Cough: Neurophysiology, Methods of Research, Pharmacological Therapy and Phonoaudiology

Review Article Int. Arch. Otorhinolaryngol. 2012;16(2):259-268.
DOI: 10.7162/S1809-97772012000200016
Cough: neurophysiology, methods of research, pharmacological therapy

and phonoaudiology
Tosse: neurofisiologia, métodos de pesquisa, terapia farmacológica e fonoaudiológica
Aracy Pereira Silveira Balbani 1
1) PhD in Medicine. Otorhinolaryngologist.
Institution: Author’s Own practice.

Tatui – SP – Brazil.
Mailing address: Aracy P. S. Balbani - Capitão Lisboa Street, 715 - Tatuí / SP – Brazil - Zip-code: 18270-070 - Telephone: (+55 15) 3259-1152 - E-mail: a_balbani@hotmail.com
Article received in March 13, 2011. Article approved in June 25, 2011.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
SUMMARY RESUMO
Introduction: The cough is the more common respiratory Introdução: A tosse é o sintoma respiratório mais comum em
symptom in children and adults. crianças e adultos.
Objective: To present a revision on the neurophysiology and Objetivo: Apresentar uma revisão sobre a neurofisiologia e os
the methods for study of the consequence of the cough, as métodos para estudo do reflexo da tosse, bem como a
well as the pharmacotherapy and phonoaudiology therapy of farmacoterapia e terapia fonoaudiológica da tosse, baseada
the cough, based on the works published between 2005 and nos trabalhos publicados entre 2005 e 2010 e indexados nas
2010 and indexed in the bases Medline, Lilacs and Library bases Medline, Lilacs e Biblioteca Cochrane sob os unitermos
Cochrane under them to keywords “cough” or “anti-cough”. “tosse” ou “antitussígenos”.
Synthesis of the data: The consequence of the cough involves Síntese dos dados: O reflexo da tosse envolve ativação de
activation of receiving multiples becomes vacant in the aerial múltiplos receptores vagais nas vias aéreas e de projeções
ways and of neural projections of the nucleus of the solitary neurais do núcleo do trato solitário para outras estruturas do
treatment for other structures of the central nervous system. sistema nervoso central. Técnicas experimentais permitem
Experimental techniques allow studying the consequence of estudar o reflexo da tosse ao nível celular e molecular para
the cough to the cellular and molecular level to develop new desenvolver novos agentes antitussígenos. Não há evidências
anti-cough agents. It does not have evidences of that anti- de que antitussígenos isentos de prescrição médica tenham
cough exempt of medical lapsing they have superior eficácia superior à do placebo para o alívio da tosse. A terapia
effectiveness to the one of placebo for the relief of the cough. fonoaudiológica pode beneficiar pacientes com tosse crôni-
The phonoaudiology therapy can benefit patients with refractory ca refratária ao tratamento farmacológico, sobretudo quando
chronic cough to the pharmacological treatment, over all when coexiste movimento paradoxal das pregas vocais.
paradoxical movement of the vocal folds coexists. Comentários Finais: A abordagem multidisciplinar tem pa-
Final Comments: The boarding to multidiscipline has basic pel fundamental no diagnóstico etiológico e tratamento da
paper in the etiological diagnosis and treatment of the cough. tosse. O otorrinolaringologista deve informar os pacientes sobre
The otolaryngologist must inform the patients on the risks of os riscos dos antitussígenos de venda livre a fim de prevenir
the anti-cough of free sales in order to prevent adverse intoxicações e efeitos adversos, especialmente em crianças.
poisonings and effect, especially in children. Palavras-chave: antitussígenos, codeína, dextrometorfano,
Keyword: anti-cough, codeine, dextromethorpha, expectorantes, tosse.
expectorants, cough.
Int. Arch. Otorhinolaryngol., São Paulo - Brazil, v.16, n.2, p. 259-268, Apr/May/June - 2012.
259
Cough: neurophysiology, methods of research, pharmacological therapy and phonoaudiology. Balbani APS.
adverse effect and poisoning, over all in infancy. Survey

