बलगमी खाँसी (Productive Cough) — सम्पूर्ण क्लिनिकल गाइड: कारण, जाँच, दवाएँ (डोज़ सहित), वरण और रोकथाम

बलगमी खाँसी (Productive / Wet Cough) — Complete Clinical Guide

परिभाषा, कारण, पैथोजेनेसिस, पैथोलॉजी, differential diagnosis, पूरा diagnostic workup, sputum protocol, evidence-based medicines (डोज़ और अवधि), supportive care, nutrition, complication और prevention — MBBS/MD स्तर पर व्यवस्थित।

Contents (Jump to)

1) Definition & Types 2) Epidemiology & Risk factors 3) Etiology — infective & non-infective causes 4) Pathogenesis & Pathology 5) Clinical features — sputum patterns & significance 6) Differential diagnosis 7) Investigations & sputum protocol 8) Treatment overview 9) Medicines — Full dosing tables (Adults) 10) Supportive care, physiotherapy & home measures 11) Nutrition — recommended & avoid 12) Complications 13) Prevention & vaccination 14) Follow-up & red flags 15) Internal links (site) 16) References & clinical notes

1) Definition & Types

Productive cough वह खाँसी है जिसमें बलगम (sputum/phlegm) निकले — यह lower respiratory tract में secretions, infection या inflammation का संकेत है।

Classification by duration

Acute: ≤2–3 weeks (most commonly viral or bacterial bronchitis/pneumonia)
Subacute: 3–8 weeks (post-infectious bronchial hyperreactivity)
Chronic: >8 weeks (COPD, bronchiectasis, chronic bronchitis, TB, bronchogenic carcinoma)

2) Epidemiology & Risk factors

Productive cough is common in outpatient and inpatient respiratory practice worldwide. प्रमुख जोखिम-कारक:

Smoking (active/passive)
Chronic lung disease (COPD, bronchiectasis, cystic fibrosis)
Immunosuppression (HIV/AIDS, steroids)
Age extremes (infants, elderly)
Environmental exposure (pollution, occupational dusts)
Poor oral hygiene, aspiration risk, alcohol

3) Etiology — Infective & Non-infective causes

Infective

Acute bronchitis (viral ± secondary bacterial)
Pneumonia (community-acquired or hospital-acquired) — typical (Strep. pneumoniae) and atypical (Mycoplasma, Chlamydia, Legionella)
Tuberculosis (pulmonary TB) — chronic productive cough, night sweats, weight loss
Bronchiectasis — recurrent purulent sputum, clubbing
Lung abscess, pulmonary empyema

Non-infective

Clinical heart failure with pulmonary congestion (pink frothy sputum)
Chronic bronchitis (COPD — "productive cough for 3 months × 2 years")
Aspiration (neurological dysphagia)
Bronchogenic carcinoma (persistent blood-stained sputum)

4) Pathogenesis & Pathology

Productive cough arises from increased mucus production (goblet cell hyperplasia, submucosal gland hypertrophy), impaired mucociliary clearance, and cough reflex activation. Infective agents cause local inflammation → neutrophil influx, cytokine release, mucus secretion and pus formation. Chronic inflammation leads to bronchial wall damage (bronchiectasis), fibrosis and progressive airflow limitation.

Pathology specimens (sputum, BAL, tissue) show organisms, inflammatory cells (neutrophils, macrophages), and in chronic disease—squamous metaplasia, fibrosis and bronchial dilation.

5) Clinical features — sputum patterns & significance

Sputum colour interpretation (practical)

Colour/Consistency	Likely significance
White/clear	Viral infection, allergic bronchitis, COPD chronic sputum
Yellow/green	Neutrophil-rich purulent sputum — bacterial infection
Rusty	Classically pneumococcal pneumonia
Frothy pink	Pulmonary edema / cardiac failure
Foul odour, purulent	Lung abscess, anaerobic infection, bronchiectasis
Blood-streaked / frank hemoptysis	TB, malignancy, severe infection, PE

Common symptoms

Persistent cough with expectoration (volume may vary)
Fever, chills (infective causes)
Dyspnea, chest pain (pleuritic in pneumonia/empayema)
Wheezing (bronchiectasis, COPD, asthma overlap)
Systemic features (weight loss, night sweats in TB)

6) Differential diagnosis — algorithmic approach

Acute onset (≤3 wk): think viral bronchitis, early pneumonia — examine fever, focal chest signs, CXR.
Subacute (3–8 wk): post-infectious inflammation, atypical infections.
Chronic (>8 wk): evaluate for COPD/chronic bronchitis, bronchiectasis, TB, cancer, aspiration.
Consider cardiac causes if pink frothy sputum or orthopnea/PND present.

