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Complications of Cough : ACCP Evidence-Based Clinical Practice Guidelines FREE TO VIEW

Richard S. Irwin, MD, FCCP
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Correspondence to: Richard S. Irwin, MD, FCCP, University of Massachusetts Medical School, Room S6-842, 55 Lake Ave North, Worcester, MA 01655; e-mail: Irwinr@ummhc.org



Chest. 2006;129(1_suppl):54S-58S. doi:10.1378/chest.129.1_suppl.54S
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Objectives: To review the spectrum and frequency of complications associated with coughing.

Design/methodology: 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.”

Results: 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.

Conclusions: 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.”

The complications of cough stem from physiologic events. It is thought that there are usually three phases involved in the cough mechanism.1 The first is an inspiratory phase, which ends before closure of the glottis; the second is a compressive phase that is characterized by contraction of thoracic and abdominal musculature against a fixed diaphragm; and the third is an expiratory phase, which consists of the rapid expulsion of air when the glottis opens. The result of these actions is the production of sufficiently high expiratory velocity to dislodge and expel secretions or foreign bodies.

During the compressive and expiratory phases, cough can be described as a modified Valsalva maneuver.23 Cough can also be accompanied by a reflex increase in vagal tone.45 Furthermore, during vigorous coughing, intrathoracic pressures of up to 300 mm Hg6and expiratory velocities of up to 28,000 cm/s, or 500 miles per hour (85% of the speed of sound),7may be generated. Coughing produces hemodynamic changes that compare favorably to chest compressions. During the expiratory phase of a vigorous cough, systolic pressures approach 140 mm Hg, compared with 75 mm Hg during chest compressions.8It has been estimated that a vigorous cough can generate from 1 to 25 J of energy.9 While the pressures, velocities, and energy of these magnitudes allow coughing to be an effective means of clearing the airways of excessive secretions and foreign material, and of providing cardiopulmonary resuscitation, they also can cause a variety of profound physically and psychosocially adverse occurrences that have the potential to lead to a significant decrease in health-related quality of life.

Knowledge of these complications should help 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.”

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 (Table 1 ). This spectrum of complications was determined with the aid of an 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.” With the exception of the referenced literature on health-related quality of life, the quality of evidence for the majority of complications displayed in Table 1 consisted primarily of nonrandomized, noncontrolled case reports and small retrospective and prospective observational studies. Two studies published by French and colleagues1011 on the impact on chronic cough on health-related quality of life were prospective and controlled.

The health-related quality of life of patients complaining of acute and chronic cough is adversely affected, and this is the most likely reason why these patients seek medical attention. Four studies1013 have prospectively shown that cough can adversely affect health-related quality of life. In chronologic order, the first study10 utilized the Sickness Impact Profile, a non-illness-specific measure of health-related dysfunction that had been modified to measure the effects of patients’ chronic cough on the performance of usual daily activities. The health-related dysfunction of patients with chronic cough is most likely to be psychosocial in nature. While the Sickness Impact Profile had not been psychometrically tested to assess the effects of cough, it revealed, in a before-and-after treatment intervention trial, that chronic cough was associated with a significant deterioration in patients’ quality of life, and that the health-related dysfunction was most likely due to psychosocial factors.12

The second study11 utilized a cough-specific quality-of-life questionnaire (CQLQ) that assessed the 28 most common reasons why patients seek medical attention because of coughing. It has been shown to be a reliable and valid tool for evaluating the impact of acute and chronic cough on adult patients, and a valid method by which to assess the efficacy of cough therapies for chronic cough. A comparison of total CQLQ scores of both chronic and acute coughers10 showed that, while the scores were similar to each other, they were both significantly higher than those for a control group of smokers who were not complaining of cough. Compared to the control subjects, patients with chronic cough complained significantly more of physical complaints (eg, lost appetite, headaches, dizziness, sweating, hoarseness, hurts to breathe, insomnia, ache all over, and exhaustion), psychosocial issues (eg, family cannot tolerate it, difficulty speaking on phone, embarrassment, upset because others think I have something wrong, and self-consciousness), functional ability impairments (eg, prolonged absences from important activities, cannot engage in important activities, cannot sing, stopped going to social activities, and had to change lifestyle), issues that adversely affected their emotional well-being (eg, fear of tuberculosis or AIDS, soiled pants, and broke a rib), extreme physical complaints (eg, sick to stomach and vomiting, retching, wet pants, and soil pants), and personal safety fears (eg, concern about cancer, want to be reassured that nothing is seriously wrong, and concern that there is something seriously wrong).

