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Concept: Cough


The role of inhaled steroids in patients with chronic respiratory diseases is a matter of debate due to the potential effect on the development and prognosis of community-acquired pneumonia (CAP). We assessed whether treatment with inhaled steroids in patients with chronic bronchitis, COPD or asthma and CAP may affect early outcome of the acute pneumonic episode.

Concepts: Asthma, Medical terms, Pneumonia, Cough, Chronic, Chronic obstructive pulmonary disease, Mucus, Respiratory diseases


Dextromethorphan (3-methoxy-N-methylmorphinan), also known as “DXM” and “the poor man’s PCP,” is a synthetically produced drug that is available in more than 140 over-the-counter cough and cold preparations. Dextromethorphan (DXM) has overtaken codeine as the most widely used cough suppressant due to its availability, efficacy, and safety profile at directed doses. However, DXM is subject to abuse. When consumed at inappropriately high doses (over 1500 mg/day), DXM can induce a state of psychosis characterized by Phencyclidine (PCP)-like psychological symptoms, including delusions, hallucinations, and paranoia. We report a noteworthy case of severe dextromethorphan use disorder with dextromethorphan-induced psychotic disorder in a 40-year-old Caucasian female, whose symptoms remitted only following treatment with a combination of an antipsychotic and mood stabilizer. While some states have begun to limit the quantity of DXM sold or restrict sales to individuals over 18-years of age, there is currently no federal ban or restriction on DXM. Abuse of DXM, a readily available and typically inexpensive agent that is not detected on a standard urine drug screen, may be an under-recognized cause of substance-induced psychosis. It is imperative that clinicians are aware of the potential psychiatric sequelae of recreational DXM use.

Concepts: Cough, Schizophrenia, Psychosis, Bipolar disorder, Psychiatry, Common cold, Codeine, Cough medicine


The effectiveness of recommended measures, such as “cover your mouth when coughing”, in disrupting the chain of transmission of infectious respiratory diseases (IRD) has been questioned. The objective of the current study was to determine the effectiveness of simple primary respiratory hygiene/cough etiquette maneuvers in blocking droplets expelled as aerosol during coughing.

Concepts: Infectious disease, Diseases and disorders, Respiratory disease, Cough, Infection, Tuberculosis, Primary school, The Current


This article focuses on recent data which highlight the clinical settings in which exhaled nitric oxide (F(E)NO) is potentially helpful, or not, as a clinical tool. It is becoming clearer that, selectively applied, F(E)NO measurements can provide reliable clinical guidance, particularly when values are low. Such values are associated with high negative predictive values (>90%). Increased F(E)NO levels are associated with much more modest positive predictive values (75%-85%) and these are less reliable. These general principles apply when diagnosing steroid responsiveness in relation to asthma, chronic cough, and COPD. Although randomised trials do not support routine use of exhaled NO measurements in uncomplicated bronchial asthma, there is evidence that in patients with difficult asthma, or asthma associated with pregnancy, F(E)NO enhances overall management, and the decision to commence or increase inhaled steroid therapy (yes/no) may be made more accurately. Exhaled NO is potentially relevant in the assessment of occupational asthma (serial measurements) and also in diagnosing bronchiolitis obliterans in lung transplant patients.

Concepts: Asthma, Cough, Chronic obstructive pulmonary disease, Nitric oxide, Bronchiole, Bronchiolitis obliterans, Exhaled nitric oxide, Bronchodilator


Dextromethorphan (DXM) in combination with antihistamines and/or pseudoephedrine is widely available as an over-the-counter remedy commonly used for relief of colds and cough. In supratherapeutic amounts, DXM can be extremely activating. These cough preparations have been adopted by many young users of recreational drugs for their psychoactive effects. When used in amounts exceeding those recommended, this practice, known as “robotripping,” may result in a manic toxidrome of psychomotor agitation, hostility, grandiose behavior, hallucinations, paranoia, and panic. A case illustration of this phenomenon is described and implications of this phenomenon discussed. There are few reports associating DXM use with bipolar symptomatology.

Concepts: Cough, Opioid, Psychosis, Ketamine, Common cold, Recreational drug use, Psychedelic drug, Dextromethorphan


The examination of cough reflex sensitivity through inhalational challenge can be utilised to demonstrate pharmacological end points. Here we compare the effect of butamirate, dextromethorphan and placebo on capsaicin-induced cough in healthy volunteers.