7) Investigations & Sputum protocol

Baseline investigations

CBC (WBC, neutrophilia in bacterial infection, anemia in chronic disease)
CRP, ESR — inflammatory markers
Blood glucose, renal & liver function tests (drug dosing considerations)
Pulse oximetry, arterial blood gas if hypoxic

Radiology

Chest X-ray PA view — consolidation, cavitation, effusion, lung fields
High-resolution CT chest — bronchiectasis, abscess, malignancy, subtle consolidation

Sputum collection protocol (best practice)

Advise deep cough sputum (morning sample) into sterile container — saliva contamination reduces yield.
Collect 2–3 consecutive early morning samples for AFB (TB) microscopy/culture if TB suspected.
Send one sample for Gram stain and culture & sensitivity (C/S) for bacterial pathogens.
If fungal infection suspected, send for KOH, fungal culture and antigen tests as appropriate.
In intubated/critically ill patients, perform endotracheal aspirate or bronchoalveolar lavage (BAL) for reliable sampling.

Microbiology

Gram stain shows predominant organisms and neutrophil presence.
Culture identifies pathogen and antibiotic sensitivity — crucial for targeted therapy in severe infections.
Rapid antigen tests / molecular assays (PCR) for influenza, RSV, SARS-CoV-2, Mycoplasma, Legionella urinary antigen are useful.

8) Treatment overview — principles

Treatment is etiology-directed:

Infective bacterial: start empiric antibiotics if clinical suspicion of bacterial pneumonia/bronchitis, modify after culture report.
Tuberculosis: follow national TB program: multi-drug ATT regimen after confirmation.
Bronchiectasis: airway clearance, long-term or targeted antibiotics for exacerbations.
Heart failure: treat cardiac failure (diuretics, afterload reduction) — pulmonary congestion improves.
Chronic bronchitis/COPD: bronchodilators, inhaled steroids, smoking cessation.

किसी भी क्लिनिकल-संदेह अवस्था में supportive care (hydration, oxygen if hypoxic, analgesia/antipyretic) प्रारम्भ करें।

9) Medicines — Full adult dosing tables (practical)

निम्न डोज़ सामान्य वयस्क निर्देश के अनुसार हैं — renal/hepatic impairment, गर्भावस्था, दवा इंटरैक्शन और स्थानीय फार्मेसी/प्रोटोकॉल के अनुसार समायोजित करें।

Antibiotics (empiric choices for community-acquired pneumonia / severe bronchitis)

Situation	Typical empiric regimen (adult)	Duration / Notes
Outpatient CAP, no comorbidity	Amoxicillin 1 g PO TDS + Doxycycline 100 mg PO BD OR Azithromycin 500 mg PO day 1 then 250 mg OD x4 days	5–7 days depending on response; local resistance patterns matter
Inpatient CAP, moderate–severe	Piperacillin-tazobactam 4.5 g IV q6–8h + Azithromycin 500 mg IV/PO day 1 then 250 mg OD OR Levofloxacin 750 mg IV/PO OD (if atypical suspected)	7–14 days; de-escalate with culture
Bronchiectasis exacerbation (severe)	Piperacillin-tazobactam 4.5 g IV q6–8h OR Cefepime/Meropenem if severe or pseudomonas risk + consider inhaled tobramycin for chronic Pseudomonas	10–14 days or guided by response
Suspected anaerobic lung abscess	Clindamycin 600–900 mg IV q8h → PO 300–450 mg q6–8h or amoxicillin-clavulanate	4–6 weeks often required
TB suspected	Refer to national TB program; start multi-drug anti-tubercular therapy (INH, Rifampicin, Pyrazinamide, Ethambutol) as per weight	Minimum 6 months regimen; confirm by sputum/CBNAAT

Expectorants & Mucolytics

Drug	Dose (Adult)	Notes
Ambroxol (syrup 30 mg/5 ml)	10 ml (60 mg) TDS — common regimen 30 mg TDS	5–7 days; safe adjunct to thin secretions
Bromhexine	8–16 mg TDS	Promotes mucus clearance
N-acetylcysteine (NAC)	600 mg PO OD (or 200 mg TDS)	Mucolytic; avoid in asthma with bronchospasm unless bronchodilator cover
Guaifenesin	200–400 mg PO every 4 hours PRN (max 2.4 g/day)	Expectorant; supportive