The third study13 utilized the Leicester cough questionnaire, which assessed 19 items that the investigators found were troublesome to patients with chronic cough. Psychometric testing revealed the Leicester cough questionnaire to be a valid and repeatable quality-of-life measure of chronic cough that is responsive to change.13

The fourth study,14 utilizing the CQLQ in a study with a control group of smokers not complaining of cough to assess gender differences in health-related quality of life in patients complaining of chronic cough, determined that women with chronic cough were probably more inclined to seek medical attention than men because their health-related quality of life was significantly more adversely affected and because they were more apt to experience physical complaints such as stress urinary incontinence, which provoked psychosocial issues such as becoming embarrassed.11 Cough reflex sensitivity was not measured in this health-related quality-of-life study11 (or in the other three studies10,1213 just reviewed). Consequently, while tussigenic inhalation challenges have shown that healthy women14and women with chronic cough15 have lower cough thresholds than healthy men and men with chronic cough, it is not known whether this finding of higher cough reflex sensitivity contributes to the greater adverse effect on health-related quality of life. Women with chronic cough are probably more inclined to seek medical attention than men because their health-related quality of life is more adversely affected and because they are more apt to experience physical complaints such as stress urinary incontinence, which provoke psychosocial issues such as becoming embarrassed.

1. In patients complaining of cough, evaluate for a variety of complications associated with coughing (eg, cardiovascular, constitutional, GI, genitourinary, musculoskeletal, neurologic, ophthalmologic, psychosocial, and skin complications), which can lead to a decrease in a patient’s health-related quality of life. Level of evidence, low; benefit, substantial; grade of recommendation, B

2. Patients with cough should have a thorough diagnostic evaluation, according to the guidelines set forth in this document, to mitigate or prevent these complications. Level of evidence, low; net benefit, substantial; strength of recommendation, B

Two large epidemiologic studies1617 have provided evidence that chronic cough, as a clinical manifestation of pulmonary infection or chronic inflammation, is associated with an increased risk of coronary artery disease or myocardial infarction. The risks in both studies were independent of the known major cardiovascular risk factors. The risk was found to be increased in the Framingham Heart Study, whether or not the cough was productive or unproductive. Whether the association is causal can only be determined by additional and controlled studies.

1. In patients complaining of cough, evaluate for a variety of complications associated with coughing (eg, cardiovascular, constitutional, GI, genitourinary, musculoskeletal, neurologic, ophthalmologic, psychosocial, and skin complications), which can lead to a decrease in a patient’s health-related quality of life. Level of evidence, low; benefit, substantial; grade of recommendation, B

2. Patients with cough should have a thorough diagnostic evaluation, according to the guidelines set forth in this document, to mitigate or prevent these complications. Level of evidence, low; net benefit, substantial; grade of recommendation, B

Abbreviation: CQLQ = cough-specific quality-of-life questionnaire

Table Graphic Jump Location
Table 1. Complications of Cough
Leith, D, Butler, JP, Sneddon, SL, et al (1986) Cough. Macklem, P Mead, J eds.Handbook of physiology: Section 3. The respiratory system: mechanics of breathing,315-336 American Physiological Society. Bethesda, MD:
 
Leith, D Cough. Proctor, D Reid, LM eds.Respiratory defense mechanism: part II. Lung biology in health and disease.1977,545-592 Marcel Dekker. New York, NY:
 
Sharpey-Schafer, E Effects of coughing on intrathoracic pressure, arterial pressure and peripheral blood flow.J Physiol (London)1953;122,351-357
 
Irani, F, Sanchis, J Inspiration- and cough-induced atrioventricular block.Can Med Assoc J1971;105,735-736
 
Francis, C, Singh, JB, Polansky, BJ Interruption of aberrant conduction of atrioventricular junctional tachycardia by cough.N Engl J Med1972;286,357-358
 
Sharpey-Schafer, E The mechanism of syncope after coughing.BMJ1953;2,860-863
 
Comroe, JH, Jr Special acts involving breathing.Physiology of respiration: an introductory text 2nd ed.1974 Yearbook Medical Publishers. Chicago, IL:
 
