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Scopolamine has been shown to cut back drooling in sufferers with developmental delays and with cerebral palsy blood pressure level chart 20 mg adalat sale, particularly blood pressure jumps around cheap 20 mg adalat otc, with greater than 50% reduction of drooling quantity in 53% of patients hypertension exercise best 20 mg adalat. Scopolamine has not been studied for long-term use and in addition causes systemic effects hypertension fact sheet quality 20 mg adalat, with unique side effects, including momentary toxic psychosis, in addition to traditional antimuscarinic effects. Using a separate mechanism, clonidine patches have also been shown to be effective at decreasing 379 Pediatric Otolaryngology hypersalivation from antipsychotic drugs by growing adrenergic activity. Blasco et al found a 90% rate of discount in drooling, with 28% rate of unwanted side effects leading to discontinuation of remedy and a wide effective dose vary from zero. Dosing of antimuscarinic medications must be balanced to management drooling whereas avoiding antagonistic unwanted aspect effects, if potential, and could additionally be variable over time as drooling volumes change. Decreasing saliva manufacturing to the diploma of xerostomia is usually uncomfortable for patients, could make speech and eating more difficult, and might lead to long-term complications, together with dental caries. Radiation therapy has been used traditionally in treating sialorrhea in geriatric sufferers aiming to render the salivary glands nonfunctional with damage to serous acinic cells. Botulinum toxin injections are a newer addition to the therapy choices for pediatric sialorrhea and use the action of a neurotoxin produced by Clostridium botulinum bacterium to decrease salivation. Inhibition of acetylcholine action at the synapse establishes a short lived useful denervation of the salivary glands and prevents salivary stimulation for a number of weeks to months following injection. Placement of injections can be accomplished with or with out ultrasound steerage however usually requires general anesthesia for pediatric sufferers. Various injection methods and dosing have been reported, including single 5 U botulinum toxin A doses in to the superficial parotid glands bilaterally, with 55% of sufferers showing perceived benefit. One controlled trial evaluating botulinum toxin efficacy and scopolamine efficacy in pediatric sialorrhea sufferers used weight classes for dosing of submandibular gland injections (15 U/ gland for sufferers weighing lower than 15 kg; 20 U/gland for 15 to 25 kg; 25 U/gland for heavier than 25 kg), with 61% response fee 2 weeks after botulinum toxin injections and inflicting fewer side effects than scopolamine therapy in the same study group. Comparisons of botulinum toxin A to toxin B show no vital difference in efficacy; nonetheless, more analysis is required to decide optimal pediatric dosing for maximal efficacy and minimal threat of problems. These research further defined the aspect impact profile of botulinum toxin injections with rare, delicate problems together with mild xerostomia, thickened saliva, transient flu-like signs, and short-lived injection website tenderness. Thickened saliva is most likely going from preferential injection of the parotid gland, eliminating its thin serous saliva manufacturing, as an alternative of the submandibular gland, which produces thicker, mucous saliva. More severe unwanted side effects reported had been facial nerve weakness, oral closure, and chewing problem from masseter muscle weakness, doubtless from diffusion of toxin from parotid injection sites, and dysphagia from systemic botulinum toxin results on pharyngeal musculature. Patients responding to botulinum toxin injections can keep away from extra invasive surgical procedures, but injections nonetheless require basic anesthesia in most pediatric sufferers and recurring injections for extended impact. Surgery Surgery is commonly thought-about when less invasive or non-permanent remedy choices fail to decrease drooling after 6 months of treatment in sufferers older than 5 to 6 years, to allow for full maturity of oropharyngeal motor coordination. It can be more helpful in sufferers unable to engage in behavioral or postural therapies or when aspiration, pneumonia, and different critical sequelae of drooling occur. One essential issue to think about when choosing a surgical procedure for a drooling affected person is the presence of aspiration, by which posterior ductal rerouting may be less helpful with its potential for posterior salivary pooling, theoretically increasing the chance of aspiration. Historically, a selection of surgical procedures have been used within the remedy of sialorrhea to interrupt innervation or gland ductal drainage, redirect ductal drainage, or remove glands totally. Techniques have advanced over time trying to enhance postoperative outcomes and keep away from the chance of further issues. These procedures can be categorized as salivary reduction or salivary diversion procedures (Table 17-4). This procedure was performed beneath local anesthesia, was fast to full, and resulted in no external scars. Improvement