A – Physiopathology:
TB originates in the tubercle bacillus (Mycobacterium tuberculosis or bovis africanum), discovered in the late nineteenth century. It is a bacillus, alcoholics, and acid resistant. It is conveyed by saliva droplets, especially during coughing, its mode of transmission is air, and the first inoculation is an inoculation chancre in paremchyme lung.

This primary infection is either overt or latent.
Primo latent infection: Totally asymptomatic, she rose with a TST in the IDR (Intra Dermo reaction) in a non-vaccinated.
Primary patent infection: There is a weakening of the condition, with weight loss and fatigue, accompanied by a cough and a fever, and chest X-ray shows the inoculation chancre.

TB disease is then said during a lung infection to BK, following the primary infection or exogenous reinfection, or, more commonly, endogenous reactivation of existing organization infected.

Risk Factors:

1. extreme ages of life
2. Immunosuppression, faisaint following a pathology (HIV) or consequence of treatment (chemotherapy, high dose corticosteroids.

Protective factors:
Prior vaccination with BCG below 15 years (80% efficiency found)

Clinic:
The mode of revelation can be brutal, with hemoptysis and pleural effusion. In most cases, installation is done gradually, with a persistent cough, productive, accompanied by a deterioration in general health (asthenia, loss of appetite, restlessness …).

A violation paremchymate use sometimes associated with tuberculous pleurisy, confirmed by the effusion seen in medical imaging. The aspirated fluid is exudative, lymphocytic.

Extra thoracic manifestations (inconstant):
Tuberculous meningitis by achieving serous. Patient listless and feverish, headache. Sometimes acute symptomatology, with severe headache, vomiting and seizures. The diagnosis is made on a drain CSF.

Tuberculous peritonitis, infrequent, with a table whose ascites aspirated fluid, exudative, is a negative bacteriology.

Pericaditis tuberculosis, a rare but life-threatening. Clinically, there are a orthopnea associated with chest pain. The effusion was confirmed by echocardiography. The biopsy is essential to prevent cardiac tamponade, fatal. The aspirated fluid affirms the diagnosis.

The lymph node tuberculosis is not symptomatic, progressive, and painless. It dominates the ganglia head and neck, the diagnosis being made on lymph node biopsy.

Urogenital tuberculosis: it is contagious and can cause infertility.

Multiorgan tuberculosis: it is mainly found in immunocompromised patients, with demonstrations variously localized poor prognosis.

B – Diagnosis:
It is confirmed by a positive TST in a patient not vaccinated and a collection highlighting the germ, and accompanied by a culture of sensitivity. The BK is mainly sought in sputum, gastric aspirate, urine and CSF, but also on sites of lymph node and blood cultures.

Mantoux test:
This is a test showing hypersensitivity tuberculin after an intradermal injection of tuberculin, measuring the diameter of induration at 72 hours post injection. The test was positive at a diameter greater than or equal to 5mm, and very positive if greater than 10mm. In this case, it is an element of presumption in favor of a primary infection or TB disease. HIV-infected patients, the positivity of the reaction is to be compared with the CD4 count, as it gradually loses its sensitivity.

Radiology:
Radiological examination of morphology is extremely variable and widespread form of nodular opacities, producing an aspect of tuberculous cavity. They have a predominance of apical and posterior regions, but also of pleural effusions or aspect of micronodules distributed evenly, producing the appearance of miliary tuberculosis.

Seropositive subjects, the signs are even more unusual that the immunosuppression is important.

Radiography allows for an initial assessment of thoracic lesions, thus realizing a reference document for verification.

C – Treatment:
It is based on antibiotic treatment for TB. Cell division of BK being slow (every 20 hours), the administration will once daily, regular fasting in the morning.

Treatment is based on a quadruple combination for 2 months and then double the 7 months. It is very important to insite to the patient on treatment compliance.

Isoniazid (Rimifon): TB is a major bactericidal, but it is hepatotoxic. It is then necessary to conduct monitoring of liver function. This hepatotoxicity is increased in combination with rifampicin. We also seek symptoms of neurotoxicity.

Rifampin (Rifadin, Rimactane): This is a major bactericidal TB, hepatotoxic, whose decision requires monitoring of blood counts to 8 days and then monthly. Requires a regular and continuous administration.