Schultz, D, Olivas, GS The use of cough cardiopulmonary resuscitation in clinical practice.Heart Lung1986;15,273-280
 
Wei, J, Greene, HL, Weisfeldt, ML Cough-facilitated conversion of ventricular tachycardia.Am J Cardiol1980;45,174-176
 
French, C, Irwin, RS, Fletcher, KE, et al Evaluation of a cough-specific-quality-of-life questionnaire.Chest2002;121,1123-1131
 
French, C, Fletcher, KE, Irwin, RS Gender differences in health-related quality of life in patients complaining of chronic cough.Chest2004;125,482-488
 
French, C, Irwin, RS, Curley, FJ, et al Impact of chronic cough on quality of life.Arch Intern Med1998;158,1657-1661
 
Birring, SS, Prudon, B, Carr, AJ, et al Development of a symptom specific health status measure for patients with chronic cough: Leicester Cough Questionnaire (LCG).Thorax2003;58,339-343
 
Fujimura, M, Sakamoto, S, Kamio, Y, et al Sex differences in the inhaled tartaric acid cough threshold in non-atopic healthy subjects.Thorax1990;45,633-634
 
Kastelik, J, Thompson, RH, Aziz, I, et al Sex-related differences in cough reflex sensitivity inpatients with chronic cough.Am J Respir Crit Care Med2002;166,961-964
 
Jousilahti, P, Vartiainen, E, Tuomilehto, J, et al Symptoms of chronic bronchitis and the risk of coronary disease.Lancet1996;348,567-572
 
Haider, A, Larson, MG, O’Donnell, CJ, et al The association of chronic cough with the risk of mycocardial infarction: the Framingham Heart Study.Am J Med1999;106,279-284
 
McCann, W, Bruce, RA, Lovejoy, FW, Jr, et al Tussive syncope.Arch Intern Med1949;84,845-856
 
McIntosh, H, Estes, EH, Warren, JV The mechanism of cough syncope.Am Heart J1956;52,70-82
 
Skolnick, J, Dines, DE Tussive syncope.Minn Med1969;52,1609-1613
 
Kerr, A, Jr, Derbes, VJ The syndrome of cough syncope.Ann Intern Med1953;39,1240-1253
 
Reisin, L, Blaer, Y, Jafari, J, et al Cough-induced nonsustained ventricular tachycardia.Chest1994;105,1583-1584
 
Omori, I, Yamada, C, Inoue, D, et al Tachyarrhythmia provoked by coughing and other stimuli.Chest1984;86,797-799
 
Jacobs, WR, Zaroukian, MH Coughing and central venous catheter dislodgement.JPEN J Parenter Enteral Nutr1991;15,491-493
 
Banyai, A, Joannides, M Cough hazard.Chest1956;29,52-61
 
Pollack, A, McDonald, HR, Ai, E, et al Massive suprachoroidal hemorrhage during pars plana vitrectomy associated with Valsalva maneuver.Am J Ophthalmol2001;132,383-387
 
Irwin, RS, Curley, FJ The treatment of cough: a comprehensive review.Chest1991;99,1477-1484
 
Patterson, W, Murat, BW Combined ambulatory esophageal manometry and dual-probe pH-metry in evaluation of patients with chronic unexplained cough.Dig Dis Sci1994;39,1117-1125
 
Ulla, J, Almohalla, C, Ledo, L, et al Coughing attacks as a cause of gastric hemorrhage in patients who have undergone percutaneous endoscopic gastrostomy: an endoscopic solution.Endoscopy2001;33,821
 
Shutsha, E, Brenard, R Hepatic cyst rupture after a coughing fit.J Hepatol2003;38,870
 
Lord, R Factors predisposing to inguinal hernia: an analysis of 1,100 cases.Aust N Z J Surg1968;37,377-381
 
Vasquez, J, Halasz, NA, Chu, P Traumatic abdominal wall hernia caused by persistent cough.South Med J1999;92,907-908
 
Leung, T, Yuen, PM Small bowel herniation through subumbilical port site following laparoscopic surgery at the time of reversal of anesthesia.Gynecol Obstet Invest2000;49,209-210
 
