steve tilley cough 7 10-2012
TRANSCRIPT
Cough 101
Recommended Reading
•The Diagnosis and Treatment of Cough Richard S. Irwin and J. Mark Madison NEJM Volume 343, Number 23 Pages 1715-1721. December 2000
•Diagnosis and Management of Cough Executive Summary. ACCP Evidence-Based Clinical Practice Guidelines Chest Volume 129 Supplement 2006
Recommended Reading
•Prevalence, pathogenesis, and causes of chronic coughKian F. Chung and Ian D. PavordLancet 371(9621):Pages 1364-74 April 2008
•Management of chronic coughIan D. Pavord and Kian F. ChungLancet 371(9621):Pages 1375-84 April 2008
Recommended Reading
•Concise Clinical Review: Controversies in the Evaluation and Management of Chronic CoughSurinder S. BirringAm J Resir Crit Care Med 183(6)Pages 708-715 March 2011
Cough 101
• Acute cough– Lasting less than 3 weeks
• Sub-acute– Lasting 3-8 weeks
• Chronic cough– Lasting 8 weeks or more
Cough is the most common reason patients seek medical attention in the United States
Acute Cough
• Duration less than 3 weeks• Most commonly due to:
1. Upper respiratory tract infection2. Lower respiratory tract infection3. Pulmonary embolism
Acute Cough
• Duration less than 3 weeks• Most commonly due to:
1. Upper respiratory tract infection2. Lower respiratory tract infection3. Pulmonary embolism
Acute cough algorithm for the management of patients ≥ 15 years of age with cough lasting
< 3 weeks
Irwin R S et al. Chest 2006;129:1S-23S
©2006 by American College of Chest Physicians
Cough and Pulmonary Embolism
• Which of the following statements are true about cough and acute PE
a) Cough associated with PE is usually productive
b) Cough is present in 50% of patients with PE
c) Cough is the predominant symptom in some patients with PE
d) The severity of cough predicts the extent of thromoboembolism in patients with PE
Cough and Pulmonary Embolism
• Which of the following statements are true about cough and acute PE
a) Cough associated with PE is usually productive
b) Cough is present in 50% of patients with PE
c) Cough is the predominant symptom in some patients with PE
d) The severity of cough predicts the extent of thromoboembolism in patients with PE
Life-threatening causes of acute cough
High index of suspicion in the elderly because classic signs/symptoms may be absent
Pulmonary embolism Heart Failure Pneumonia
Subacute cough algorithm for the management of patients ≥ 15 years of age with cough
lasting 3 to 8 weeks
Irwin R S et al. Chest 2006;129:1S-23S
©2006 by American College of Chest Physicians
Subacute cough algorithm for the management of patients ≥ 15 years of age with cough
lasting 3 to 8 weeks
Irwin R S et al. Chest 2006;129:1S-23S
©2006 by American College of Chest Physicians
Post-infectious cough
• Cough more than 3 weeks following an upper or lower respiratory tract infection
• Usually resolves in 4 weeks
• Anti-tussive medications and steroids can help with symptoms
Chronic Cough• Chronic cough of undetermined etiology
accounts for 10-40% of a pulmonologist’s outpatient practice
How good can we be at making a diagnosis?
• Studies show that the etiology of chronic cough can be determined by a well-trained pulmonologist…..
a) Less than 50% of the time
b) 60-70% of the time
c) 70-80% of the time
d) 80-90% of the time
e) 90-100% of the time
How good can we be at making a diagnosis?
• Studies show that the etiology of chronic cough can be determined by a well-trained pulmonologist…..
a) Less than 50% of the time
b) 60-70% of the time
c) 70-80% of the time
d) 80-90% of the time
e) 90-100% of the time
How good can we be at making a diagnosis?
• Studies show that the etiology of chronic cough can be determined by a well-trained pulmonologist…..
a) Less than 50% of the time
b) 60-70% of the time
c) 70-80% of the time
d) 80-90% of the time
e) 90-100% of the time
Can you cure your patient?
• Studies show that treatment success rates for chronic cough can be as high as…..
a) Less than 50%
b) 50-60%
c) 60-70%
d) 70-85%
e) 85-100%
Can you cure your patient?
• Studies show that treatment success rates for chronic cough can be as high as…..
a) Less than 50%
b) 50-60%
c) 60-70%
d) 70-85%
e) 85-100%
Chronic Cough- Etiology• In non-smoking adults with a normal
CXR who are not taking ACE inhibitors, chronic cough is almost always due to which of the following 3 conditions?
a) Congestive Heart Failureb) Upper Airway Cough Syndrome (UACS)c) Asthmad) Gastroesophageal reflux disease (GERD)e) Chronic Bronchitis
Chronic Cough- Etiology• In non-smoking adults with a normal
CXR who are not taking ACE inhibitors, chronic cough is almost always due to which of the following 3 conditions?
a) Congestive Heart Failureb) Upper Airway Cough Syndrome (UACS)c) Asthmad) Gastroesophageal reflux disease (GERD)e) Chronic Bronchitis
Etiology of Chronic Cough
= UACS + NAEB ?