rates of 74% in a single examine by Mullins et al in 1979 showed more vital decision of Table. Sialorrhea Advantages Salivary reduction Nerve sectioning Fast process, under local anesthesia Simple process, decreases move predictably Excellent discount in salivary quantity Nerve regrowth can lead to want for repeated sectioning; poor results, process abandoned. Temporary gland swelling, potential for sialocele or sialoliths Increased procedure complexity and danger to surrounding buildings (eg, facial nerve branches, hypoglossal and lingual nerves), exterior scar, larger danger of xerostomia, dental caries Risk of anterior caries, ranula if sublingual gland not excised, duct obstruction, potential aspiration threat Risk of sialocele, potential aspiration risk, duct obstruction, parotid and facial swelling, parotitis Disadvantages Ductal ligation Gland excisions Salivary diversion Submandibular duct rerouting No external scar, reduces anterior pooling/spillage Parotid duct rerouting No external scar, reduces anterior pooling/spillage of skinny saliva 382 Chapter 17: Drooling and Salivary Aspiration drooling in patients who underwent careful transection of the whole tympanic plexus of Jacobson nerve. Grewal et al concluded in 1984 that combining each nerve sections was more effective at stopping nerve regrowth and recurring sialorrhea, however general printed success charges of nerve section research fell between 50% and 80%. Risks of the nerve transection procedures included an unavoidable lack of style in the anterior two-thirds of the tongue innervated by facial nerve fibers within chorda tympani, potential xerostomia, dental caries, tympanic membrane perforations, otitis media, or recurrence of drooling from nerve regeneration. Salivary duct surgical procedure for sialorrhea was introduced in 1967 by Theodore Wilkie with parotid duct relocation to the tonsillar fossa to redirect salivary move to the posterior oropharynx. This method was modified by Wilkie and Brody a number of years later to embrace submandibulectomy (removal of each submandibular glands), leading to an 85% discount in drooling but an related 35% price of adverse effects. Bilateral submandibulectomy became a logical surgical goal as a result of the submandibular glands produce roughly 70% of saliva quantity, and excision of the glands reliably and dramatically reduced salivary quantity. However, gland removal procedures-submandibulectomy, parotidectomy, and sublingual gland excisions-involve risk of exterior scarring, irreversible xerostomia, and facial nerve harm. Subsequently, salivary ductal ligation grew to become well-liked because of easy accessibility to the gland ducts trans-orally with minimal dissection and dependable discount in saliva volume. Ligation works by inducing gland atrophy from useful obstruction to reduce saliva manufacturing and block salivary move immediately, with 4-duct ligation studies reporting charges of sixty four. Submandibular ductal ligations lead to larger rates of sialoliths (salivary stones) due to more mucous saliva with the higher calcium content and viscosity of submandibular gland saliva, and the upward slanting course of Wharton duct causing retention of particulates. Four-duct ligation procedures with suture ties are advantageous for ease of entry to the ducts for ligation and predictable decreases in saliva manufacturing. Duct clipping and laser photocoagulation have been investigated as potential procedural variations of ductal ligation aiming to lower surgical time and extent of dissection even additional. Treatment choices range from behavioral modifications, to medications, to botulinum toxin injections, and surgical procedure, however most of the remedy options have unwanted side effects that should be thought-about together with the potential for an enchancment in drooling. Patients derive probably the most benefit from an individualized strategy to their drooling to take away correctible causes, avoid irreversible procedures and identified side effects the place potential, and handle potential aspiration risk. Use of glycopyrrolate and other anticholinergic drugs for sialorrhea in youngsters with cerebral palsy. Intraductal laser photocoagulation of the bilateral parotid ducts for discount of drooling in patients with cerebral palsy. Major salivary duct clipping for management issues in developmentally challenged youngsters. The therapy of drooling by ultrasound-guided intraglandular injections of botulinum toxin kind A in to the salivary glands. Effect of botulinum toxin within the treatment of drooling: a controlled scientific trial. A systematic evaluate for proof of efficacy of anticholinergic medicine to treat drooling. Four-duct ligation: a simple and efficient remedy for persistent aspiration from sialorrhea. Transdermal scopolamine for reduction of drooling in developmentally delayed youngsters. Botulinum toxin A injection of salivary glands in children with drooling and persistent aspiration. Use of benzhexol hydrochloride to control drooling of youngsters with cerebral palsy. Successful treatment of drooling in youngsters with neurological disorders with botulinum toxin A or B. Most instances are brought on by self-limited illnesses