Streptomycin: bactericidal antibiotic, its use is relatively limited due to its toxicity cochleovestibular.

Pyrazinamide (Pirilene): This is a bactericidal antibiotic association. It requires an assessment prior kidney and liver.

The rifabutin (Ansatipine): It is a bacteriostatic antituberculosis of the same family as rifampicin. It gives an orange color to urine, tears and contact lenses, the patient must be informed. May cause neutropenia, necessitating regular monitoring of blood counts.

D – Prevention:
It involves the protection and vaccination of healthy subjects, isolation and treatment of infected individuals, and chemoprophylaxis of exposed individuals.

Vaccination technique:
It is performed by intradermal injection of 0.1 ml of vaccine, causing a wheal discolored. For injection, use of syringes for intradermal injection 1ml subdivided into hundredths, mounted with short needles (10 mm) and thin (0.45 mm) (28G needles in the Anglo-Saxon nomenclature).

The recommended injection site is the external face of the middle third of the arm. The suites are simple, the papule disappeared within 30 minutes post injection. In terms of side effects, note the possible emergence of a small nodule at the injection site, which may ulcerate, dry er fester, leaving a small scar depigmentation and indelible.

I – Ideal Gas Law
Gases are compressible, and expand at an elevated temperature. This law, called the ideal gas law, relates the pressure P, volume V and temperature T of a gas in the following formula:

PV = nRT where

• n represents the number of molecules per gram of gas,
• R is the gas constant
• T is expressed in absolute temperature (T c 273 °)

Note that under physiological conditions “normal” correspond to 1 atmosphere is 760mmHg at 0 ° c

II – The law of partial pressures, or Dalton’s law
The gas pressure is the representation of the currency turmoil of gas molecules on the walls of its container. Each gas acts independently of others, so that the sum of partial pressures of each gas is the total pressure.

Note P total = P gas 1 gas 2 + P +…+ P gas n
Or more simply: P = ΣP Total partial

III – Act of Henry
Gas will tend to balance the pressure in the gaseous state and pressure as a dissolved in a liquid with which it is connected. This phenomenon allows the expulsion of carbon dioxide dissolved in blood at the end, the latter comprising a pressure wound greater than the ambient air.
The relationship is as follows:

V = (P/760) Qa

Where V is the volume of gas dissolved in ml, P the partial pressure of dissolved gas (mmHg), Q the volume of liquid in which gas is dissolved and the solubility coefficient of gas. (0.023 for oxygen, 0.49 for CO2, standard conditions (1 atmosphere, 37 ° C)).

Genetic Aspect
Cystic fibrosis gene located on chromosome 7, encodes the first membrane protein called CFTR conditioning the quality of ion exchange between the glands and the lumen of the bronchus, but also upper respiratory tract, pancreas, digestive tract, the bile ducts.

Respiratory Events
Especially during the first year of life.
Then shift to attacks (super infection) characterized. Worsening respiratory symptoms with impaired general condition.
The bacterial colonization of the trachea bronchial tree is most often initially with Staphylococcus aureus or Haemophilus influenzae.
Then move to the pyocyaneus (very virulent, almost inaccessible to ATB and defense mechanisms).

Extra Respiratory Events

• Pancreatic disease (90% of cases)
• Intestinal
• Hepatobiliary
• Nutritional disorders:
  • maldigestion of fat
  • increased energy needs related respiratory disability.
• Genital Event:
• delayed puberty
• infertile men (95% of cases)
• decreased fertility in women (but may have children with a risk of having a child with ¼: genetic counseling mandatory).

Diagnosis
Easy when the typical picture combines childhood respiratory symptoms and digestive.
Difficult when the atypical forms are very moderate in their expression (bronchiectasis isolated, isolated intestinal damage, male infertility, diabetes).
At the slightest doubt, make further investigations in a specialized center, including the sweat test: this review is to determine the quantity of chlorine in sweat after collection on filter paper.
The collection is done by forearm trans-cutaneous irradiation with pilocarpine, which causes sweating at this level, or on the back and forehead sweating after saline.
The rate of chlorine in sweat is normally well below 50 mmol / l.
If rate> 60 mmol / l in children: positive
If> 70 mmol / l in adults: positive


The nasal DDB often negative values when they are high.
Standard = – 19 mv
Average CF = – 36 mv

Genetic analysis
search for a known mutation in the CFTR gene in cases of suspected cystic fibrosis (Lab specialized).