Sanyai, A, Jefferson, PA, Kirby, DF Percutaneous endoscopic gastrostomy button malfunction with severe cough.Gastrointest Endosc1989;35,118-119
 
Annunziata, G, Gunasekaran, TS, Berman, JH, et al Cough-induced Mallory-Weiss tear in a child.Clin Pediatr1996;35,417-419
 
Wergowske, G, Carmody, TH Splenic rupture from coughing [letter].Arch Surg1983;118,1227
 
El-Hammady, S, Ghoneim, M Acute complete inversion of the bladder.BMJ1971;3,306-307
 
Schen, R, Zurkowski, S Increased serum creatine phosphokinase activity with violent coughing.N Engl J Med1973;289,328-329
 
Horsburgh, A Medical memoranda: rupture of the rectus abdominis muscle.BMJ1962;2,898
 
Love, W Rupture of rectus abdominis muscle.BMJ1962;2,1130
 
McCarthy, D, Durkin, TE Rupture of the rectus abdominis muscle.BMJ1963;2,58-59
 
Anderton, R Rectus abdominal muscle pulled by coughing.JAMA1972;222,486
 
Ducatman, B, Ludwig, J, Hurt, RD Fatal rectus sheath hematoma.JAMA1983;249,924-925
 
Lee, T, Greenberger, PA, Hahrwold, DL, et al Rectus sheath hematoma complicating an exacerbation of asthma.J Allergy Clin Immunol1986;78,290-292
 
George, L, Rehman, SU, Khan, FA Diaphragmatic rupture: a complication of violent cough.Chest2000;117,1200-1201
 
Kallay, N, Crim, L, Dunagan, DP, et al Massive left diaphragmatic separation and rupture due to coughing during an asthma exacerbation.South Med J2000;93,729-731
 
Derbes, V, Haran, T Rib fractures from muscular effort with particular reference to cough.Surgery1954;35,294-321
 
Long, A Stress fracture of the ribs associated with pregnancy.Surg Clin North Am1962;42,909-919
 
Kopscanyi, I, Laczay, A, Nagy, L Cough fracture of ribs in infants with dyspnoea.Acta Paediatr Acad Sci Hung1969;10,93-98
 
Lorin, M, Slovis, TL, Haller, JO Fracture of ribs in psychogenic cough.N Y State J Med1978;78,2078-2079
 
Roberge, R, Morgenstern, MJ, Osborn, J Cough fracture of the ribs.Am J Emerg Med1984;2,513-517
 
Hjalmarsson, S, Asmundsson, T, Sigurdsson, J, et al Major hemorrhage as a complication of cough fracture [letter].Chest1993;104,1310
 
Abid, Q, Podila, SR, Kendall, S Sternal dehiscence after cardiac surgery and ACE inhibitors.Eur J Cardiothorac Surg2001;20,203-204
 
Torrington, K, Adornato, BT Cough radiculopathy: another cause of pain in the neck.West J Med1984;141,379-380
 
Ulyat, D, Judson, JA, Trubuhovich, RV, et al Cerebral arterial air embolism associated with coughing on a continuous positive airway pressure circuit.Crit Care Med1991;19,985-987
 
Shugar, J, Som, PM, Eisman, W, et al Non-traumatic cerebrospinal fluid rhinorrhea.Laryngoscope1981;91,114-120
 
Zlab, M, Moore, GF, Daly, DT, et al Cerebrospinal fluid rhinorrhea: a review of the literature.Ear Nose Throat J1992;71,314-317
 
Vaya, A, Resureccion, M, Ricart, JM, et al Spontaneous cervical epidural hematoma associated with oral anticoagulant therapy.Clin Appl Thromb Hemost2001;7,166-168
 
Hamilton, W, Woodburn, RA, Harper, HT, Jr Arterial, cerebrospinal and venous pressures in man during cough and strain.Am J Physiol1944;141,42-50
 
Kerr, A, Eich, RH Cerebral concussion as a cause of cough syncope.Arch Intern Med1961;108,138-142
 
Strauss, M, Longstreth, WT, Jr, Thiele, BL Atypical cough syncope.JAMA1984;251,1731
 
Kapoor, W, Karpf, M, Wieand, S, et al A prospective evaluation and follow-up of patients with syncope.N Engl J Med1983;309,197-204
 
