Airway & Respiratory, Columns

Know When Airway Discomfort is Indicative of Something Serious

Issue 3 and Volume 42.

“I‘ve been feeling really weak recently.”

Mr. G describes his symptoms with an uncertain voice. You’ve been sent to care for him, a 69-year-old male with an unknown medical problem. You found him sitting at the table, drinking a hot cup of tea.

Mr. G tells you he feels silly about calling, but this morning he almost passed out twice; once after he got up and was walking to the bathroom and the second just before he called 9-1-1, while he was standing at the kitchen counter getting his cup of tea. He’s sure it’s just a cold and he’s a bit dehydrated but thought he should have EMS check him out.

He appears to be in good shape, and tells you he has a history of high blood pressure and high cholesterol, for which he takes enalapril and simvastatin. His pulse is 80 and strong, blood pressure is 140/90, respirations are 18 per minute. His lung sounds present with bi-basilar crackles in the lower lobes and clear in the upper lobes.

He denies being short of breath but has been coughing continually during your assessment. When you ask him about the cough he says he’s not sure when it began; the majority of the time the cough is nonproductive, but occasionally he coughs up some mucous, sometimes tinged with blood. Mr. G doesn’t appear to be experiencing an immediate life-threatening event, but the coughing, dizziness and almost passing out has several possible causes that should be considered.

Discussion

Coughing is a normal response that protects the airway. Typically, when an irritant enters the airway, the body responds by drawing in a quick breath and then closes the glottis as the air is forced out. This increases the pressure in the airways, which helps move the irritant out of the air passages. As the air is forced out past the closed glottis, the recognizable coughing sound is made. A cough that persists for several days or increases in its intensity and frequency can be a sign of a serious condition.

When caring for a patient with a cough, remember that the droplets from a cough can travel several hundred miles per hour. This means that anyone in the room may potentially be exposed to an infectious pathogen when the patient coughs.

Place a surgical mask on the patient and the providers in the room. A surgical mask may make a patient short of breath, so consider placing oxygen under the surgical mask. A regular non-rebreather mask by itself isn’t adequate protection from a pathogen in a coughing patient.

For Mr. G, the cough could be a sign of several conditions that can be associated with his complaint of feeling weak and dizzy. The patient may be correct that his weakness and cough may “just be a cold,” as a virus in the upper or lower airway can cause a cough. Other infectious conditions such as pneumonia and tuberculosis can present with a cough. These typically cause a productive cough, meaning the patient will expel green or yellow mucous, which may be tinged with blood.

Lung cancer may also cause a cough with a bloody discharge. Breath sounds with pneumonia and lung cancer can present similarly, both with unilateral, isolated adventitious sounds. Lung cancer isn’t considered contagious, but there’s no way in the out-of-hospital setting for us to know if the cough is caused by a cancer, virus or bacteria. Cover the cough and provide oxygen as necessary based on the patient’s complaint and pulse oximetry.

Heart failure can cause a patient to cough. When the left ventricle begins to fail, the blood backs into the pulmonary circulatory system and fluid will eventually be pushed into the alveolar spaces. These patients may also feel weak and won’t want to lay down. They need to remain sitting to keep the fluid at the bottom of their lungs. In the early stages of heart failure, the cough won’t be productive. During the later stages of heart failure, the cough may produce a pink, bubbly sputum. Lung sounds vary based on the stage of heart failure. In early stages, lung sounds may be clear to auscultation. In the later stages of the disease, crackles can be heard in the bases bilaterally.

This condition isn’t contagious. Maximize the patient’s oxygen, and suction as necessary, or, if in the later stage, the administration of continual positive airway pressure (CPAP) may help relieve the patient’s shortness of breath and relieve the cough.

Some medications can cause a chronic cough. A common medication class to cause a non-productive cough are angio-converting enzyme (ACE) inhibitors. These medications work to control blood pressure by causing the blood vessels to dilate. There’s nothing EMS can do to manage this cough. In some cases, the ACE inhibitor can cause angioedema or swollen lips and tongue, which can look a lot like an allergic reaction.

Conclusion

Be sure to recognize a cough and ask the patient about it: How long have they had the cough? Is the cough productive? If it is, what is the color and consistency of the stuff being coughed up? Auscultation of lung sounds may help identify the cause of the cough. In this case, Mr. G was diagnosed as having an early stage of heart failure.

Be sure to inform the receiving facility of the potential for infectious contamination. The presence of the cough may be dismissed by the patient, especially if they’ve had the cough for a while. It still should be considered an important finding and should be incorporated into the patient assessment. Be thorough and be safe.