ensuing from viral infections of the higher respiratory tract that resolve within 2 to three weeks. However, prolonged cough is a possible reason for discomfort for the child, anxiousness for the parent, and sleep disturbance for both. Fear of a big underlying pathology and the potential for damage are frequent parental concerns, and indeed continual cough might portend a more serious disorder. Mechanism Cough is the sudden and violent expulsion of air in late inspiration after the whole closure of the laryngeal sphincter. This ends in the fast expulsion of deep lung gaseous contents and facilitates clearance of abnormal secretions and infections, as properly as expulsion of overseas our bodies. Cough also prevents international materials from getting into the trachea within the first place. Cough requires a neurologically competent larynx and pharynx in addition to diaphragm and chest wall. Patients with vocal cord paralysis or loss of afferent sensation of the larynx could not have a reliable cough and could also be prone to aspiration and lower airway issues. Patients with diaphragmatic paralysis also might not be able to generate an efficient cough. Cough receptors are present in varying concentrations within the mucosa of the entire respiratory tract, together with the larynx, trachea, bronchi, pharynx, and nasal passages. Sensory fibers of the afferent limb, when stimulated by incidental contact or strain with a overseas physique or noxious agent, transmit impulses to the cough heart in the medulla.

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Although extra widespread in people of Eastern European and Japanese descent and uncommon in children pulse pressure 42 adalat 20 mg buy generic, aspirin sensitivity can also worsen signs (Farooque & Lee prehypertension que es discount adalat 30 mg otc, 2009) arterial nephrosclerosis buy cheap adalat 20 mg line. Generally hypertension and exercise cheap 30 mg adalat overnight delivery, signs embody profound rhinorrhea, tearing, and severe bronchospasm occurring within 1 hour of publicity. Monitoring control In addition to allergen avoidance and pharmacotherapy, assessment of asthma management is a crucial element of bronchial asthma management. Like severity, control can be decided primarily based on the domains of current impairment and future risk. Specific areas of assessment include symptoms, lung operate, quality of life, history of exacerbations, adherence to and unwanted effects attributable to medicines, patient�provider communication and satisfaction, and biomarkers of irritation. Evaluation of those areas relies on parent/child recall over the previous 2�4 weeks. Control is described as properly controlled, not nicely controlled, and very poorly controlled. Parents (and the child if old enough) must be instructed on tips on how to monitor their asthma. To use a peak move meter, the child ought to be instructed to � � � � � place the indicator at "0," stand or sit up and tall, take a deep breath, place the mouthpiece in the mouth (behind teeth) with lips wrapped tightly across the mouthpiece, and blow quick and onerous in a single breath. The peak circulate zone system may be defined to mother and father and children using the visitors mild analogy. The green zone (>80% of personal finest or predicted) indicates that asthma is properly managed on current therapy. The purple zone (<50% of private finest or predicted) is considered the "hazard zone" and requires quick medical consideration. Therefore, earlier than taking action primarily based on a single studying, the mother and father ought to guarantee that correct method was used through the measurement. Alternatively, if the child coughs or spits in to the gadget, the values may be falsely excessive. Managing exacerbations Although stopping exacerbations is a objective of bronchial asthma management, exacerbations continue to happen. It is important to acknowledge that severe exacerbations can occur at any stage of Asthma 209 asthma severity; in other phrases, even those with intermittent bronchial asthma can have a extreme exacerbation. Exacerbations are managed both at house or in the hospital, relying on their stage of severity. This focus additional underscores the significance of educating mother and father and children the method to self-manage asthma. General residence administration contains knowing how to use an asthma motion plan, recognizing early indicators of an exacerbation, and removing allergens from the surroundings. In addition, the health-care provider may need to contemplate a brief course of oral corticosteroids presently. Children with severe standing asthmaticus are in danger for sudden deterioration and respiratory arrest. Most suppliers hold oxygen saturation 95% so as to give the affected person as much reserve as attainable. Oral corticosteroids must be given if the patient has not already received them. Intravenous hydration could also be needed if the affected person has been unable to drink or eat. Adjunct 210 Nursing Care in Pediatric Respiratory Disease therapies such as intravenous magnesium or heliox-driven albuterol nebulization could additionally be thought-about. National certification for bronchial asthma educators