Vigorous Coughing Research Articles

INTRACTABLE COUGH CAUSING SPONTANEOUS RECTUS SHEATH HEMATOMA

TOPIC: Signs and Symptoms of Chest Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cough is a physiologic mechanism that causes airways to be cleared of foreign materials and excess secretions. The violent expiration is associated with rapid contraction of the diaphragm and the abdominal wall muscles leading to an increase in intraabdominal pressures. Longstanding untreated cough can lead to spontaneous abdominal wall hematomas. (1) CASE PRESENTATION: A 65-year-old gentleman presented to the Emergency Room with right lower quadrant abdominal pain of one-week duration. He had no past medical history. He was noted to have a persistent intractable cough for one month. Prior to the onset of cough, he had one week of loss of taste and smell, nasal congestion, nasal discharge and postnasal drip. According to him, the cough was so bad that he felt like he was going to burst. Although his family insisted, he did not get the cough evaluated. His vital signs were stable. Physical examination showed ecchymosis, a small palpable mass and tenderness in the right lower quadrant. Lung exam was unremarkable. Lab work unremarkable with normal platelet count and coagulation profile. Computed Tomography (CT) of the abdomen/pelvis showed an intramuscular vascular mass of 9 cm within the right rectus abdominis suggestive of a hematoma which was managed conservatively. Of note, he was not on any anticoagulants. On 1 month follow-up, he had complete resolution of abdominal pain, ecchymosis, mass and tenderness in the right lower quadrant. However, he continued to have a persistent cough for which he was referred to pulmonology. He visited the pulmonary clinic after 5 months of referral. At that time, he had become dependent on over-the-counter (OTC) oral decongestants and antihistamines. He had no reflux symptoms, no allergies, was a lifetime nonsmoker, employed as a banker and had a Labrador for 11 years. CT chest showed normal lung parenchyma. Pulmonary function tests revealed features of mild obstructive lung disease. His OTC medications were stopped and he was given a course of oral prednisone along with fluticasone and azelastine nasal spray with dramatic improvement and complete resolution of cough. DISCUSSION: Sustained cough results in over contraction and overstretching of abdominal muscles with an increase in intra-abdominal pressures. (2) Vigorous coughing plausibly generates shear forces high enough to tear superior and inferior epigastric vessels along the posterior aspect of long rectus muscle which results in rectus sheath hematomas. Almost 29% of spontaneous rectus sheath hematomas are the result of sustained cough the risk of which increases with the use of anticoagulants. (3) While these hematomas are conservatively managed, patients should undergo a thorough evaluation and treatment of cough to prevent its recurrence. CONCLUSIONS: This case highlights the potential of sustained vigorous cough to cause abdominal wall hematomas even in the absence of anticoagulants. REFERENCE #1: 1. Fuller RW, Jackson DM. Physiology and treatment of cough. Thorax. 1990;45(6):425-430. doi:10.1136/thx.45.6.425 REFERENCE #2: 2. Kodama K, Takase Y, Yamamoto H, Noda T. Cough-induced internal oblique hematoma. J Emerg Trauma Shock. 2013;6(2):132-134. doi:10.4103/0974-2700.110789 REFERENCE #3: 3. Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore). 2006;85(2):105-110. doi:10.1097/01.md.0000216818.13067.5a DISCLOSURES: No relevant relationships by Fady Jamous, source=Web Response No relevant relationships by Swaminathan Perinkulam Sathyanarayanan, source=Web Response