Evolution and Prognosis
The survival rate has been greatly improved in recent years: early diagnosis, advances in antibiotic treatment, care of patients in specialized centers

Prognosis Depends

• Metabolic status and respiratory
• Bronchial colonization in relation to Pseudomonas aeruginosa.
• Occurrence of complications (right heart failure, cirrhosis, pneumothorax)

Care and Treatment
Regular practice of respiratory physiotherapy
- Antibiotic therapy adapted to the ECBC (sputum):

• for loss of appetite, weight loss
• increased cough or sputum purulence
• Preventive / aerosol aminoglycosides

- Bronchodilators
- Influenza Vaccination anti systematic
- Transplant when severe hepatic cirrhosis
- Gene therapy = hope (the goal is to transfer the CFTR gene in respiratory epithelial cells patients)

Cons respiratory failure

• ANTAD, CARDIF
• medical supervision (control saturation)
• technical surveillance (check flow meters)

Supports 100% for the ALD

• antipyretic
• broncho-dilators if necessary.

Complications

• Bacterial bronchitis (infection).
• Cough with muco purulent sputum associated with relatively abundant dyspnea.
• Bronchial, snoring, which may be accompanied by signs of respiratory control.
• sometimes vital prognosis.

Signs of severity of bronchitis

• Dimensions major
• Sweating important
• Cyanosis
• Confusion
• Pics hypertensive

(in this case, since resuscitation on respiratory decompensation in response to hypercapnia by hypoventilation.)
Investigations

• Radio Lung etiology.
• NFS VS if needed (hyper leukocytosis).
• ECBC in cases of bronchitis repeatedly resistant to antibiotic treatments.

The most common germs

• Pneumococcal
• Haemophilus

Treatment
Course of antibiotics for 8 days:

• Clamoxyl ® (amoxicillin).
• augmentin ® in case of resistance.
• mucolytic (thinner)
• chest physiotherapy if major congestion, or extreme ages of life.
• broncho-dilators if wheezing or asthma.
• cortisone in chronic bronchitis.
• hydration.

In case of allergy to penicillin, opt for macrolides:
josacine ®
erythromycin ®
Zithromax ® (5 days)
Healing is often positive, but if there is worsening, hospitalize the subject.
infusion therapy
O2
blood gases.

Preventing bronchitis

• Anti-influenza vaccination.
• Anti pneumococcal vaccination on fragile subject, every 5 years.
• Avoid tobacco
• Incentives immunity.

In cases of recurrent bronchitis, verify the absence of home dental sinusitis untreated.

B) Pneumonia
More serious than bronchitis, there are more germs in question.
- Infection of the parenchyma (bronchioles and alveoli related).
- In children under 6 years, speaks often of viral infection.

• RSV (respiratory syncytial virus)
• Haemophilus
• pneumococcal

- For children over 6 years pneumococcus.
- In the young adult pneumococcus, mycoplasma pneumonial.
- In the elderly:

• pneumococcal
• Haemophilus
• enterobacteria
• anaerobic
• Morganella catarrhalis

The clinic differs according to the causal bacteria.

Pneumonia Bacterial Pneumonia
= Acute lobar pneumonia.
- Start often brutal.
- Severe pain on the right side, followed by chills, fever (39/40 °)
- 2 days later, stained sputum, sometimes associated with dyspnea, especially when the pneumonia is extended.
- Crackles.
- Dullness next (associated pleural effusion).
- No pain in the lung itself (pleurisy is painful).

Reviews
- Radio pulmonary shows a home with localized alveolar opacity systematically (following a well segmented area of the lung).
- Air bronchogram: image bronchi intact.
- Pleural reaction
- NFS: show hyper leukocytosis (either very high or very low mean a sign of seriousness).
- CRP: increase
- Blood cultures if the patient is feverish, shivering.
- ECBC if we fear a germ-resistant, or nosocomial infections.

Evolution
Good, on antibiotics for 8 to 10 days with penicillin (amoxicillin ®)
afebrile patients 24 to 48 hours later.
disappearance of symptoms and pain.
radio, the lung re slower ..
If allergic to penicillin, cephalosporin 2nd or 3rd generation (Rocephine ®) or macrolides.
The evolution is usually favorable, but fear the pneumococcal pneumonia among the elderly, alcoholics and those suffering from HIV (when the blood culture is positive).