INTRODUCTION made in 63 Casualties North Americans disclosed that
5.7% of the poisonings in minors of 12 years had been
The cough is a mechanism of protection of the aerial provoked by anti-cough and anti-flu, with predominance
ways and also the more common respiratory symptom in of the cases (64%) in children of two the five years of
children and adults. It can elapse of innumerable infectious age (3).
causes (Table 1) and not infectious (Table 2), to be
characterized as it dries or productive, and classified, in The toxicity of the exempt anti-cough of lapsing
accordance with the duration, in acute (less than 3 weeks), and the inconclusive data of its clinical effectiveness (4)
sub-acute (3-8 weeks) or chronicle (more than 8 weeks) had taken the authorities of health of Canada to contraindicate
(1,2). them it the minors of six years and to adopt measured of
security you add: warning in papal brief on the cares in the
The cough paroxysms can harm the quality of life of use for children of 6 the 12 years and standardization of
the patient for intervening with sleep, to provoke packings (bottle to the test of opening for the child,
dysphonia, vomits, chronic headache or urinary incontinence. followed of batcher cup) (5). In Brazil, the warning consists
in papal brief of that anti-cough they do not have to be used
Anti-cough and mucolytics - many of which are in lesser children of two years of age, and the pharmaceutical
exempt of medical lapsing, are between consumed industries are not obliged to use packings to the manuscript
medicines more in the world. They offer to risk of test for children.
Table 1. Infectious causes of cough.

Examples of etiological agents
Virus Cooled common adenovirus, coronavirus, enterovirus, parainfluenza
Influenza (flu) virus influenza A e B
Bronchiolitis respiratory synctial virus (VSR)
Tranqueobronquitis acute virus influenza, VSR
Hantavirus virus Juquitiba, Araraquara, Castelo dos Sonhos, Laguna Negra, Anajatuba
Bacteria Whooping Cough Bordetella pertussis
Tranqueobronquitis acute Mycoplasma pneumoniae
Rinosinusites (syndrome of the cough Streptococcus pneumoniae
of the by airmail superior one) Haemophilus influenzae
Moraxella catarrhalis
Bacterial Pneumonia Streptococcus pneumoniae
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Haemophilus influenzae
Mycobacteriosis typical and atypical Mycobacterium tuberculosis
Parasites Eosinophilia pulmonary parasitic Ascaris lumbricoides

(Syndrome of Loeffler) Ancylostoma duodenale
Strongyloides stercoralis
Chronic Schistosomiasis Pulmonary Schistosoma mansoni
Larva migrans visceral Toxocara canis, Toxocara cati
Singamus Syngamus laryngeus
Protozoan Visceral Leishmaniasis Leishmania chagasi
Fungus Aspergillosis Aspergillus spp
Blastomycosis Blastomyces dermatitidis
Cryptococcosis Cryptococcus neoformans
Histoplasmosis Histoplasma capsulatum
Paracoccidioidomycosis Paracoccidioides brasiliensis
Pneumocystosis Pneumocystis jiroveci
260
Table 2. Not infectious causes of cough.
Medicines Inhibitors of the converting enzyme of the angiotensin

Beta blockers
Interferon peguilado (bronchial mod)
Methotrexate (pneumonitis)
Cardiovascular Diseases Pulmonary Edema
Pulmonary Embolism
Gastroesophageal Reflux
Foreign Body Aspiration
Neoplasias
Asthma Variant of the asthma with cough (a)
Pulmonary illness obstructive chronicle
Inhalation of irritating Gas mustard, formaldehyde
Pneumoconiosis Silicosis
Anothers After-infectious coughAtopic Cough (b)Psychogenic Cough
Note:
(a) Variant with cough of the asthma: responsive chronic cough to the bronchodilator use or inhalator/systemic corticosteroids.
(b) Atopic cough: chronic cough without reversible blockage of the aerial flow nor bronchial hyperresponsiveness, in which there
is sanguineous eosinophilia or in sputum, or rise of the specific serum IgE, or coetaneous test of positive immediate hypersensitivity.
Refractory to the therapy with responsive bronchodilator and to the use of corticosteroids inhalation or antihistaminic H1.
In 2007, a manufacturer removed of the world-wide Neurofisiology of the Cough