Pacemaker-generated stress fracture of the second rib: a case report

BackgroundPocket-related complications following the implantation of cardiovascular implantable electronic devices primarily include pocket hematoma, infection, skin erosion or decubitus, device migration, and Twiddler's syndrome, with other pathologies such as nerve impairment or bone lesions being extremely rarely encountered. We report a case of a 20-year old asthenic, non-athlete female patient presenting with a device-generated fracture of the second rib several months after sub-muscular permanent pacemaker implantation due to repeated bilateral pre-pectoral pocket infections.Case presentationA 20-year old female patient was readmitted to our institution 9 months following sub-pectoral implantation of a permanent pacemaker, complaining of severe pocket-related pain, which arose spontaneously in the absence of direct trauma, intense physical activity or vigorous coughing, and was associated with normal day-to-day activity. To rule out a pacemaker re-infection, a native computed tomography and a positron emission tomography—computed tomography of the thorax were performed. Both modalities excluded an infection but showed a healing fracture and a focus of enhanced metabolic activity in the anterolateral part of the right second rib, indicating a non-traumatic or stress fracture of the bone. Consequently, a complete extraction of the pulse generator and both leads was performed and the smallest available single-chamber pulse generator with a single atrial electrode was implanted in the sub-fascial, pre-muscular pocket in the now recovered and uninfected left subclavicular region, alleviating patient’s severe pain symptoms and significantly enhancing her quality of life.ConclusionsIn the absence of direct trauma, intense physical activity or vigorous coughing, we assume that in this asthenic girl a normal day-to-day motion of the right shoulder has persistently forced the sub-muscularly placed pulse generator toward thoracic wall, putting increased repetitive pressure force on the underlying bones, finally causing a fatigue stress fracture of the second rib. In asthenic phenotype patients with small thorax and short subclavicular distance, a sub-muscular pacemaker implantation can potentially cause unique and unexpected pocket-related adverse events necessitating advanced diagnostics and timely treatment.

Blood Shift During Cough: Negligible or Significant?

Rationale: It was reported how forceful rhythmic coughing can provide effective blood flow during ventricular fibrillation without direct chest compression. This mechanism of cough-assisted cardiopulmonary resuscitation constitutes a form of “cardiac massage” secondary to the intrathoracic and intra-abdominal pressure changes during cough. We have previously shown that significant blood shifts (BSs) occurs from the thorax to the extremities during expulsive maneuvers and that abdominal pressure controls the outflow of blood from the splanchnic vasculature. This mechanism was called abdominal circulatory pump. BS was quantified by using double body plethysmography (DBP), which combines total body plethysmography and opto-electronic plethysmography.Aim: We hypothesized that coughing activates also the abdominal circulatory pump, being an additional mechanism that displaces a circulatory output sufficient to maintain consciousness in a patient with a non-beating heart.Methods and Results: We studied seven healthy subjects (age: 28.6 ± 2.5 years) during series of voluntary coughs at three different operating volumes: after a spontaneous tidal volume, at total lung capacity (TLC) and at an intermediate volume. BS from the thorax to the extremities were measured by DBP during quiet breathing and during cough at each operating lung volume. BS during cough resulted significantly higher than during quiet breathing (p < 0.05). During the compressive phase, the blood outflow is around 200 ml, whereas during the expulsive phase BS increased (p < 0.05) with increasing operating volume, being almost 700 ml at TLC. At lower operating volume it is almost 400 ml.Conclusion: Deep, vigorous coughing and the consequent fluctuations in intra-thoracic and intra-abdominal pressure activate both the thoracic and the abdominal pump mechanism. The former leads the low-resistance pulmonary veins to empty into the left heart. The latter can generate a circulatory output from the splanchnic region, which acts as a blood reservoir, to other body tissues. These findings might help to better understand the cardiopulmonary interactions during cough, particularly in patients with unstable cardiac function, and the mechanism by which coughing during unstable cardiac rhythms can maintain consciousness in human subjects.