White, C, Zimmerman, TJ, Ahmad, M Idiopathic hypertrophic subaortic stenosis presenting as cough syncope.Chest1975;68,250-253
 
Larson, S, Sances, A, Jr, Baker, JB, et al Herniated cerebellar tonsils.J Neurosurg1974;40,524-528
 
Williams, B Cough headache due to craniospinal pressure dissociation.Arch Neurol1980;37,226-230
 
Sands, G, Newman, L, Lipton, R Cough, exertional, and other miscellaneous headaches.Med Clin North Am1991;75,733-747
 
Moncada, E, Graff-Radford, SB Cough headache presenting as a toothache: a case report.Headache1993;33,240-243
 
Perini, F, Toso, V Benign cough “cluster” headache.Cephalalgia1998;18,493-494
 
Morgan-Hughes, J Cough seizures in patients with cerebral lesions.BMJ1966;2,494-496
 
Natelson, S, Molnar, W Malfunction of ventriculoatrial shunts caused by the circulatory dynamics of coughing.J Neurosurg1972;36,283-286
 
Herr, R, Call, G, Banks, D Vertebral artery dissection from neck flexion during paroxysmal coughing.Ann Emerg Med1992;21,88-91
 
Castelnuovo, P, Mauri, S, Bignami, M Spontaneous compressive orbital emphysema of rhinogenic origin.Eur Arch Otorhinolaryngol2000;257,533-536
 
Young, S, Bitsakou, H, Caric, D, et al Coughing can relieve or exacerbate symptoms in asthmatic patients.Respir Med1991;85(suppl),7-12
 
Prasad, R, Mukerji, PK, Gupta, H Herniation of the lung.Indian J Chest Dis Allied Sci1990;32,129-132
 
Sheka, K, Williams, LG Spontaneous intercostal lung hernia.J Natl Med Assoc1984;76,12101212–1213
 
Ayers, D, LeFeuvre, A, Barker, P Surgical repair of intercostal pulmonary hernia secondary to cough induced rib fracture.J R Nav Med Serv2002;88,55-56
 
Weissberg, D, Refaely, Y Hernia of the lung.Ann Thorac Surg2002;74,1963-1966
 
Bundy, J, Pontier, PJ Cough-induced hydrothorax in peritoneal dialysis.Perit Dial Int1994;14,293
 
Curley, F, Irwin, RS, Pratter, MR, et al Cough and the common cold.Am Rev Respir Dis1988;138,305-311
 
Irwin, R, Pratter, MR, Holland, PS, et al Postnasal drip causes cough and is associated with reversible upper airway obstruction.Chest1984;85,346-352
 
Macklin, M, Macklin, CC Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions: an interpretation of the clinical literature.Medicine1944;23,281-358
 
Naggar, C Pneumatosis intestinalis following common upper-respiratory-tract infection.JAMA1976;235,2221-2222
 
Roe, P, Kuklarni, BN Pneumomediastinum in children with cough.BMJ1967;61,147-150
 
Glauser, F, Bartlett, RH Pneumoperitoneum in association with pneumothorax.Chest1974;66,536-540
 
Benedict, E Rupture of the bronchus from bronchoscopy during a paroxysm of coughing.JAMA1961;178,509-510
 
Kravitz, P The clinicial picture of “cough purpura,” benign and non-thrombocytopenic eruption.Va Med1979;106,373-374
 

Figures

Tables

Table Graphic Jump Location
Table 1. Complications of Cough

References

Leith, D, Butler, JP, Sneddon, SL, et al (1986) Cough. Macklem, P Mead, J eds.Handbook of physiology: Section 3. The respiratory system: mechanics of breathing,315-336 American Physiological Society. Bethesda, MD:
 
Leith, D Cough. Proctor, D Reid, LM eds.Respiratory defense mechanism: part II. Lung biology in health and disease.1977,545-592 Marcel Dekker. New York, NY:
 
Sharpey-Schafer, E Effects of coughing on intrathoracic pressure, arterial pressure and peripheral blood flow.J Physiol (London)1953;122,351-357
 
Irani, F, Sanchis, J Inspiration- and cough-induced atrioventricular block.Can Med Assoc J1971;105,735-736
 