market, preventively, anti-cough contends hydrochloride
of clobutinol, for the risk to draw out interval QT and to Peripheral Components
induce cardiac arrhythmia (torsades of pointes) (6).
However, this active principle still is commercialized by The reflected arc of the cough is initiated in the
other companies (7). respiratory epithelium, diaphragm, pericardium, pleura,
peritoneum or esophagus through the stimulation of
The otolaryngologist use to take care of cases of mecanoreceivers, nociceptors (chemoreceptors) or Aä
followed cough of pharyngeal irritation or unchained by staple fibers (1). In the 2,3%-4,2% of the population
contact with perfumes and other inhalants, variations of consequence it can also be evoked by the palpation of the
temperature and acts of speaking, laughing or to sing. external auditory meatus - more commonly of its wall
Frequent the physician and pediatrician direct patients to postero-inferior, in one or both the ears -, for stimulation of
the specialist investigates the syndrome of the cough of the the auricular branch of vacant nerve (nerve of Arnold)
by airmail superior one, before called dripping after-nasal. (8,9).
For everything this, is necessary that the In experimentation animals, the bilateral section of
otolaryngologist knows the scientific neurophysiologies of the superior laryngeal nerve does not modify the
the cough, methods for its study and the pharmacologic consequence of the cough. The bilateral section of the
and phonoaudiologic treatment for relief of the symptom, recurrent laryngeal nerve abolishes the cough provoked
boarded subjects in this revision. for mechanical or electric stimulation of the mucous of the
larynx and superior portion of the trachea, but does not
intervene with the consequence provoked for the acid
LITERATURE REVIEW vapor inhalation.
The original works had been searched for this not The mechanoreceptors of low threshold answer the
systematic revision, of revision, meta-analysis and published mechanical stimulations. The pulmonary receivers of sprain
between 2005 and 2010 and indexed stories of case in the (slowly adapting stretch receptors - SARs and rapidly
bases Medline, Lilacs and Library Cochrane under them to adapting stretch receptors - RARs) are activated physiological
keywords “cough” or “anti-cough”. by the variation of the pulmonary volume during the
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breath, while the mechanossensors of esophageal tension for the stimulation mechanics of the trachea is intensified
are stimulated by the deglutition. In pathological conditions, by the instillation of capsaicin in the nasal mucous or
edema of the mucosa or the brochoconstriction can activate esophageal, indicating that in the brainstem there are
them. Such receivers have the small sensitivity the chemical integration between the sensitive afferents of the triplet
stimulations (acid). nerve in the nasal mucous and the wander afferents
trachea-bronchial and esophageal (15,16). This would be
The nociceptors or chemoreceptors answer the one of the predisposing mechanisms to the cough in the
chemical stimulations (capsaicin, bradicinin, prostaglandins, patients with sinonasal conditions (syndrome of the cough
acid), heat (temperature above of 42oC) and some extreme of the by airmail superior one) or gastroesophageal reflux.
mechanical stimulations.
The glutamate seems to be the main excitatory
The myelinated staple fibers of fast adaptation Aä, neurotransmitter of the ways central offices of the cough,
called receiving of cough, have important paper in the while the neurocinines (substance P, neurocinines and the
defense of the aerial ways; therefore they are very sensible B) would be neuromodulatory. It has been searched the
to the contact of liquids or main particles with the mucous anti-cough central action of antagonists of the receiver of
of the larynx, trachea and principal bronchis. They possess neurocinines (17).
distinct physiological characteristics of the ones of the
RARs and SARs, not activated by the capsaicin or bradicinin The consequence suffers voluntary control from the
(10) and it believes that its main function is the regulation cerebral cortex. The selective stimulation of staple fibers C
of the consequence of the cough evoked in the extra with capsaicin in animals under general anesthesia does not
pulmonary aerial ways. evoke cough (16,17). In human beings, the impulse to
cough generally precedes the motor act of the cough and
The myelinated staple fibers of type C are not the can be suppressed voluntarily (18). On the other hand, the
nociceptors become vacant more numerous in the bronchis psychogenic cough, that answers for 3 to 10% of the cases
and lungs the (11) and responsible for the bother of the of chronic cough in infancy, can be provoked by the
impulse to cough. They express some ionic canals of patient and if to reveal with or without ticks (motor or
membrane, between which transient receiving potential vocal), ceasing during sleep (19).