has been obtainable since 2002 from the National Asthma Educator Certification Board (National Asthma Educator Certification Board, n. It ought to include all members of the health-care group and may occur across numerous settings. Additionally, the nurse ought to develop a partnership with the mother and father and the kid. This partnership contains the event of mutually agreed-upon treatment goals. The baby must be concerned as much as attainable in establishing targets of remedy. Such a relationship will allow the nurse to effectively assess barriers to care as nicely as adherence to treatment. All sufferers should receive fundamental training relating to bronchial asthma in a culturally competent method. The important parts of an academic program embody basic details about asthma, how to assess the level of control, how asthma is treated (this consists of information about medications and allergen avoidance), how to use prescribed devices, how to Asthma 211 respond to indicators and signs of worsening asthma, and when and where to search medical attention. The academic plan should be individualized to meet the wants of the mother and father and youngster and should embody the supply of an bronchial asthma motion plan. Prior to providing the education, the nurse should make an evaluation of what the parents and baby already learn about asthma. This evaluation offers the nurse with the chance to reinforce correct messages and to appropriate inaccurate ones. The nurse also needs to decide how much info to present at every setting in order not to overwhelm the parents and the kid. Basic information When providing information about the basic details, the nurse must emphasize the function irritation performs in asthma. This will assist the mother and father and youngster understand the purpose of the medicines prescribed. Allergen/trigger avoidance the parents and the kid should obtain individualized instruction and recommendation concerning environmental management measures (specific measures had been mentioned earlier in this chapter). In such conditions, the nurse ought to work with the family and refer them to resources which may be out there in the community. When discussing environmental management measures, the nurse should bear in mind to embody an assessment of the daycare and college surroundings as the youngster spends a great deal of time in these places. In addition to practicing good hand washing, the dad and mom must be inspired to have their baby (if not allergic to the vaccine or eggs) vaccinated with the influenza vaccine. Medications and supply gadgets When offering information about medications, the nurse ought to embrace the name of the medication, the dose, the dosing interval, and the unwanted facet effects. Another essential reality to reinforce in regard to drugs is the difference between long-term management medications and quick-relief drugs. Because most bronchial asthma medications are administered by way of inhalation, the nurse should ensure that the dad and mom and baby know and follow the proper approach and priming suggestions. This begins by ensuring the most acceptable delivery gadget is selected for the kid. If the child is prescribed a nebulizer, the "blow-by" technique should be discouraged. Inspiratory circulate rates are additionally necessary when deciding on a medicine supply gadget. Self-management the mother and father and child ought to be instructed on how to self-manage asthma at house. This is greatest achieved with using an bronchial asthma motion plan (Bhogal, Zemek, & Ducharme, 2006). The baby ought to be concerned within the growth of the bronchial asthma action plan, and it should be written in terms Asthma 213 that are understood by the mother or father and older youngster. Studies have demonstrated that preserving educating supplies simple and concise improves health-care knowledge (Paasche-Orlow et al. Key parts of an asthma motion plan embrace what to do every day, when to step up therapy, and when to contact the health-care supplier. In a Cochrane Review evaluating symptom versus peak flow-based asthma action plans, no vital variations in rates of exacerbations requiring oral steroids or admissions, lung function, symptom scores, and quality of life have been famous. Findings did reveal that youngsters utilizing symptombased asthma motion plans experienced a decrease threat of exacerbations requiring an acute care go to. However, knowledge have been inadequate to suggest using one methodology over the opposite (Bhogal et al. Adherence and barriers to care the nurse should work with the kid to determine if there are any barriers to carrying out the agreed-upon asthma action plan. Examples embrace patient/family psychological issues, lack of insurance coverage, long wait instances for appointments, inconvenient workplace hours, lack of communication with the health-care provider, medication unwanted side effects, and the need for daily remedy (Adams, Dreyer, Dinakar, & Portnoy, 2004). By speaking with the parents/child and addressing the considerations, adherence will likely enhance (Williams et al. Parents must be made aware that giving drugs to infants, toddlers, and preschoolers can sometimes be difficult.