Tracheal Rupture With Extensive Subcutaneous Emphysema Involving the Face

SESSION TITLE: Critical Care SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Tracheal rupture is a rare but life-threatening complication that most commonly occurs after blunt trauma of the neck and chest. Iatrogenic rupture is extremely rare and can occur after intubation, bronchoscopy, or esophagectomy. CASE PRESENTATION: A 51-year-old woman with a past medical history of hypertension presented with facial, neck, and chest wall swelling and crepitus. The patient underwent endoscopic gastric balloon removal one day earlier. 2 days after the procedure, the patient complained of discomfort around her face, neck, and chest. On admission, her examination was notable for palpable crepitus around her scalp, face, orbits, neck, and chest. The chest X-ray showed pneumomediastinum and subcutaneous emphysema (Images A and B). Chest computed tomography (CT) scan of the chest revealed extensive severe subcutaneous, fascial plane, and intramuscular emphysema, involving the scalp, face, neck, and chest (Images C-G, arrow). Additionally, there was diffuse pneumomediastinum extending to the thoracoabdominal junction, and a tear at the posterior tracheal wall. Three-dimensional (3D) CT reconstruction revealed a 5 centimeter posterior tracheal wall tear (Image H). The patient was taken emergently for surgical intervention and repair of the tracheal wall, and recovered fully. DISCUSSION: There are multiple factors which can contribute to tracheal rupture, and they can be divided into mechanical factors that include trauma during intubation, overinflation of the cuff and vigorous coughing, manipulation or surgical intervention within the airway, and anatomical factors. Overinflation of the cuff and sudden movement of the endotracheal tube are the most common causes, while a direct tear caused by the tube itself is rare [1]. Published literature on tracheal rupture has shown a female predominance and mean age over 50 years [2]. This is believed to be due to a weaker pars membranosa in women, as well as a smaller tracheal diameter which makes women more vulnerable to cuff overinflation. Male sex is an independent factor adversely influencing mortality [3]. The clinical manifestations of tracheal injury include subcutaneous emphysema, mediastinal emphysema, pneumothorax, and respiratory distress. They usually appear during surgery or in the immediate post-operative period. Subcutaneous emphysema is the most common symptom and also a protective factor, as its presence alerts to the possible existence of tracheal rupture and accelerates the steps towards its definitive diagnosis and treatment. Diagnostic confirmation is usually made by bronchoscopy. Consensus on the management of tracheal rupture has not yet been reached. Early surgical repair has traditionally been the mainstay of treatment. However, there are now more clinicians who opt for conservative treatment in patients with small ruptures (<2cm), and in selected patients with minimal, non-progressive symptoms. CONCLUSIONS: Tracheal rupture is a very rare condition but it carries a high morbidity and mortality. Diagnostic suspicion is essential, with subsequent confirmation by bronchoscopy. The condition is most common in elderly women, although the risk of death is higher in men. Iatrogenic causes occur most commonly after intubation. Reference #1: Conti M, Pougeoise M, Wurtz A, Porte H, Fourrier F, Ramon P, Marquette CH. Management of postintubation tracheobronchial ruptures. Chest. 2006;130:412-418. Reference #2: Hofmann HS, Rettig G, Radke J, Neef H, Silber RE. Iatrogenic ruptures of the tracheobronchial tree. Eur J Cardiothorac Surg. 2002;21:649-652. Reference #3: Minambres E, Buron J, Ballestros MA, et al. Tracheal rupture after endotracheal intubation. Eur J Cardiothorac Surg. 2009;3:1056-1062. DISCLOSURE: The following authors have nothing to disclose: Radu Postelnicu, Gaetane Michaud No Product/Research Disclosure Information

An Unusual Association in an Uncommon Disease: Two Cases of Spontaneous Pneumomediastinum Associated with Pneumorrhachis.

Pneumomediastinum, the presence of free air in the mediastinum, is described as spontaneous pneumomediastinum when there is no apparent cause such as trauma, surgery, interventional procedures, or intrathoracic infections. Pneumorrhachis is a rare clinical condition, consisting of intraspinal air. The main causes are iatrogenic, traumatic, and nontraumatic. Spontaneous mediastinum is usually associated with subcutaneous emphysema and, occasionally, with pneumothorax; however, its association with pneumorrhachis is extremely rare. Here, we present two rare cases of spontaneous pneumomediastinum associated with pneumorrhachis caused by vigorous coughing.