vanilloid (TRPV) 1 the 4 - numerous also in larynx mucous
(12) -, and transient receiving potential ankyrin-1 (TRPA- The efferent ways of the cough pass through the
1), activated directly for irritating chemistries (10) as the nerves vacant and phrenic and of the spinal motoneuron
allicina of the onion and the garlic, the isothiocyanate of the until the expiratory musculature, resulting in the characteristic
mustard and formaldehyde (13). sequence of respiratory movements already exhaustingly
described in literature (1,2,7).
The ideal anti-cough of peripheral action would
have to inhibit staple fibers C selectively, to abolish the Reflection Modulation
pathological paroxysms of cough without harming the
physiological mechanism of defense of the Aä staple fibers The consequence of protection of the aerial ways is
against aspiration. This could occur for the use of: 1) an a dynamic mechanism that follows the coming-of-age of
antagonist of ionic canals TRPV or TRPA-1, or 2) of a similar the central nervous system (SNC) and suffers influence
medicine to the local anesthetics, capable to block from hormone and neuro-humoral factors.
specifically a sodium canal regulated for voltage and, thus,
to inhibit the potential of action in staple fibers C (10). The In the just-born mammals, especially the premature,
current lines of research of new anti-cough test molecules the presence of secretion, gastric content or other liquids
with these actions. in the superior aerial ways (VAIN) result in movements of
deglutition and closing of glottis, apnea, bradycardia and
Core components redistribution of the sanguineous flow for vital agencies.
The action of the interleukins in the SNC sensitizes the
The afferent ways of the cough converge to the consequence and draws out apneas (20), what would
nucleus of the solitary treatment in the brainstem, main explain the biggest risk of sudden death in the neonates
point of the regulation of the consequence. Of their break with infections of the superior aerial ways (IVAS).
multiple there neural projections to: the reticular formation,
ambiguous nucleus, periaqueductal cinereous substance In pig younglings are observed biochemists changes
and dorsal nucleus of rafe (14). and bioelectric in the motoneuron respiratory in the first
month of life. Gradual it diminishes the occurrence of
In the experimental models, the cough provoked deglutition and apnea, and the cough starts to be the main
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of the protective consequence of the aerial ways, concentration of capsaicin capable to provoke five or more
characteristic component that it is remained in adult life motor acts of cough. The method is considered reproducible
(20,21). and safe in human beings, but some individuals complain
of transitory pharynx irritation after exposition to the
In human beings the sensitivity of the consequence capsaicin.
of the cough is bigger in the women and patients with IVAS
or variant with cough of asthma (tussigenic asthma) (22). The acid citric has greater probability to cause
sensation of breathlessness and ardor in pharynx. The
It has given controversial on the effect of the ultrasonic nebulizer of distilled water is insufficient to
smoking in the threshold of the consequence of the cough. activate the consequence of cough in up to 20% of the
Some studies show increase of the threshold in smokers, people, but it can induce bronchospasm symptomatic in
perhaps for central or peripheral action of the nicotine, or others, what it reduces the reproducibility and security of
for the increase of the thickness of the layer of respiratory the method.
mucus, that it would difficult the activation of the receivers
you become vacant tracheobronchial. This phenomenon is Studies of the effectiveness of anti-cough can suffer
reversible in few weeks, reasons for which many people the bias from the demulcent effect (stimulation to the
complain of cough more after to stop to smoke. However, saliva secretion and mucus in the VAS for the sugars) of
other smoking suffer of chronic cough - possibly for the placebo formulated in boiled (22) or of the voluntary
inflammatory process in the aerial ways -, alleviated for the inhibition of the cough.
abstinence of cigarette (23).
In the clinical research, the use of questionnaires
The converting enzyme of the angiotensin (ECA) (Burden of Cough Questionnaire, Cough Specific Quality
degrades not only the angiotensin, but also the bradicinin, of Life Questionnaire, Leicester Cough Questionnaire) is
substance P and neurocinines, which sensitize staple fibers useful to evaluate the impact of the cough in the quality of
C. For this reason, about 20% of the patients who use life of patient (27).
inhibiting antihypertensives of the ECA have cough as
collateral effect (1,24). The symptom tends to disappear
after about four weeks the interruption of the use of Pharmacologic teraphy of cough
antihypertensive (25).
Anti-cough of peripheric action
Methods of study of cough The dropropizine and its levodropropizine