Francis, C, Singh, JB, Polansky, BJ Interruption of aberrant conduction of atrioventricular junctional tachycardia by cough.N Engl J Med1972;286,357-358
 
Sharpey-Schafer, E The mechanism of syncope after coughing.BMJ1953;2,860-863
 
Comroe, JH, Jr Special acts involving breathing.Physiology of respiration: an introductory text 2nd ed.1974 Yearbook Medical Publishers. Chicago, IL:
 
Schultz, D, Olivas, GS The use of cough cardiopulmonary resuscitation in clinical practice.Heart Lung1986;15,273-280
 
Wei, J, Greene, HL, Weisfeldt, ML Cough-facilitated conversion of ventricular tachycardia.Am J Cardiol1980;45,174-176
 
French, C, Irwin, RS, Fletcher, KE, et al Evaluation of a cough-specific-quality-of-life questionnaire.Chest2002;121,1123-1131
 
French, C, Fletcher, KE, Irwin, RS Gender differences in health-related quality of life in patients complaining of chronic cough.Chest2004;125,482-488
 
French, C, Irwin, RS, Curley, FJ, et al Impact of chronic cough on quality of life.Arch Intern Med1998;158,1657-1661
 
Birring, SS, Prudon, B, Carr, AJ, et al Development of a symptom specific health status measure for patients with chronic cough: Leicester Cough Questionnaire (LCG).Thorax2003;58,339-343
 
Fujimura, M, Sakamoto, S, Kamio, Y, et al Sex differences in the inhaled tartaric acid cough threshold in non-atopic healthy subjects.Thorax1990;45,633-634
 
Kastelik, J, Thompson, RH, Aziz, I, et al Sex-related differences in cough reflex sensitivity inpatients with chronic cough.Am J Respir Crit Care Med2002;166,961-964
 
Jousilahti, P, Vartiainen, E, Tuomilehto, J, et al Symptoms of chronic bronchitis and the risk of coronary disease.Lancet1996;348,567-572
 
Haider, A, Larson, MG, O’Donnell, CJ, et al The association of chronic cough with the risk of mycocardial infarction: the Framingham Heart Study.Am J Med1999;106,279-284
 
McCann, W, Bruce, RA, Lovejoy, FW, Jr, et al Tussive syncope.Arch Intern Med1949;84,845-856
 
McIntosh, H, Estes, EH, Warren, JV The mechanism of cough syncope.Am Heart J1956;52,70-82
 
Skolnick, J, Dines, DE Tussive syncope.Minn Med1969;52,1609-1613
 
Kerr, A, Jr, Derbes, VJ The syndrome of cough syncope.Ann Intern Med1953;39,1240-1253
 
Reisin, L, Blaer, Y, Jafari, J, et al Cough-induced nonsustained ventricular tachycardia.Chest1994;105,1583-1584
 
Omori, I, Yamada, C, Inoue, D, et al Tachyarrhythmia provoked by coughing and other stimuli.Chest1984;86,797-799
 
Jacobs, WR, Zaroukian, MH Coughing and central venous catheter dislodgement.JPEN J Parenter Enteral Nutr1991;15,491-493
 
Banyai, A, Joannides, M Cough hazard.Chest1956;29,52-61
 
Pollack, A, McDonald, HR, Ai, E, et al Massive suprachoroidal hemorrhage during pars plana vitrectomy associated with Valsalva maneuver.Am J Ophthalmol2001;132,383-387
 
Irwin, RS, Curley, FJ The treatment of cough: a comprehensive review.Chest1991;99,1477-1484
 
Patterson, W, Murat, BW Combined ambulatory esophageal manometry and dual-probe pH-metry in evaluation of patients with chronic unexplained cough.Dig Dis Sci1994;39,1117-1125
 
Ulla, J, Almohalla, C, Ledo, L, et al Coughing attacks as a cause of gastric hemorrhage in patients who have undergone percutaneous endoscopic gastrostomy: an endoscopic solution.Endoscopy2001;33,821
 
Shutsha, E, Brenard, R Hepatic cyst rupture after a coughing fit.J Hepatol2003;38,870
 
Lord, R Factors predisposing to inguinal hernia: an analysis of 1,100 cases.Aust N Z J Surg1968;37,377-381
 