An Unusual Cause of Hepatic Rupture

Introduction: The Liver is a highly vascular organ that is vulnerable to traumatic injury because of its size and fixed position in the right hypochondrium. We present a unique case of a patient who presented with hepatic rupture following vigorous coughing. Case description: An 83 year-old female with history of chronic obstructive pulmonary disease presented with epigastric pain, nausea and vomiting following an episode of vigorous cough on exposure to dust. She denied hematemesis, melena or fever. Physical examination: heart rate 102/min, and blood pressure 109/56 mm Hg, decreased breath sounds with bilateral wheezing, diffusely tender, distended abdomen with guarding but no rigidity. Laboratory data: Total bilirubin 4.5 mg/l, Aspartate transaminase 43 IU/l, Alanine transaminase 99 IU/l, Alkaline phosphatase 136 IU/l, Serum lipase 51 U/l, negative hepatitis panel. Chest X-ray showed no rib fractures. Computed tomography (CT) revealed large fluid collection posterior to the stomach, no bowel perforation or cholecystitis. CT guided drainage showed bilious fluid. She was initially managed conservatively with the drain in place but failed to improve. Endoscopic retrograde cholangiopancreatography (ERCP) showed an obvious leak of contrast from the left lobe of the liver flowing and draining through the drain. Sphincterotomy and stent placement were done during ERCP with significant improvement in her condition. Hepatobiliary (HIDA) scan after 4 weeks showed no bile leak and stent was removed. Discussion: Hepatic laceration is often a fatal complication of trauma, pregnancy, anticoagulant therapy, connective tissue disorders, liver infiltrative diseases, hepatocellular carcinomas, and rarely cough as in our case. Patients present with severe right upper quadrant pain, abdominal distention, anemia or hypotension. Suspicion of injury is raised from presentation, physical examination and laboratory findings. CT abdomen usually confirms the injury and defines injury grade. Biliary tree disruption is a frequent complication of non-operative management; diagnosis and evaluation of the leak site may be made by ERCP and HIDA scan. Drainage of the bile collection followed by close observation serves as definitive therapy, but some patients have persistent bilious drainage that can be managed by ERCP with sphincterotomy and/or biliary stent placement. Conclusion: Hepatic laceration, though life-threatening, is not a well-described complication of cough. This report provides a detailed account of such a complication along with an unlikely site of bile collection occurring secondary to vigorous coughing.Figure 1Figure 2Figure 3

Intercostal Lung Hernia: A Case for Conservative Treatment

Lung herniation, defined as the protrusion of the lung beyond the thorax, is rarely encountered in the clinical setting. Most pulmonary hernias are caused by congenital defects and thoracic trauma. Spontaneous hernias are uncommon. We present a 70 year old patient with spontaneous intercostal lung herniation following a bout of bronchitis and several days of vigorous coughing. We highlight the pitfalls in establishing a diagnosing, present the outcome with conservative management, review the literature and outline the types, causes, incidence, and treatment options.

Middle East Respiratory Syndrome Coronavirus Superspreading Event Involving 81 Persons, Korea 2015.

Since the first imported case of Middle East respiratory syndrome coronavirus (MERS-CoV) infection was reported on May 20, 2015 in Korea, there have been 186 laboratory-confirmed cases of MERS-CoV infection with 36 fatalities. Ninety-seven percent (181/186) of the cases had exposure to the health care facilities. We are reporting a superspreading event that transmitted MERS-CoV to 81 persons at a hospital emergency room (ER) during the Korean outbreak in 2015. The index case was a 35-yr-old man who had vigorous coughing while staying at the ER for 58 hr. As in severe acute respiratory syndrome outbreaks, superspreading events can cause a large outbreak of MERS in healthcare facilities with severe consequences. All healthcare facilities should establish and implement infection prevention and control measure as well as triage policies and procedures for early detection and isolation of suspected MERS-CoV cases.

A Case of Significant Endobronchial Injury due to Recurrent Iron Pill Aspiration.

Gastric mucosal damage by iron pills is often reported. However, iron pill aspiration is uncommon. Oxidation of the impacted iron pill causes bronchial mucosal damage that progresses to chronic bronchial inflammation, necrosis, endobronchial stenosis and rarely, perforation. We reported a case of a 92-year-old woman with chronic productive cough and significant left-sided atelectasis. Bronchoscopy revealed substantial luminal narrowing with exudative inflammation of the left main bronchus. Bronchial washing cytology showed necroinflammatory exudate and a small amount of brown material. Mucosal biopsy showed diffuse brown pigments indicative of ferrous pigments, crystal deposition, and marked tissue degeneration. After vigorous coughing, she expectorated dark sediments and her symptoms and radiological abnormalities improved. There are a few such reports worldwide; however, this was the first case reported in Korea. Careful observation of aspiration-prone patients and early detection of iron pill aspiration may prevent iron pill-induced bronchial injury.

