodilators andcorticosteroids– When refractory, an assessment of airway inflammation should be performedpersistent airway eosinophiliaaggressive antiinflammatorytherapy A leukotriene receptor antagonistbefore systemic corticosteroids
Asthma
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Gastro-oesophageal Reflux
GORD accounts alone or in combination for 10-40% of chronic cough
Two Mechanismsa. Aspiration to larynx/
tracheab. Acid in distal
oesophagus stimulates vagus and cough reflex
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Gastro-oesophageal Reflux Symptoms
GI Symptoms
If Aspiration main mechanism
Heart burnWaterbrash/ Sour tasteRegurgitationMorning Hoarseness
If Vagal - NO GI symptoms
Cough Features
Throat clearingWorse at night / risingOn eatingReflex
hypersensitivity
CXR -normal or hiatus hernia
Spirometry normal
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Gastro-oesophageal Reflux
Reflux may be due to Medications or Foods Reflux may be due to Medications or Foods
Drugs and foods that Drugs and foods that reducereduce lower esophageal lower esophagealsphincter (LES) pressure and can cause increasedsphincter (LES) pressure and can cause increasedreflux include:reflux include:
TheophyllineTheophylline Chocolate ChocolateOral Oral ββ adrenergic agonists adrenergic agonists Caffeine CaffeineNSAIDsNSAIDs Peppermint PeppermintAscorbic acidAscorbic acid Alcohol AlcoholCalcium Channel BlockersCalcium Channel Blockers Fat Fat
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Gastro-oesophageal RefluxInvestigation Oesophageal pH monitoring for 24 Oesophageal pH monitoring for 24 hours (+diary) hours (+diary) 95% sensitive and specific 95%95% sensitive and specific 95%
Ba swallow not sensitive enoughBa swallow not sensitive enough
Endoscopy - may confirm but false -Endoscopy - may confirm but false -ve rateve rate
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Endoscopy can show GORD, but Endoscopy can show GORD, but cannot cannot
confirm GORD as the cause of cough.confirm GORD as the cause of cough.
GED
© Slice of Life and Suzanne S. Stensaas
GED
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– Chronic cough– Not exposed to environmental irritants nor smoke– Not taking an ACEI– Chest radiograph is normal or near normal and stable– Symptomatic asthma has been ruled out– UACS has been ruled out– NAEB has been ruled out
profile of patient with chronic cough due to GERD:
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GERD – Dietary and lifestyle modifications– Acid suppression therapy, and– prokinetic therapy – response assessed ,1 -3months. When empiric regimen fails, GERD not ruled out as a cause of chronicCough; objective investigation for GERDrecommended because– empiric therapy may not have been intensive enough– medical therapy may have failed– surgery may be considered
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Chest X-Ray and Differential of Cough
Normal CXR Gastro-oesophageal
reflux Post-nasal Drip Smokers cough/
Chronic Bronchitis Asthma COPD Bronchiectasis Foreign body
Abnormal CXR Left ventricular
failure Lung cancer Infection/ TB Pulmonary fibrosis Pleural effusion
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Acute Bronchitis cough with or without phlegm up to 3 weeks.
A diagnosis of acute bronchitis should not be madeunless there is no clinical or radiographic evidence ofpneumonia, and the common cold, acute asthma, or anexacerbation of COPD have been ruled out .
For patients with a putative diagnosis of acutebronchitis, routine treatment with antibiotics is notjustified and should not be offered.
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Chronic Bronchitis chronic cough and sputumexpectoration occurring on most days for at least 3months and for at least 2 consecutive years should begiven a diagnosis of chronic bronchitis when otherrespiratory or cardiac causes of chronic productivecough are ruled out. stable patient suddenly experiences asudden clinical deterioration with increased sputumvolume, sputum purulence and/or worsening ofshortness of breath, this is referred to as an acuteexacerbation of chronic bronchitis, as long asconditions other than acute tracheobronchitis are ruled out
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Chronic Bronchitis avoidance of personal tobacco use, passive smokeexposure, and other environmental irritants. For stable patients:– Short-acting inhaled Β agonists, inhaled ipratropium, oraltheophylline and combined inhaled long-acting Β agonists andinhaled corticosteroids may improve cough
For an acute exacerbation:bronchodilators (Β agonistand/or ipratropium), oral antibiotics, and oral or in severecases IV corticosteroids are useful but their effects on coughhave not been systematically evaluated.