Vasquez, J, Halasz, NA, Chu, P Traumatic abdominal wall hernia caused by persistent cough.South Med J1999;92,907-908
 
Leung, T, Yuen, PM Small bowel herniation through subumbilical port site following laparoscopic surgery at the time of reversal of anesthesia.Gynecol Obstet Invest2000;49,209-210
 
Sanyai, A, Jefferson, PA, Kirby, DF Percutaneous endoscopic gastrostomy button malfunction with severe cough.Gastrointest Endosc1989;35,118-119
 
Annunziata, G, Gunasekaran, TS, Berman, JH, et al Cough-induced Mallory-Weiss tear in a child.Clin Pediatr1996;35,417-419
 
Wergowske, G, Carmody, TH Splenic rupture from coughing [letter].Arch Surg1983;118,1227
 
El-Hammady, S, Ghoneim, M Acute complete inversion of the bladder.BMJ1971;3,306-307
 
Schen, R, Zurkowski, S Increased serum creatine phosphokinase activity with violent coughing.N Engl J Med1973;289,328-329
 
Horsburgh, A Medical memoranda: rupture of the rectus abdominis muscle.BMJ1962;2,898
 
Love, W Rupture of rectus abdominis muscle.BMJ1962;2,1130
 
McCarthy, D, Durkin, TE Rupture of the rectus abdominis muscle.BMJ1963;2,58-59
 
Anderton, R Rectus abdominal muscle pulled by coughing.JAMA1972;222,486
 
Ducatman, B, Ludwig, J, Hurt, RD Fatal rectus sheath hematoma.JAMA1983;249,924-925
 
Lee, T, Greenberger, PA, Hahrwold, DL, et al Rectus sheath hematoma complicating an exacerbation of asthma.J Allergy Clin Immunol1986;78,290-292
 
George, L, Rehman, SU, Khan, FA Diaphragmatic rupture: a complication of violent cough.Chest2000;117,1200-1201
 
Kallay, N, Crim, L, Dunagan, DP, et al Massive left diaphragmatic separation and rupture due to coughing during an asthma exacerbation.South Med J2000;93,729-731
 
Derbes, V, Haran, T Rib fractures from muscular effort with particular reference to cough.Surgery1954;35,294-321
 
Long, A Stress fracture of the ribs associated with pregnancy.Surg Clin North Am1962;42,909-919
 
Kopscanyi, I, Laczay, A, Nagy, L Cough fracture of ribs in infants with dyspnoea.Acta Paediatr Acad Sci Hung1969;10,93-98
 
Lorin, M, Slovis, TL, Haller, JO Fracture of ribs in psychogenic cough.N Y State J Med1978;78,2078-2079
 
Roberge, R, Morgenstern, MJ, Osborn, J Cough fracture of the ribs.Am J Emerg Med1984;2,513-517
 
Hjalmarsson, S, Asmundsson, T, Sigurdsson, J, et al Major hemorrhage as a complication of cough fracture [letter].Chest1993;104,1310
 
Abid, Q, Podila, SR, Kendall, S Sternal dehiscence after cardiac surgery and ACE inhibitors.Eur J Cardiothorac Surg2001;20,203-204
 
Torrington, K, Adornato, BT Cough radiculopathy: another cause of pain in the neck.West J Med1984;141,379-380
 
Ulyat, D, Judson, JA, Trubuhovich, RV, et al Cerebral arterial air embolism associated with coughing on a continuous positive airway pressure circuit.Crit Care Med1991;19,985-987
 
Shugar, J, Som, PM, Eisman, W, et al Non-traumatic cerebrospinal fluid rhinorrhea.Laryngoscope1981;91,114-120
 
Zlab, M, Moore, GF, Daly, DT, et al Cerebrospinal fluid rhinorrhea: a review of the literature.Ear Nose Throat J1992;71,314-317
 
Vaya, A, Resureccion, M, Ricart, JM, et al Spontaneous cervical epidural hematoma associated with oral anticoagulant therapy.Clin Appl Thromb Hemost2001;7,166-168
 
Hamilton, W, Woodburn, RA, Harper, HT, Jr Arterial, cerebrospinal and venous pressures in man during cough and strain.Am J Physiol1944;141,42-50
 
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    Print ISSN: 0012-3692
    Online ISSN: 1931-3543