Incidence, risk factors and clinical outcomes of peripherally inserted central catheter spontaneous dislodgment in oncology patients: A prospective cohort study

PurposePeripherally inserted central catheter (PICC) spontaneous dislodgment is insidious in onset and prone to cause complications. We performed a prospective cohort study to examine the incidence, risk factors and clinical results of PICC spontaneous dislodgment in oncology patients to facilitate successful early diagnosis, prophylaxis and management. Patients and methodsConsecutive oncology patients, undergoing placement of PICCs, were enrolled and prospectively followed up until their catheters were removed or PICC spontaneous dislodgment presented. The patients with PICC spontaneous dislodgment or catheter-associated thrombosis (CRT) were followed up for an extra three months from the date of diagnosis. The main endpoint was PICC spontaneous dislodgment, and the sub-endpoints were CRT and catheter in-place time. The PICC insertion team, nurses, interventional radiologists and oncology doctors collected longitudinal data. ResultsOver a total of 60,894 days of cumulative follow-up, 21 out of 510 PICCs presented spontaneous dislodgment, leading to an incidence rate of 4.12%. The CRT rate of the group with PICC spontaneous dislodgment was much higher than that of the group without PICC spontaneous dislodgment (RR=17.46, 95% CI: 8.29–36.82, p=1.09×10−17). Five baseline exposure factors, including primary lung cancer, metastatic lung cancer, chest radiotherapy, vigorous coughing and severe vomiting, were significant risk factors of PICC spontaneous dislodgment. Basilic vein access (odds ratio [OR]=0.39, 95% CI: 0.16–0.95, P=0.04) was a protective factor against PICCSD in univariate analysis. Among these factors, the independent significant risk factors were vigorous coughing (OR=6.14, 95% CI: 1.70–22.16, P=0.01) and severe vomiting (OR=3.70, 95% CI: 1.28–10.68, P=0.02). ConclusionThe incidence rate of PICC spontaneous dislodgment is 4.12% (0.34 per 1000 catheter-days); PICC spontaneous dislodgment significantly increases the risk of CRT and shortens catheter in-place time. Vigorous coughing and severe vomiting were independent risk factors of PICC spontaneous dislodgment among oncology patients.

The large spectrum of pulmonary complications following illicit drug use: Features and mechanisms

Damage to lungs may occur from systemic as well as inhalational exposure to various illegal drugs of abuse. Aspiration pneumonia probably represents the most common pulmonary complication in relation to consciousness impairment. Some pulmonary consequences may be specifically related to one given drug. Prolonged smoking of marijuana may result in respiratory symptoms suggestive of obstructive lung disease. Non-cardiogenic pulmonary edema has been attributed to heroin, despite debated mechanisms including attempted inspiration against a closed glottis, hypoxic damage to alveolar integrity, neurogenic vasoactive response to stress, and opiate-induced anaphylactoid reaction. Naloxone-related precipitated withdrawal resulting in massive sympathetic response with heart stunning has been mistakenly implicated. In crack users, acute respiratory syndromes called “crack-lung” with fever, hemoptysis, dyspnea, and pulmonary infiltration on chest X-rays have been reported up-to 48h after free-base cocaine inhalation, with features of pulmonary edema, interstitial pneumonia, diffuse alveolar hemorrhage, and eosinophil infiltration. The high-temperature of volatilized cocaine and the presence of impurities, as well as cocaine-induced local vasoconstriction have been suggested to explain alveolar damage. Some other drug-related pulmonary insults result from the route of drug self-administration. In intravenous drug users, granulomatous pneumonia with multinodular patterns on thoracic imaging is due to drug contaminants like talcum. Septic embolism from right-sided endocarditis represents an alternative diagnosis in case of sepsis from pulmonary origin. Following inhalation, pneumothorax, and pneumomediastinum have been attributed to increased intrathoracic pressure in relation to vigorous coughing or repeated Valsalva maneuvers, in an attempt to absorb the maximal possible drug amount. In conclusion, pulmonary consequences of illicit drugs are various, resulting in both acute life-threatening conditions and long-term functional respiratory sequelae. A better understanding of their spectrum and the implicated mechanisms of injury should help to improve patient management.