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Non-AsthmaticEosinophilic Bronchitis eosinophilicairway inflammation, similar to asthma.– In contrast to asthma, not associated with variable airflowlimitation or airway hyperresponsiveness.– the differences infunctional associations are related to differences inlocalization of mast cells within the airway wallThere is smooth muscle infiltration in asthmaThere is epithelial infiltration in non-asthmatic eosinophilicbronchitis
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Non-AsthmaticEosinophilic Bronchitis chronic cough with normal cxrnormal spirometry, and no evidence of airwayhyperresponsiveness.– Diagnosis- eosinophilic airwayInflammation inhaledcorticosteroids– The dose and duration of treatment differ– When a causal allergen or occupational sensitizer is identified,avoidance is the best treatment The condition can be transient, episodic, or persistentunless treated; occasionally, patients my require longtermprednisone therapy
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Bronchiectasis 0-4% Most cases in adults are idiopathic; however, in theabsence of an obvious cause, a diagnostic evaluation foran underlying disorder will reveal such a disorder up to47% of the time and treatment for the underlyingdisorder may slow or halt the progression of airwaydisease up to 15% of the time.
In patients with suspected bronchiectasis without acharacteristic chest radiograph, HRCT is the diagnosticprocedure of choice (specificity and sensitivity > 90%
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Non-BronchiectaticSuppurative Airway Disease bronchiolitis.
When the more common causes of cough have been ruledout, consider non-bronchiectatic suppurative airwayDiseases in patients with– Incompletely or irreversible airflow limitation, small airwaysdisease on HRCT, or purulent secretions on bronchoscopy. Direct signs: airway dilation or wall thickening; “tree-in-bud”
Indirect signs: air-trapping (mosaic attenuation on expiration)– Successful management depends upon identification of the specificunderlying disorder. Lung biopsy may be required.
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Lung Tumors Cough and productive cough > 65%and > 25% of patients yet 0-2% of all patients
– Risk factors include heavy smoker with new onset cough;a change in the characteristics of a pre-existing cough;hemoptysis; exposure to passive cigarette smoke, asbestos,radon; COPD, and family history of lung cancer
In patients with a suspicion of airway involvement bya malignancy, even when the chest radiograph isnormal, bronchoscopy is indicated.
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Cough From Aspiration Due toOral-Pharyngeal Dysphagia
acute stroke [> 33%], cervical spine surgery [>40%]– Cough while eating may indicate aspiration; but, aspirationmay be clinically silent– patients with dysphagia should undergo videofluoroscopic orflexible endoscopic evaluation of swallow to identify appropriatetreatment– Patients with a reduced level of consciousness are at high risk
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ACE-Inhibitors and Chronic CoughIncidence: 5-20%Onset: one week to six monthsMechanism
Bradykinin or Substance P increaseUsually metabolized by ACE) PGE2 accumulates and vagal
stimulation. Treatment: switch to Angiotensin II
Receptor Blockers (ARBs)
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Habit, Tic, and Psychogenic Cough in Adult and Pediatric Populations
ruling out tic disorders (includingTourette’s syndrome) and uncommon causes of chroniccough, and cough improves with behavior modification orpsychiatric therapy.
– unexplained cough.
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Chronic Interstitial PulmonaryDisease
may be a presenting orcomplicating feature.
IPF, sarcoidosis, andhypersensitivity pneumonitis
IPF, there is an associated ↑ sensitivity to capsaicin &sputum levels of nerve growth factor and brain-derivedneurotropic factor suggesting a functional upregulation ofsensory neurons of the lung
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Occupational and EnvironmentalConsiderations in the Cough Patient
Chronic Cough Due to TBand Other Infections
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Peritoneal Dialysis and Cough
22% compared to 7%in patients on hemodialysis.– Although both groups frequently receive medicationswhich can potentially trigger cough such as ACEIs andΒ blockers and both groups are at increased risk forfluid overload and pulmonary edema, the increasedrisk associated with peritoneal dialysis most likelyrelates to GERD that can be initiated or exacerbatedby increased intraperitoneal pressures.
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In immunocomprimised
the initial diagnostic algorithm is the same as that for immunocompetent persons
< 200 cells/μL or > 200 cells/μL with unexplained fever, weight loss, or thrush who have unexplained cough should be suspected of having Pneumocystis pneumonia, tuberculosis, and other opportunistic infections, and should be evaluated accordingly
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Uncommon Causes of ChronicCough
– Until uncommon causes have been ruled out, the diagnosis ofunexplained cough should not be made.
– The workup is never done unless a chest CT scan andbronchoscopy have been performed and are normal.