enantiomers reduce the sensitivity of staple fibers C
Although it has numerous afferent sensitive in the become vacant (28). In Brazil, several of its presentations
aerial ways, rats and mice do not present the typical motor in boiled must contain sugar and a presentation of the
act of the cough, making it difficult its evaluation. Thus, the dropropizine in tablets has tartrazine yellow colouring,
guinea pig is the specie of small postage more used in what it contraindicates them, respectively, for diabetic and
experiments (13,16). people with intolerance to the acetylsalicylic acid.
In the experimental works the cough can be Anti-cough of central action

provoked by the direct electric micro stimulation of the
nucleus of the solitary treat after decerebration (26), or by The dextromethorphan, clobutinol and the
stimulation electric/mechanics of the mucous of the aerial Cloperastine fendizoate have not narcotic action in the
ways in conscientious animals or under general anesthesia. brainstem.
As much in the experimental works how much in The dextromethorphan is agonist of the receiver
the physicians some chemical stimulations can be used or not opioid sigma-1 and antagonist of receiving N-metil-D-
cough agent: capsaicin, acid (citric, ascetic, tartaric) and aspartate (NMDA) of the glutamate. Its action is similar to
ultrasonic nebulized of distilled water (“fog”). the one of acid LSD (LSD), ketamine and psilocybin. The
dextromethorphan is metabolized by cytochrome P450
The capsaicin is the causes of cough more used, (enzyme CYP2D6), and individuals that metabolizes it
managed in dose only or project dose-reply. It provokes slowly are more susceptible to the psychoactive effect,
cough immediately, reason for which recommends evaluate exactly in the therapeutically doses. The medicine interacts
the effect in the 15 seconds after the nebulizer. Generally with inhibitors of mono amine oxidase (HAND) and inhibiting
the parameter analyzed in the studies dose-reply is the antidepressants of the reuptake of serotonin (29). It has
263
register of fatal poisoning for dextromethorphan in child detect, of not invasive form, the acidification of VAS for
(30). gastroesophageal reflux, and thus to prevent the unnecessary
use of IBPs.
Clobutinol delays the ventricular repolarization and
is arrhythmogenic (31). Already it had relate of anaphylaxis Expectorants, mucolytics and others
for medicine (32).
The guaifenesin expectorant is glyceril ether of
The Cloperastine fendizoate is sedative of the guaiacol, resin of the plant Guajacum officinale L., the
cough and also it has peripheral action, desensitize the guaiacol. This species does not have to be confused with
afferents you become vacant tracheobronchial. It interacts the guaco (Mikania glomerata Spreng.), whose leaves
with inhibitors of the HAND. popularly are used in Brazil in the preparation of infusion
or decaocto for the combat to the cough.
Anti-cough narcotic (morphine and codeine)
primarily acts in the opioid receivers ì in the nucleus of the The guaifenesin has anti-cough effect in patients
solitary treatment in the guinea pig. However, naloxone, with IVAS, but it does not inhibit the consequence of cough
antagonist of these receivers, does not hinder the anti- in submitted healthy volunteers to the capsaicin inhalation.
cough action of codeine in cat14. It is possible, then, that Its accurate mechanism of action completely is not clarified
the narcotics also act in not-opioid receivers - perhaps of and the more frequent adverse effect are: chronic headache,
glutamate, serotonin or nociceptin - in SNC (17,26). nauseas and vomits.
The codeine is one of the anti-cough most efficient, The vasicine is an originally isolated alkali of leaves of
however commonly it provokes collateral effect (nauseas, Adhatoda vasica, indicated for Ayurveda as expectorant
intestinal constipation) and can cause dependence (26). (35). Also the leaves of Sida cordifolia L. (Malvaceae),
popularly known in Brazil as mauve-white, they contain
The anti-cough of central action can boosting the vasicine.
effect depressor of the SNC of the alcohol, hypnotic and
sedatives. The hydrochloride of bromhexine is a synthetic
derivative of the vasicine. The hydrochloride mucolytics of
Inhibitors of the protonic bomb ambroxol is an active metabolite of the bromhexine and
has antirust, anti-inflammatory properties, surfactant and of
In many cases of chronic cough it has symptoms or local anesthetic, the last one for blockade of sodium canals.
signals of gastroesophageal reflux (RGE), and the inhibitors Their adverse effects are: nauseas, vomits, abdominal pain
of the protonic bomb (IBPs), associates or not to the and coetaneous eruption. The super dosage can provoke
prokinetic ones (bromoprid, domperidone), commonly dyspneia, ataxia and convulsions (36). Ambroxol is not
are prescribed as therapeutically test. However, the meta- approved by the Food and Drug Administration for use in
analysis of 18 randomized and controlled studies, being U.S.A. (37).
five in children and 13 in adults, indicates that it does not
have benefit of the indiscriminate use of the IBPs in chronic The potassium iodide still is found in the
cough (33). formularization of some expectorants and its drawn out use