Eine seltene Komplikation nach heftiger Hustenattacke

A 85-year-old man presented to the emergency department with acute onset of right-sided chest pain after vigorous coughing. Physical examination revealed a progressive hematoma and a palpable bulge that enlarged with expiration. A CT-Scan confirmed a lateral lung herniation with a dissection of the intervertebral muscle. The Patient underwent a surgical reconstruction of the chest wall defect and an additional Mersilene Mesh repair of a consecutive diaphragmal rupture. The patient had an uneventful recovery and was discharged on postoperative day 11.

Symptomatic intercostal lung hernia secondary to sternal dehiscence surgery

Patient: Male, 60Final Diagnosis: Iatrogenic intercostal lung herniaSymptoms: —Medication: No medicationClinical Procedure: Surgically cerrectedSpecialty: Thoracic surgeryObjective:Unusual clinical courseBackground:Iatrogenic intercostal lung hernia is a rare thoracic pathology. Injury of intercostal muscles and costocondral separation during median sternotomy and sternal dehiscence surgery are important factors in the development of hernia. We report for the first time a case of a 60-year-old man with acquired lung hernia after sternal dehiscence surgery, presenting as chest pain and exertional dyspnea.Case Report:A 60-year-old man presented with a 6-week history of progressive exertional dyspnea, particularly following vigorous coughing. Past medical history included slight chronic obstructive pulmonary disease and coronary artery bypass grafting surgery 8 weeks previously, using the left internal mammary artery for the left anterior descending artery via median sternotomy and sternal dehiscence by the Robicsek method. A chest X-ray showed intact sternal and parasternal wires, but the bilateral lung parenchyma appeared normal. A spiral computed tomography scan of the chest found intercostal herniation of the anterior segment of the left upper lobe. The lung hernia was repaired surgically to relieve exertional dyspnea and incarceration, and to improve respiratory function. The postoperative course was uneventful and the patient recovered well.Conclusions:Intercostal lung hernia after median sternotomy and sternal dehiscence surgery is rare, and it has been previously reported on. Preventive techniques include gentle manipulation of the sternal retractor, avoidance of rib fractures, and using a protective method of intercostal arteries and nerves such as Sharma technique. Thoracic surgeons should be aware of this rare complication in sternal dehiscence surgery.

PNEUMOCEPHALUS AS A COMPLICATION OF NASAL OXYGEN INHALATION

15 October 2011 Dear Editor, Pneumocephalus, defined as the presence of air or gas in the cranial cavity is rare in infants. We report pneumocephalus in an 8-month-old male infant after receiving oxygen through nasal prongs. The boy presented in paediatric emergency with respiratory distress for 1 day preceded by running nose and fever for 3 days. His immunization was up-to-date and there was no history of cough. On examination, he had tachypnoea (respiratory rate 64/min) with subcostal retractions; oxygen saturation in pulse oximetry was 82%. Systemic examination revealed fine crackles in the chest. Chest X-ray showed hyperinflation with mild infiltrations in lungs. He was diagnosed as having bronchiolitis and was given humidified oxygen through nasal prongs at a flow rate of 2 L/min along with other supportive management. The following morning, a soft bulge over anterior fontanel of size 3 × 4 cm was noticed though there was no facial puffiness or subcutaneous emphysema over scalp. Base of the anterior fontanel was apparently closed. Cranial computed tomographic scan revealed the presence of multiple focal areas of air both inside the cranium and bulging out over the anterior fontanel without any evidence of intracranial haemorrhage (Fig. 1). Sepsis screen and blood culture were negative. Guarded lumbar puncture revealed normal cerebrospinal fluid pressure. Biochemical and microbiological examinations were also normal. Oxygen was stopped as retractions became less severe and saturation was maintained at 90–94% at room air. The bulge of anterior fontanel gradually subsided. He was discharged on day 14. Follow-up did not reveal any abnormality over next 1 year. Computed tomography scan of brain showing multiple focal areas of air both inside the cranium and bulging out over the anterior fontanel. Pneumocephalus has been reported in infants in association with meningitis and secondary to meningomyelocele.1-3 Intracranial anaerobic and aerobic infections are known to produce gas by putrefaction of intracellular protein derived from autolysis and by decomposition of glucose.2 In the present child there was no evidence of meningitis or vigorous coughing which might have lead to subcutaneous emphysema. Probably nasal oxygen flow tracked through the cribriform plate into the extra-axia spaces and finally dissected out through cranial sutures and collected over anterior fontanel. Nasal prongs are widely used in infants. Though airway mucosal blood flow is reported to be maintained,4 humidification and temperature may not be maintained and in some cases may cause excessive expiratory pressure loading.5 After extensive literature search we could find only a single case report of pneumocephalus with concomitant use of the high-flow nasal cannula where the authors also found subcutaneous scalp emphysema and pneumo-orbitis.6