– Evaluate for the possibility of drug-induced cough and consider therapeutic trial of withdrawal
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Uncommon -Pulmonary causes• Tracheobronchomalacia• Tracheobronchomegaly• Airway stenosis/str/F.B• Broncholithiasis• Pulmonary Langerhans cell histiocytosis • Pulmonary alveolar proteinosis • Pulmonary alveolar microlithiasis• pulmonary edema • Pulmonary embolism• Lymphangioleiomyomatosis • Connective tissue disorders ‡ • Vasculitides• Miscellaneous (eg, vocal cord dysfunction, surgical
sutures in airways)
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Uncommon-Non-pulmonary causes High altitude Tonsillar hypertrophy Thyroid disorders (goiter, thyroiditis Esophageal disorders
(tracheoesophageal and bronchoesophageal fistula
Inflammatory bowel diseases (eg, Crohn disease and ulcerative colitis
Mediastinal masses Drug-induced cough
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Unexplained chronic cough—20%
Diagnosis by exclusion
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Making the DiagnosisCommon Differentials
Gastro-Oesophageal
Reflux
Post-nasal Drip-allergic rhinitis
-bacterial sinusitis
Lung Disease-normal CXR
-abnormal CXR
Non-structural
ACE-Inhibitors
Tobacco
Habit Cough
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Cause of Cough Treatment
Treating the Specific Underlying Cause(s)
Asthma, cough variant asthma Bronchodilators and inhaled corticosteroids
Eosinophilic bronchitis Inhaled corticosteroids; leukotriene inhibitors
Allergic rhinitis and postnasal drip Topical nasal steroids and antihistamines
Topical nasal anticholinergics (with antibiotics, if indicated)
Gastroesophageal reflux Conservative measures
H2-Histamine antagonist or proton pump inhibitor
Angiotensin-converting enzyme inhibitorDiscontinue and replace with alternative drug such as angiotensin II receptor antagonist
Chronic bronchitis/chronic obstructive pulmonary disease (COPD) Smoking cessation
Treat for COPD
Bronchiectasis Postural drainage
Treat infective exacerbation and airflow obstruction
Infective tracheobronchitis Appropriate antibiotic therapy
Treat any postnasal drip
Symptomatic Treatment (Only After Considering the Cause of Cough)
Acute cough likely to be transient (e.g., upper respiratory viral infection)
Simple linctus
Persistent cough, particularly nocturnal Opiates (codeine or pholcodeine)
Persistent, intractable cough due to terminal incurable disease Opiates (morphine or diamorphine)
Local anesthetic aerosol
Cough in children Simple linctus (pediatric)
Table 29.4 -- Treatments for Cough
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Cough Suppressant and ProtussivePharmcologic Therapy
– Mucolytic agents not in patients with bronchitis.– Zinc preparations are not to colds– Peripheral and central antitussive agents - chronic bronchitis – Opioids in lung cancerprotussive agents are effective – cough clearance (amiloride in CF; hypertonic saline inBronchitis)– DNAse is not effective -cf
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When the etiology of cough is unknown
When specific therapy requires a period of time before it can work
When specific therapy will be ineffective, as in inoperable lungcancer
Protussive therapy is intended to enhance cougheffectiveness to promote clearance of airway secretions
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Nonpharmacologic AirwayClearance Therapy
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theprincipal strength of diagnostic testing is in rulingout suspected possibilities. The principal limitation isthat a positive test result cannot necessarily be reliedon to establish the diagnosis; a positive test result hasnot been able to consistently predict a favorableresponse to specific therapy. A positive test result, byitself, is not diagnostic of the cause of cough unless afavorable response to therapy is witnessed.
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Respiratory Complications
Pneumothorax
Subcutaneous emphysema
Pneumomediastinum
Pneumoperitoneum
Laryngeal damage
Cardiovascular Complications
Cardiac dysrhythmias
Loss of consciousness
Subconjunctival hemorrhage
Central Nervous System Complications
Syncope
Headaches
Cerebral air embolism
Potential Complications from Excessive Cough
Musculoskeletal Complications
Intercostal muscle pain
Rupture of rectus abdominis muscle
Increase in serum creatine phosphokinase
Cervical disc prolapse
Gastrointestinal Complications
Esophageal perforation
Other Complications
•Social embarrassment
Depression
Urinary incontinence
Disruption of surgical wounds
Petechiae
Purpura
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Efficacy of Therapy
health-related quality-of-life instruments
tussigenic challenges flow-volume loops cough counting over 24 h
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The benefits of Cough Assist? Clients with Neuromuscular conditions have a weak cough due to loss ofrespiratory muscle strength Coughing clears secretions, food particles and foreign substances The cough assist increases the flow of air out, which helps theclient to cough Combats fatigue and discomfort from manual assisted coughing Possible Prophylactic use – maintains lung tissue compliance/flexibility Future research may suggest that clients may not needtracheotomies (Bach, 2004) Possibility of preventing and shortening hospital visits Improved quality of life and prolonged life (Bach,2000)
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Basic I.S. Maneuver• Slow, deep breath in to total lung capacity (ideal)• 5 to 10 second breath hold• Coughing– between breaths– at end of treatment• Causes increased transpulmonary pressure gradient• Further expansion of alveoli above current amount
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A New Device Enables Quantitative Cough Assessment• The LifeShirt® incorporates motion-sensing transducers, electrodes,a microphone, and a 3-axis accelerometer into a lightweight, washable vest that is available forpatients ≥5 years of age.• Using integrated input from the motion sensors and microphone, the frequency and intensity of coughcan be measured with a high degree of accuracy • The device discards events such as throat-clearing, sneezing, sighing, or talking.• Time-stamped data are stored on a compact flash card housed within the recorder and canbe uploaded to the manufacturer, VivoMetrics, Inc, for analysis using specialized software.•
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Role of cough in ACUTE MI ?
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