can induce hypothyroidism.
HUNT et al. (2006) 34 had evaluated 22 adult
patients with chronic cough and 22 healthy volunteers Clinical studies show that the monotherapy with n-
how much to the occurrence of cough and the measures acetyl-cysteine or erdosteine does not have anti-cough
of pH of the condensed vapor of the air exhaled in the half effect, but the mucolytics are good coadjutants in the
following hour to the lemonade ingestion. It had decline treatment of respiratory above, presumably for its antirust
of pH after about 15 minutes, significantly more accented effect (25).
in the individuals with chronic cough of what in the
volunteers. Some commercial marks of exempt anti-cough of
medical lapsing associate the dropropizine, the
The eight patients who cough in the period where levodropropizine or the dextromethorphan with classic
pH of exhaled air remained below of 7,4 had been the ones H1 antihistamines (diphenhydramine, doxylamine) in the
that had answered to the therapy made with IBP during formularization. These antihistamines help to alleviate
one month - the pharmaceutical, doses and dosage had not the cough thanks to its peripheral action and to the
been specified. The researchers suggest to apply this control of the atopy, but its effect in the SNC cause
method in the selection of the cases of chronic cough to sleepiness (25).
264
In the consulted systematic revisions did not prove cough, antihistamines and inhibitors of protonic bomb
that the effectiveness of guaifenesin (4), of methylxanthines (46,48). The diagnosis is confirmed through the
(theophylline, aminophylline and caffeine) (38), of nasofibrolaryngoscopy.
antihistamines (39) and the antagonist of the receiver of
montelukast leukotriene (40,41) either superior to the one Researchers had followed during two months 87
of placebo for relief of the cough in children. adults with chronic cough to medicines, having been 73%
of the feminine sex, divided in a group have randomly
Since immemorial times the common sense controlled and other submitted the individual sessions of
recommends the honey of bee for relief of the dry cough. phonoaudiologic therapy (orientations of vocal hygiene,
The honey is demulcent and contains phenols with antirust exercises for abdominal breath and voluntary relaxation of
and antimicrobial. It is cheap and safe for use in bigger the larynx musculature). They had evaluated the cough
children of one year and, pasteurized, rare provokes and the vocal quality of the participants (analysis acoustics
allergic reaction (42). and for electroglottography) and had only evidenced
significant improvement of both in the group submitted to
A randomized study compared the effect of the phonoaudiologic therapy (48).
administration, 30 minutes before sleeping, 5 ml of honey
or dextromethorphan on the nocturnal cough and the MURRY researchers and cols. (2010) (47) had evaluated
quality of the sleep of 105 children and adolescents with the sensitivity of the mucous larynx in 16 adults with
IVAS. One third group of patients did not receive treatment. chronic cough, larynx dyskinesia and refractory symptoms
The dextromethorphan was formulated in order to have of laryngopharynx reflux to the treatment with IBP. The
similar aspect and flavor to the ones of the honey, so that nasofibrolaryngoscopy was made before and after three
the participants of the study could not distinguish them. months of treatment with IBP managed two times to the
The patients who had used honey had significant reduction day (drugs and doses not informed) combined with
of the nocturnal cough in comparison with that they had respiratory retrain (exercises for acquisition of respiratory
not received treatment, benefit not gotten with rhythm and stimulation to the abdominal breath, made
dextrometorfane (43). during 10 to 15 minutes, two times to the day). The
threshold of the consequence of adduce of the PPVV was
Another randomized work analyzed the effect of a gotten when applying air pulses compressed with
nocturnal dose of 2,5 ml of honey, or 7,5 mg of changeable pressure in the mucous of the aryepiglottic
dextromethorphan, or 6,25 mg of diphenhydramine, or fold, innervated for the superior laryngeal nerve, with
nasal hygiene with physiological serum on the nocturnal visualization of the movement of adduce of the PPVV to
cough of 139 children of two the five years with IVAS. The the nasofibrolaryngoscopy. The sensitivity of the mucous
frequency and the intensity of the nocturnal cough, was significantly bigger to the ending of the treatment, and
according to story of the parents, had been significantly the 12 patients who had completed the study had presented
lesser in the group of children that used honey (44). cure of the larynx dyskinesia and the cough. The authors
consider that edema derive from the larynx mucosa of acid
Although these favorable results, there is not scientific reflux would reduce the sensitivity of the mechanoreceptors
consensus on the indication of the honey in the therapy of becomes vacant, and the cough and the adduce of the
the acute cough in children (45). PPVV would be adaptive answers for defense of the aerial
ways against aspiration in this circumstance.
Phonoaudiologic therapy on cough