Queer consequence of cough: atrial myxoma embolization with acute occlusion of the abdominal aorta

We introduce a rare case of sudden paraplegia preceded by vigorous coughing. This case demonstrates that detachment of a myxoma fragment can possibly be triggered by an abrupt increase in intrathoracic pressure. It is a potential complication that has never been reported in the literature. This case illustrates that clinicians should consider cardiac myxoma in a patient with an embolic event of ambiguous etiology, especially when the event is preceded by a forceful, valsalva maneuver-like action.

Cough-Induced Intercostal Lung Herniation Requiring Surgery: Report of a Case

Lung herniation is a rare event defined by protrusion of the lung through an abnormal weakness in the thoracic wall. We report a case of spontaneous intercostal pulmonary herniation, which occurred as a result of vigorous coughing. We repaired the herniation by approximating the ribs with heavy stitches. The mechanism of intercostal muscle disruption, and the etiology and treatment of lung herniations, are discussed.

Complications of Cough: ACCP Evidence-Based Clinical Practice Guidelines

To review the spectrum and frequency of complications associated with coughing. Ovid MEDLINE literature review (through March 2004) for all studies published in the English language, including case series and case reports, since 1966 using the MeSH terms "cough" and "complications." The complications of cough appear to stem from physiologic events. The magnitude of pressures, velocities, and energy that is generated during vigorous coughing allow coughing to be an effective means of clearing the airways of excessive secretions and foreign material, and providing cardiopulmonary resuscitation; however, they can also cause a variety of profound physical and psychosocial complications. The adverse occurrences include cardiovascular, constitutional, GI, genitourinary, musculoskeletal, neurologic, ophthalmologic, psychosocial, respiratory, and skin complications, and a decrease in health-related quality of life. Knowledge of the spectrum of complications should enable clinicians to appreciate (1) the impact of cough on patients, (2) why it is imperative to exhaust all possible diagnostic and therapeutic options to eliminate cough, and (3) why it is inappropriate to minimize a patient's complaint of cough and/or advise him/her to "live with it."