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Potential etiologies could be categorized as causes of decreased swallowing or increased saliva production (Table 17-1) prehypertension effects 20 mg adalat order otc. Cerebral palsy is among the primary diagnoses associated with decreased swallowing blood pressure in elderly adalat 30 mg buy line, with 10% to 37% of pediatric cerebral palsy patients affected arteria circunfleja 20 mg adalat generic otc. Other widespread causes of decreased swallowing embrace psychological retardation and orthognathic abnormalities such as anterior open chunk and macroglossia blood pressure medication dosages 20 mg adalat proven. Production Oral irritation-ulcerations, infection, trauma, dental appliances Medication side effects- cholinergic effects from anticonvulsants, clozapine, risperidone, nitrazepam, bethanecol Gastroesophageal reflux disease Organophosphate toxicity risperidone; nitrazepam; bethanecol) or organophosphate and heavy metal (eg, mercury, thallium) toxicity. Assessment Assessing a affected person with sialorrhea and deciding on acceptable management includes an evaluation of the severity of drooling and the chronicity and progression of any underlying etiology. The quantity of drooling can be quantified with direct measurement of saliva volume, with several totally different strategies or with a number of grading methods to assess its frequency, severity, and any issues (Table 17-2). Immediate visual evaluation can present energetic drooling, perioral pores and skin irritation, or maceration, with an entire examination including a nasal examination for potential nasal airway obstruction, evaluation of dentition for caries and malocclusion, tongue dimension and any energetic thrusting, and assessment of head posture and place. The Drooling Impact Scale: a measure of the impression of drooling in youngsters with developmental disabilities. Management Treatment of sialorrhea depends on the severity of the issue and short-term versus everlasting underlying etiologies and age, with the objective of eliminating extreme saliva and spilling while maintaining a moistened, wholesome oral cavity. In sufferers youthful than 5 years who 377 Pediatric Otolaryngology are otherwise healthy, reassurance is suitable because drooling will are most likely to resolve with time. The remainder of patients could be handled in a progressive method to maximize conservative measures earlier than contemplating more aggressive options in unresponsive circumstances (Box 17-2). This contains oral stimulation applications with speech remedy to improve oro-motor coordination and proprioception, decrease tongue thrusting, and prompt jaw and lip closure. Swallowing prompts with auditory alerts or other cues, educating oral motor expertise and oral consciousness, or palatal training appliances can information the affected person to higher control lip and jaw closure and tongue movements and reduce drooling. One key pharmacologic target to control drooling is the postganglionic muscarinic M 3 receptor, the place parasympathetic motion of acetylcholine normally stimulates salivary glands to increase saliva production. Several antimuscarinics that block this motion have been shown to effectively inhibit salivation. They embody benztropine, benzhexol hydrochloride (trihexyphenidyl), glycopyrrolate, and scopolamine (Table 17-3). Their effects on extra-salivary muscarinic receptors and on easy muscle tissue which are conscious of acetylcholine might cause systemic results together with dilation of pupils, increased heart rate, decreased intestine motility, urinary retention, and reduced sweating. Headache, irritability, confusion, nausea, tachycardia, blurred imaginative and prescient, xerostomia, and decreased taste are a number of of the commonest unwanted side effects, and these anticholinergics are contraindicated in sufferers with glaucoma, obstructive uropathy, gastrointestinal obstruction, myasthenia gravis, or asthma to stop exacerbations. Studies available in the literature exhibiting the effectiveness of scopolamine, benztropine, and Box. Drooling Oral stimulation applications Behavior modifications Medication Botulinum toxin injections or surgical therapy 378 Chapter 17: Drooling and Salivary Aspiration Table. Effects Xerostomia, blurred vision, hyperactivity, irritability, constipation, urinary retention Scopolamine 1. Efferent impulses, in flip, journey from the medulla to the top organs, together with the diaphragm, intercostals muscles, laryngeal adductors, and external chest wall muscular tissues, by way of the vagus and phrenic nerves. This results in a violent Valsalva maneuver, which acts to expel particles or the noxious offending agent. The cough reflex is weak in untimely neonates and develops by about age 5 years; this fact correlates with 5 years as the age at which unintentional nut aspiration becomes much less widespread. Among kids from start to 18 months of age, the most typical causes of continual cough are gastroesophageal reflux 390 Chapter 18: Chronic Cough in Children Box. Cough Cough-dominant bronchial asthma Infections Acute and chronic sinusitis Adenoiditis