Concepts: Pharmacology, Clinical trial, Cough, Effect, Randomized controlled trial, Effectiveness, Effects unit, Reflexes


There is a strong association between obesity and gastroesophageal reflux disease (GERD). GERD-related questionnaires have been developed in order to objectify symptoms. However, none of them has been tested in obese population.

Concepts: Cancer, Asthma, Cough, Obesity, Gastroesophageal reflux disease, Esophageal cancer, Barrett's esophagus


Lung hernias are rare and their pathogenesis is few described. They are defined as the protrusion of lung parenchyma through the chest wall: intercostal space, inter-costo-clavicular, supra-clavicular or diaphragmatic hiatus. Lung hernias are classically divided into congenital and acquired hernias. Those are usually post-traumatic or post-surgical but can be provoked by cough. Clinical diagnosis is often evident but is confirmed by chest radiograph and especially computed tomography. Major risks are lung incarceration and necrosis but also ventilatory distress due to paradoxical respiration, in case of large defect. Treatment is first and foremost surgical but debated and should consider the localization, the size, the length of evolution and the possible infectious context. We report the case of a right basi-thoracic lung hernia induced by a cough fit, in a patient with chronic bronchitis.

Concepts: Spinal disc herniation, Asthma, Lung, Pneumonia, Cough, Surgery, Medical imaging, Parenchyma


Associations of gastroesophageal reflux disease (GERD) with extraesophageal manifestations, such as chronic cough, asthma, and laryngitis, are reported frequently, and there is a strong evidence of biological plausibility in support of this relationship. On the other hand, extraesophageal reflux disease (EERD) is usually multifactorial in nature with reflux being just one of the several potential contributing cofactors. Moreover, the accuracy of currently available diagnostic tests for EERD is suboptimal, and therefore the causal relationship between GERD and EERD remains far from being conclusively proven. In addition, there is a general paucity of data supporting a beneficial effect of anti-reflux treatments on symptoms of patients with suspected EERD. Therefore, diagnostic as well as therapeutic management of EERD remains largely empirical. Current guidelines suggest an initial empiric trial of proton pump inhibitors in patients without alarm features, who present also typical GERD symptoms. For those patients who improve with PPIs, GERD is presumed to be the etiology. In patients with refractory reflux, combined impedance/pH monitoring might provide the single best strategy for evaluating reflux symptoms. In this context, as symptoms ascribable to GERD may depend on other causes, investigations that excludes GERD can help to redirect the diagnostic and treatment efforts to other pathological conditions. The present review intends to discuss the current state of knowledge regarding the challenging diagnostic and therapeutic management of patients with suspected EERD, emphasizing the points of strengths and limitations of currently available diagnostic options, and to provide an update on major diagnostic innovations in this area.

Concepts: Causality, Asthma, Medical terms, Cough, Gastroenterology, Gastroesophageal reflux disease, Esophageal pH Monitoring, Lansoprazole


Patients with influenza release aerosol particles containing the virus into their environment. However, the importance of airborne transmission in the spread of influenza is unclear, in part because of a lack of information about the infectivity of the airborne virus. The purpose of this study was to determine the amount of viable influenza A virus that was expelled by patients in aerosol particles while coughing. Sixty-four symptomatic adult volunteer outpatients were asked to cough 6 times into a cough aerosol collection system. Seventeen of these participants tested positive for influenza A virus by viral plaque assay (VPA) with confirmation by viral replication assay (VRA). Viable influenza A virus was detected in the cough aerosol particles from 7 of these 17 test subjects (41%). Viable influenza A virus was found in the smallest particle size fraction (0.3 μm to 8 μm), with a mean of 142 plaque-forming units (SD 215) expelled during the 6 coughs in particles of this size. These results suggest that a significant proportion of patients with influenza A release small airborne particles containing viable virus into the environment. Although the amounts of influenza A detected in cough aerosol particles during our experiments were relatively low, larger quantities could be expelled by influenza patients during a pandemic when illnesses would be more severe. Our findings support the idea that airborne infectious particles could play an important role in the spread of influenza.

Concepts: Microbiology, Cough, Influenza, Influenza pandemic, Assay, Influenza vaccine, Influenzavirus A, Viral plaque