Postinfectious Cough: ACCP Evidence-Based Clinical Practice Guidelines

Patients who complain of a persistent cough lasting >3 weeks after experiencing the acute symptoms of an upper respiratory tract infection may have a postinfectious cough. Such patients are considered to have a subacute cough because the condition lasts for no >8 weeks. The chest radiograph findings are normal, thus ruling out pneumonia, and the cough eventually resolves, usually on its own. The purpose of this review is to present the evidence for the diagnosis and treatment of postinfectious cough, including the most virulent form caused by Bordetella pertussis infection, and make recommendations that will be useful for clinical practice. Recommendations for this section of the guideline were obtained from data using a National Library of Medicine (PubMed) search dating back to 1950, which was performed in August 2004, of the literature published in the English language. The search was limited to human studies, using the search terms "cough," "postinfectious cough," "postviral cough," "Bordetella pertussis," "pertussis infection," and "whooping cough." The pathogenesis of the postinfectious cough is not known, but it is thought to be due to the extensive inflammation and disruption of upper and/or lower airway epithelial integrity. When postinfectious cough emanates from the lower airway, this is often associated with the accumulation of an excessive amount of mucus hypersecretion and/or transient airway and cough receptor hyperresponsiveness; all may contribute to the subacute cough. In these patients, the optimal treatment is not known. Except for bacterial sinusitis or early on in a B pertussis infection, therapy with antibiotics has no role, as the cause is not bacterial infection. The use of inhaled ipratropium may be helpful. Other causes of postinfectious cough are persistent inflammation of the nose and paranasal sinuses, which leads to an upper airway cough syndrome (previously referred to as postnasal drip syndrome), and gastroesophageal reflux disease, which may be a complication of the vigorous coughing. One type of postinfectious cough that is particularly virulent is that caused by B pertussis infection. When the cough is accompanied by paroxysms of coughing, posttussive vomiting, and/or an inspiratory whooping sound, the diagnosis of a B pertussis infection should be made unless another diagnosis is proven. This infection is highly contagious but responds to antibiotic coverage with an oral macrolide when administered early in the course of the disease. A safe and effective vaccine to prevent B pertussis is now available for adults as well as children. It is recommended according to CDC guidelines. In patients who have a cough lasting from 3 to 8 weeks with normal chest radiograph findings, consider the diagnosis of postinfectious cough. In most patients, a specific etiologic agent will not be identified, and empiric therapy may be helpful. A high degree of suspicion for cough due to B pertussis infection will lead to earlier diagnosis, patient isolation, and antibiotic treatment.

Ectopic placement of AMS 800 urinary control system pressure-regulating balloon

The AMS 800 sphincter urinary control system (artificial urinary sphincter) is frequently placed in patients with scarred retroperitoneal spaces. Placement of the pressure-regulating balloon (PRB) requires a second abdominal incision in the traditional perineal surgical technique. In the new transverse scrotal incision method of sphincter placement, the transversalis fascia is pierced to place the PRB in the space of Retzius. We present a novel technique of ectopic PRB placement requiring neither a second incision nor piercing the fascia. Nineteen patients underwent ectopic PRB placement during artificial urinary sphincter placement. Most patients (n = 17) were incontinent after radical prostatectomy, two were incontinent after transurethral resection of the prostate. Cuff placement was through a scrotal (n = 10) or perineal (n = 9) incision. In all patients, the incision was displaced toward either inguinal ring. A finger was passed through the ring forcibly cephalad and a space developed anterior to the transversalis fascia but beneath the abdominal muscles. The PRB was passed into this space. The results of our study have shown that ectopic placement is easier and quicker. The PRB is usually not palpable. Two PRB hernias into the upper scrotum were noted after vigorous coughing. Two patients developed urethral atrophy under the cuff at 3 and 5.5 years. No erosions, infections, or mechanical failures were noted. Early outcomes with ectopic PRB placement seemed similar to that of traditional locations.

A Case of Endobronchial Tuberculosis with Repeated Expectoration of Nodular Tissues

Herein, we report a case of tumorous endobronchial tuberculos is with successful recovery of atelectasis without any significant bronchial stricture, after repeated expectorations of nodular tissues. A 24 -year-old male patient was pre 󰠀sented with persistent cough. The patient was diagnosed to be suffering from tuberculous lymphadenitis on right axillar and mediastinum of lung, and was subsequently treated with anti tuberculosis agents. After two months, clinical deteriorations and atelectasis were observed on right upper lob e of lung. Multiple endobronchial tumorous lesions, which obstructed the right main bronchus, were revealed on bronchosc opy, and based on the endobronchial biopsy findings we confirmed that the patient was suffering from endobronchial tuberculosis. We decided to administer antituberculosis agents without any additional procedure. After few weeks, the patient spontaneously expectorated nodular tissues with vigorous coughing. Later on, the symptoms and atelectasis disappeared and the patient was completely recovered. This case shows that in patients suffering from tumorous endobronch ial tuberculosis, endobronchial mass can be expectorated spontaneously without sequelae of significant bronchial stenosi s. (Tuberc Respir Dis 2005; 59: 204-208)Key words : Endobronchial tuberculosis, Atelectasis, Bronchoscopy