Pneumonia Tuberculosis Pertussis Adenovirus Influenza Congenital Laryngeal cleft Tracheoesophageal fistula Subglottic stenosis Tracheomalacia Vascular compression Congenital heart disease Vocal twine paralysis Environmental Cigarette smoke Pollution Genetic Cystic fibrosis Immotile cilia syndrome Aspiration Saliva Gastroesophageal reflux illness Foreign physique Psychogenic Neoplastic Neoplasms of the tracheobronchial tree Laryngotracheal papillomatosis Airway hemangioma Mediastinal tumor Box. In toddlers and younger kids, the most common cause of persistent cough is recurrent viral sickness; in affected kids, the diseases are of typical period, but the disease-free interval may be very temporary. Allergies, chronic sinusitis, cough-dominant bronchial asthma, cystic fibrosis, bronchitis, and pneumonia are additionally incessantly encountered in this age group. This is also the age group during which bronchial or different airway foreign our bodies mostly present. In school-aged youngsters, cough-dominant bronchial asthma, infections (sinus and lung), psychogenic cough (habit cough), and allergic reactions predominate as the causes of cough. Character of Cough Cough may be characterized primarily based on tonal qualities as properly as the presence or absence of secretions. Barky cough is typical of subglottic disease (croup, subglottic stenosis, subglottic cyst, or hemangioma). Brassy cough is similar in tone but emanates extra from the chest, suggesting tracheobronchial issues (bronchitis, tracheomalacia, tracheal stenosis). In pertussis, a high-pitched "whoop" sound frequently follows the paroxysms of cough within the early levels of the illness. A wet or productive cough usually is current in pulmonary infections, bronchitis, persistent sinusitis, or any infection producing an abundance of mucous and secretions. A dry cough may be associated to infections producing minimal secretions or to noninfectious processes such as airway anomalies, cough-dominant asthma, airway international physique, or habit cough. Hemoptysis could suggest the presence of a neoplasm, vascular anomaly, or extreme irritation. As a outcome, cough persisting for more than 4 weeks ought to be considered continual and deserves more than medical evaluation. Cough that recurs after acceptable therapy might warrant endoscopic evaluation for an underlying airway downside. In newborns and infants, timing of the cough in relation to feeding could counsel a trigger. Children with gastroesophageal reflux more generally cough after feeding and when positioned supine. However, as a end result of nighttime is the quietest time of day, the presence of any cough at night time is commonly unsettling to dad and mom. However, cough present solely during train is more usually associated with asthma or psychogenic etiology. Additional History Additional historical info could additionally be useful in identifying the etiology of a continual cough. A historical past of endotracheal intubation, especially in a younger youngster with a historical past of prematurity, suggests the presence of an acquired airway lesion. Parents of toddlers should be requested about circumstances that may suggest ingestion or aspiration of a international body. Symptoms of wheezing in affiliation with continual cough are common in very younger youngsters due to the small caliber of their airways; nonetheless, wheezing also needs to alert the clinician to the potential for bronchial asthma. The clinician must also inquire about environmental irritants that delay the decision of cough, such as tobacco smoke, and about any recurrent infections that may suggest an immune deficiency. For instance, the absence of cough during the workplace go to could prompt further inquiry in to the actual frequency of cough and exacerbating elements. Children whose coughing ceases when requested to concentrate on different things during the examination are more probably to have behavior cough. Tachypnea and stridor related to cough are sometimes immediately obvious on preliminary affected person contact. Anterior rhinoscopy may be performed using an otoscope with a large-diameter speculum. Auscultation of the neck and chest will yield essential information about the situation of the decrease airway and lungs. In cough caused by subglottic pathology, stridor can usually be appreciated over the neck. Decreased breath sounds over the chest could indicate an aspirated overseas physique or consolidation because of infection. Wheezing is most suggestive of bronchial asthma, although foreign bodies and airway anomalies ought to be entertained as nicely. Investigation the historical past and scientific examination are helpful in establishing these diagnoses from Box 18-1 which might be the most likely causes of continual cough in a child. A clinical follow guideline from the American College of Chest Physicians proposes that these causes be further categorised as particular or nonspecific causes of cough evaluated based mostly on a set of indicators (Box 18-3). Specific cough is often moist and associated with underlying respiratory or systemic disease.

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