Pneumonia germs intra cellular (or atypical pneumonia).
- Mycoplasma p.
- Legionella p.
- Chlaemidiae.
The onset is gradual and usually preceded by an attack ENT.
There is a high frequency of respiratory signs associated extra.

• myalgia
• fatigue
• headache
• neurological disorders
• GI symptoms (nausea, diarrhea)
• signs urine (haematuria).
• cough, fever, dry or oily.
• dyspnea more or less important.

Will retain an epidemiological context (legionellosis)
Germs can be highlighted in a bacteriological or you search the antigens of these microbes (urine, blood, sputum), or one looks for antibodies (serology research seroconversion after 2 to 3 weeks).
Radio pulmonary pneumonia often non-systematic (diffuse).

Biology
GB normal, decreasing or increasing.
Often elevated CRP.
Hepatic disturbances.
Anemia
Macrolide treatment (not penicillin) 2 to 3 weeks.

Staphylococcal pneumonia.
Often reaches the age extremes of life, hospital patients who underwent invasive tests (resuscitation, catheters, surgery, …).
Table febrile

• Fever 39/40.
• Cough with bronchial congestion.
• Dyspnea important.
• Bilateral pneumonia, diffuse, incremental (start with a home, then develops into untreated, can cause pleurisy and pyopneumothorax).
• Often, crackling of the 2 sides.
• Poor condition of the patient.

Radio pulmonary alveolar several homes
NFS increasing GB
CRP increased
- Search for isolating bacterial germs that are 2 types, namely, the meticulously s Staph aureus, and Staphylococcus aureus meticulously r:
blood culture
ECBC
Brushing protected.
- Bi therapy immediately for 10 to 15 days.
- If patient catheter or prosthesis: sampling at this level (if causal bacteria, remove dentures or catheters).

Pneumonia gram negative bacilli (Enterobacteriaceae).
Often patients with nosocomial or older, or ethyl, or patients weakened (immunocompromised).
- Altered state generally quite profound.
- Persistent fever.
- Increasing dyspnea.
- Sputum often purulent.
The radio show pulmonary several homes, including bases (fear of inhalation pneumonia)
- Risk of abscess (lung abscess).
- Demonstration of the causative agent: difficult, especially if the germs are anaerobic.

Treatment
2 to 3 antibiotics associated (sensitivity).

C) Lung abscess
Serious complication of a bacterial lung infection that occurs in a necrotic lung obstruction.
- Bronchorrhea often causes a vomica (sputum expectoration important)
- Occurs often in a fragile subject, ethyl, or after surgery.

Three phases
pre suppurative with clinical alarming
cough, fever, purulent sputum

phase vomica, and transient improvement.

phase of chronic suppuration open
oscillating fever, bronchorrhea daily general condition altered.

The radio show necrosis (cavity in the lung with a standard hydro aerique).
NFS increase in GB.

Treatment
Antibiotics for a month.
Anaerobic augmentin è ® ® or flagyl.

Evolution
Often to poor healing.
Possible complications in the form of future malignant or aspergilloma (fungus on the cavity to be the cause of hemoptysis).
You can go to surgery to sterilize a home.

Viral Pneumonia
- Background epidemic.
- Dry cough + fever.
- Myalgia, with ENT.
Clinical and biological poor.
On the radio: image “hilifuge” not systematic.

Evolution
Spontaneously favorable few days, but with:
rest
antipyretic
O2 to extreme ages of life.
In the elderly, the fear of decompensation of diabetes or cardiovascular disease.
Treatment
Antiviral (rare)

Definitions
At apnea: is the cessation of breathing greater than 10 seconds.
In obstructive apnea: is a cessation of breathing by pharyngeal obstruction related to hypotonia of pharyngeal muscles with persistence of respiratory movements.
A central apnea: is the cessation of respiratory drive with stop motion and respiratory flow.
A hypopnea: it decreased ventilation of about 50%.
A syndrome of sleep apnea: it is from 10 apneas + hypopneas per hour of sleep.
A syndrome of severe sleep apnea: is when the apnea-hypopnea index greater than 30%.