DISCUSSION
It is esteem that half of the patients with chronic
cough present some degree of motor dysfunction of the The neurophysiology of the cough is complex,
vocal folds (PPVV), the larynx dyskinesia, in which there is involving activation of receiving multiples in the aerial
involuntary paradoxical supply of the PPVV during the ways and of neural projections of the nucleus of the solitary
inspiration or expiration (46). The larynx dyskinesia can be treatment for other structures of the central nervous
unchained by: inhalation of irritating (smoke or vapors), system.
low temperature or extreme humidity of air, motor acts
that involve the respiratory musculature (physical exercise, To unmask the physiopathology relation between
speaks, laugh, deep inspiration or deglutition) or stresses the cough, the acidification of the aerial ways and the
(47). In these patients the pulmonary test of function and larynx dyskinesia is a field of instigate research in
the oxymetry of pulse generally are normal, and the cough Laryngology. Recent studies point that many patients with
is refractory to the pharmacologic treatment with anti- chronic cough have sensitive neuropathic of the recurrent
265
laryngeal nerve, extending the understanding of the placebo for the relief of the cough. Also is not proven the
problem and opening the perspective of therapeutically effectiveness of the guaifenesin, the methylxanthines,
with neuromodulatory as the gabapentin and the pregabalin montelukast and antihistamines for the treatment of the
(49-51). cough in children.
The importance of the etiological diagnosis of the The phonoaudiologic therapy can benefit patients
cough is unquestionable. However, many sick people with refractory chronic cough to the pharmacologic
appeal to the self-medication with anti-cough and mucolytics treatment.
- or they request that the doctor prescribes them - to
attenuate the discomfort until identifies the cause of the
symptom and if she initiates the specific treatment. ACKNOWLEDGEMENTS
The dextromethorphan and clobutinol had started The author is thankful the Mrs. Márcia Arruda and
to be commercialized in the decade of 1950. Since then, it Marinalva Aragão for the valuable assistance with the
remains questionable the advantage of these anti-cough in bibliography.
relation to placebo and have succeeded the stories of
serious collateral effect. Therefore, it is desirable that the
Brazilian associations of medical specialties and the National BIBLIOGRAPHIC REFERENCES
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poisonings. In this direction, it is convenient to standardize 2. Bouajaoude ZC, Pratter MC. Clinical approach to acute
in the Country the packings of anti-cough for pediatric use, cough. Lung 2010, 188 (suppl. 1):S41-6.
becoming obligator the bottle the test of opening for the
child and the batchers small glass. 3. Schaefer MK, Shehab N, Cohen AL, Budnitz DS. Adverse
events from cough and cough medications in children.
Although the innumerable experiments of Pediatrics. 2008, 121:783-7.
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phonoaudiologic therapy in cases of refractory chronic empresa+Boehringer+Ingelheim+sobre+a+retirada+do+
cough to the pharmacologic treatment encourages to the mercado+dos+ medicamentos+Silomat%C2%AE+
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Review Article Int. Arch. Otorhinolaryngol. 2012;16(2):259-268.

Cough: neurophysiology, methods of research, pharmacological therapy

1) PhD in Medicine. Otorhinolaryngologist.

Institution: Author’s Own practice.

adverse effect and poisoning, over all in infancy. Survey

Table 1. Infectious causes of cough.

Parasites Eosinophilia pulmonary parasitic Ascaris lumbricoides

Table 2. Not infectious causes of cough.

Medicines Inhibitors of the converting enzyme of the angiotensin

In 2007, a manufacturer removed of the world-wide Neurofisiology of the Cough

Methods of study of cough The dropropizine and its levodropropizine

In the experimental works the cough can be Anti-cough of central action

Phonoaudiologic therapy on cough

8. Gupta D, Verma S, Vishwakarma SK. Anatomic basis of

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