Bronchodilators & Inhaled therapies

Drug / Formulation	Dose	Indication
Salbutamol (Metered Dose Inhaler)	100 µg per puff; 2 puffs PRN, repeat q4–6h PRN (use spacer)	Bronchospasm relief
Ipratropium bromide inhaler	2 puffs TDS–QID	Add in severe COPD/bronchitis
Inhaled corticosteroid (eg. Budesonide)	200–400 µg BID	Chronic airway inflammation / asthma overlap

Adjunctives & supportive meds

Drug	Dose	Use
Paracetamol	500–1000 mg PO q4–6h PRN (max 3 g/day)	Fever, myalgia
Normal saline nebulization	3–5 ml via nebulizer q6–8h	Hydration of secretions
Oral corticosteroid (short course)	Prednisolone 30–40 mg OD for 3–5 days (selected cases)	Severe COPD exacerbation/bronchospasm

Important: Antibiotics should be used judiciously — avoid in simple viral sputum unless clinical, radiological or microbiological evidence of bacterial infection. For TB, follow programmatic protocols and drug susceptibility testing (DST) when indicated.

10) Supportive care, chest physiotherapy & home measures

Hydration & humidification

अच्छी hydration mucus को पतला करती है — 2–3 L/day (unless cardiac/renal contraindication). Humidifiers or steam inhalation (सावधानी: scald risk) help secretion mobilization.

Airway clearance techniques

Postural drainage and percussion (chest physiotherapy) — especially bronchiectasis
Active cycle of breathing techniques (ACBT), huff cough
Use of positive expiratory pressure (PEP) devices in chronic disease

When to give oxygen

SpO₂ <92% (or per local target) → supplemental oxygen to maintain SaO₂ 92–96% in most adults (COPD targets 88–92% where applicable).

Hospitalization criteria

Severe dyspnea, hypoxia, confusion, sepsis
Inability to tolerate oral intake or significant comorbidity (cardiac, renal)
Radiological evidence of lobar pneumonia, empyema, lung abscess

11) Nutrition — Recommended & Avoid

अच्छी पोषण स्थिति wound/illness से recover करने में मदद करती है; विशेषकर chronic lung disease में protein energy malnutrition को दूर करना आवश्यक है।

High-quality protein: eggs, lean meat, fish, paneer, legumes — aim 1.2–1.5 g/kg/day in catabolic states
Energy dense foods for those with weight loss: nuts, dried fruits (anjeer), whole grains
Vitamin C rich fruits (guava, citrus) for immune support
Hydrating soups, broths and warm herbal teas (ginger, tulsi)

Avoid / Limit

Smoking and exposure to second-hand smoke
Excessive dairy if it worsens sputum viscosity in individual patients (subjective)
Alcohol (reduces cough reflex, aspiration risk)

साइट के nutrition guide पर विस्तृत macro/micronutrient roles देखें: Complete Medical Nutrition Guide.

12) Complications

Pneumonia → respiratory failure
Empyema, lung abscess (require drainage ± prolonged antibiotics)
Bronchiectasis (recurrent purulent sputum, hemoptysis)
Hemoptysis — life-threatening if massive
Sepsis / Multiorgan dysfunction in severe infection

13) Prevention & Vaccination

Smoking cessation programs
Vaccination: annual influenza vaccine; pneumococcal vaccination per age/comorbidity (PCV13/PPV23 per local schedule)
Good hand hygiene, mask use in high risk seasons
Oral hygiene to reduce aspiration pneumonia risk

14) Follow-up & Red flags (when to seek urgent care)

Follow-up depends on cause — typical pneumonia review within 48–72 hours if outpatient; CXR resolution expected in 2–6 weeks. Red flags:

Worsening breathlessness, SpO₂ fall
High persistent fever despite antibiotics
Massive hemoptysis (>200–600 ml/24 h per local definition)
Significant chest pain, confusion, poor oral intake

15) Internal links — related posts (site)

Internal linking selected to provide cross-reference without repetitive linking to a single page multiple times.

16) References & Clinical notes

Local and international pneumonia/ATS/IDSA guidelines for CAP management (follow local adaptation).
National TB program guidelines for diagnosis & ATT dosing and duration.
Bronchiectasis management consensus and airway clearance protocols.
Vaccination schedules per national immunization program.

(उपरोक्त guideline references का उपयोग clinical decision making के लिए करें; हमेशा नवीनतम राष्ट्रीय/अन्तर्राष्ट्रीय guidance check करें।)

Productive Cough: Definition, Causes, Symptoms & Treatment