Epidemiology
9 Apnea Syndrome Sleep button:
4 3 to 5% of the male population,
4 1 to 2% of the female population.
9 Risk factor: hypertension, stroke, myocardial infarction, car accidents, social gene.

Screening

• Polygraphie respiratory recording of nocturnal SaO 2, respiratory movements, respiratory flow, snoring.
• Polysomnography: respiratory polygraphy + + EEG + EMG electro-occulogramme.

Pathophysiology
Snoring: is the vibration of the posterior wall of pharynx narrowed.
Obstructive:
pharyngeal closure during inspiration in sleep (Promotes alcohol, sedatives, …)
respiratory movements persist when there is a struggle of O 2 desaturation, and bradycardia microréveil, taken with noisy inspiratory tachycardia.

Clinical signs

• Often a man over 45 years, generally obese
• Snoring loud sometimes prolonged apnea,
• restless sleep, wake-up call Apnea
• Asthenia morning, daytime sleepiness (watching TV, driving, reading a newspaper, …), morning headaches, impaired concentration, impotence, urinary frequency at night.
• Anomaly anatomical reduction of the soft palate, large uvula, chin back, enlarged tongue, tonsils, deviated nasal septum.

Balance Sheet
nocturnal SaO 2: desaturation “comb”
Polysomnography:
apnea, SaO 2 mean, minimum desaturation snoring, sleep stage IV + REM sleep, microreveils,
superficial sleep, stage I and II, little sleep III and IV and some REM sleep.
Polygraph,
Cephalometry
pulmonary function tests + blood gases: Research pulmonary chronic obstructive associated hypercapnia.

Treatment
A Medical: diet, no alcohol at night, not sleeping pills, light dinner.
A Mechanics:
Pressure continues positive night life, keeps the airways open.
effective pressure from 6 to 14 cm H 2 O
pressure fixed or variable, humidifier.
Education equipment (nasal breathing, prevent leaks, although the address mask, protection of the nasal bridge)
dramatic effect with disappearance of drowsiness,
side effects or unwanted noise, rhinitis, conjunctivitis, …
A Surgical:
uvulo-palato-pharyngoplastie,
tonsillectomy,
vegetation
advancement of the mandible.
A oral prosthesis,
Sometimes adding O 2 on the mask.

B-vascularization:
There are two blood circulation in the lungs: the first is provided by the bronchial vessels (arteries and veins, bronchial) and provide the organ of oxygen and substances necessary for its operation. The second, consisting of veins and pulmonary arteries serves the function of gas exchange.

C-The pleura
The pleura consists of two sheets, one attached to the lungs, the visceral and the other adjacent to the chest wall, the parietal. The pleural space is imbued with a thin layer of liquid, which by capillary action, holds the two layers joined together, and provides a sliding sheets against one another without friction excessive. The pleural cavity is a “virtual”, but becomes really in certain pathologies, such as pneumothorax (presence of air between the two layers, causing their uncoupling and retraction lung), hemothorax (even principle), pleurisy.
The pleura can grow the lung during the expansion of the chest, thus causing a depression which results in the incoming air into the lungs is inspiration. This mechanism of variation of pressure in the socket which allows gas exchange.

D-The respiratory muscles
To achieve the inspiration, the respiratory muscles must oppose the elastic resistance of lungs, tending naturally to retract on itself and the friction of two layers of the pleura. For this, several muscles are involved: the diaphragm, scalene and intercostal and, to a lesser extent, sternocleidomastoid mastoid:

• Like all fluids, air flows from areas of high pressure to low pressure areas. The respiratory muscles act together on the coast. They have a special, double obliquity (hat down and forward reverse).
• The diaphragm, large muscle dome separates the abdominal cavity of the chest cavity, innervated by the phrenic nerves (C 3 C 4 C 5). The contraction causes a decrease in its curvature, up to 10cm.
• The external intercostal muscles, they are innervated by the intercostal nerves, from D1 to D12.
• The scalene, sternocleidomastoid mastoid, trapezius and paravertebral them, can be contracted at a rate significant ventilatory.

The expiration, it is naturally passive part of the natural elasticity of the lungs. Forced expiration will involve the abdominal muscles (by raising the diaphragm), the external intercostal.

II-Physiology:

A – Volumes usual
There are several types of respiratory volumes, highly dependent on age, size and sex of the subject:
The tidal volume, VC, firstly, is the volume inhaled normally and naturally in a quiet breathing at rest.
The inspiratory reserve volume, IRV is the volume available during a forced inspiration, as well as the expiratory reserve volume, ERV, obviously is the volume expired during a forced expiration. It thus determines the vital capacity (VC) of an individual as the sum of its current volume, added an inspiration and forced expiration: one obtains the formula
CV = VRI + VC + ERV
At the end of forced expiration, there remains an air volume expellable by the individual, this is called the residual volume RV determining the functional residual capacity RV + ERV.

B – Control of breathing
To adapt to changing circumstances, whether they be internal during physical exertion, for example, or external, when changes in the composition or pressure of the atmosphere, ventilation suits by situations, witnessed a complex neural activity can interpret all necessary information.

a – the nerve centers:
The nerve centers located in the hemispheres (the central nervous system) are responsible for modifications volunteers in activities developed, but are absolutely not sensitive to changes in blood composition and different metabolic requirements. It has also been demonstrated by sections of the central nervous system, the basic ventilation system was not affected as the pons and the medulla remained intact.

In 1890, L. FREDERICQ was the first to demonstrate that the nervous breathing are directly sensitive to the composition of the blood passing through them: He has therefore made the experience of traffic cephalic cross two dogs.
In this experiment, represented by the diagram above, Fredericq irrigated head of the first dog with the blood of the second body, and vice versa. He then strangled the first dog breath closed, and found that it is the second dog hyperventilates increasing, while the former will leave quietly suffocate the body.
This experience has highlighted the sensitivity of nerve centers respiratory blood composition, while the rest of the body did not respond and left stifle.
We now know that this is the content of O 2 / CO 2 and pH of blood stimulant activity of respiratory centers, through chemo and baroreceptors (usually located on the junction of the butt aorta).
Similarly, a significant decrease in the partial pressure of O 2 (Pa O2), determine an increase in breathing rate. Here, the pH and Pa CO2 did not change, the decrease in Pa O2 is the only stimulus.

Reflexes modifying the respiratory rate:
In addition to the cerebral hemispheres, which voluntarily alter this rate, there are different reactions that can alter significantly the respiratory rate.
The cough reflex: There are many nerve endings located on the epithelial cells of mucous larynx, the bronchi, which are stimulated by inhalants, dust, gases, irritants, foreign bodies … Their stimulation triggers the cough reflex by laryngeal and bronchial constriction.
Similarly, stimulation of myelinated fibers in the epithelium of the bronchi and bronchioles results in hyperventilation, bronchoconstriction, and a contraction of the larynx.
The propriorecepteurs placed at the limb muscles causes an increase of respiration during stimulation, to increase the intake of oxygen before the changes of partial pressures of O2 CO2 does it charge.
Baroreceptor blood pressure causes hypo ventilation in cases of hypertension and conversely.
Other stimuli:

• Stimulus hormones: adrenaline in large quantities shows hyperventilation. It would act by stimulating chemoreceptors arterial
• Stimulus temperature: a temperature increase from 37 to 39 degrees Triple naturally ventilation, hypocapnia resulting mask by reducing it by half. This stimulus is seen, but its mechanism is still unknown.

C – Physiology of pulmonary respiration
In adult humans, there are about 23 divisions between the trachea and air sacs. The first 16 have a role in conduction and there goes on no gas exchange. The 3 following these few cells, but especially beyond the 20th Division that will form the respiratory bronchioles. The exchange surface of cells is particularly extensive, there were 3 500 000 000 cells for an area of 80-90 m 2.
The cell wall has a striated by the blood capillaries in contact. This wall is very thin, about 0.3 mu.m and contains pores allowing gas flow between them. There are also elastic fibers, giving the lung’s skeleton, phagocytic cells and epithelial cells secrete surfactant. There are two blood systems, the pulmonary and bronchial system, one for oxygenation and the other in the vasculature.
The gas exchange there are so passive, pressure gradient, according to the law of Henry. At inspiration, the pressure O 2 atmosphere is higher than that of blood, it causes its dissolution, while at the end is the partial pressure of blood CO 2 which is lower than atmospheric.
The airways provide a variety of roles, in addition to the conduction of gas: The adjusting temperature and humidity of inspired air that reaches those of the body at cellular as well as purification and filtration the latter, thanks to hair cells, mucus and cough.