Chronic Cough sometimes has more than one cause
1 = single cause of cough
2 = 2 causes of cough
3 = 3 causes of cough
Causes of Cough in Children and Adults
= UACS
Guideline for Evaluating Chronic Cough
• A systematic, diagnostic approach has been validated in immunocompetent patients- 5 step plan:
– Step 1: Review history and exam focusing on the most common causes of chronic cough
– Step 2: Order a CXR in nearly all patients
(except perhaps young non-smokers with presumed UACS)
Guideline for Evaluating Chronic Cough
– Step 3: Do not order additional tests in present smokers or patients taking ACE inhibitors until the response to smoking cessation or drug discontinuation for at least 4 weeks can be assessed. Cough due to smoking or ACE inhibitors should improve substantially or disappear during this time-frame of abstinence.
– Step 4: Order additional diagnostic tests or embark on empiric treatment
Tests for evaluating Chronic Cough
Guideline for Evaluating Chronic Cough
– Step 5: Determine the cause(s) of cough by observing which specific therapy eliminates cough as a complaint.• If the evaluation suggests more than one
possible cause, initiate treatment in the same sequence that the abnormalities were discovered
• Since cough can be simultaneously caused by more than one condition, do NOT stop therapy that appears to be partially successful; rather, sequentially add to it.
Guideline for Evaluating Chronic Cough
Step 1 Step 2 Step 3
Step 4 Step 5
Upper Airway Cough Syndrome
Upper Airway Cough Syndrome
• Common cause of chronic cough in all age groups– Second most common cause in children– Most common cause in adults and the elderly
• In addition to cough, UACS can also cause– Wheeze– Dyspnea
Upper Airway Cough Syndrome
• Clues to UACS– History of
• Need to frequently clear their throat• Friend/relative notices that the patient frequently
clears their throat• Sensation of dripping into throat• Nasal symptoms
– Physical Exam demonstrating• Secretions in nose or oropharynx• Cobblestone appearance of mucosa
Causes of Upper Airway Cough Syndrome
UACS
• Diagnosis of UACS as a cause of cough is established when:
a) frequent throat clearing is elicited from the history
b) cobblestoning and phlegm are present on physical examination of the posterior pharyxnx
c) cough responds favorably to specific therapy aimed at eliminating the drip
UACS• Diagnosis of UACS as a cause of cough
is established when:a) frequent throat clearing is elicited from
the historyb) cobblestoning and phlegm are present
on physical examination of the posterior pharyxnx
c) cough responds favorably to specific therapy aimed at eliminating the drip
UACS-Sinusitis
Treatment-Sinusitis
• Antibiotics directed against H. Flu, S. Pneumonia, oral anaerobes
• Oral antihistamine/decongestant x 3 weeks• Intranasal decongestant for maximum of 5
days– e.g. oxymetazoline 2 sprays each nostril bid
x 3 days only
Treatment- Allergic Rhinitis
• Allergen avoidance
• Intranasal steroid
• Antihistamine
• Antihistamine/decongestant
• Allergen immunotherapy
Nasal Steroids
Antihistamines
Treatment- other UACS
• Perennial non-allergic, post-infectious, environmental irritant, vasomotor rhinitis
– Antihistamine/decongestant– Intranasal steroids– Intranasal ipratropium bromide for vasomotor rhinitis– Non-histamine mediated rhinitidies do not respond
as well to newer generation H1-antagonists; try older ones with anti-cholinergic activity
Asthma• Second most common cause of cough in
adults
• Clues that chronic cough is due to asthma:– Episodic wheezing, dyspnea– Reversible airflow obstruction– Bronchial hyperresponsiveness
• Confirmed by resolution of cough with asthma treatment
Cough Variant Asthma• 30-60% of patients presenting with
chronic cough that was due to asthma had cough as their ONLY symptom
Non-asthmatic Eosinophilic Bronchitis (NAEB)
•Normal CXR
•Normal spirometry
•Normal methacholine challenge
•Sputum eosinophilia
•Treatment- inhaled corticosteroids
Treatment- Asthma
• Inhaled corticosteroid
• ICS/LABA combination
• Oral steroids for empiric trial of efficacy is not recommended since oral steroids may improve cough resulting from any inflammatory disease
GERD• Suspect GERD when…
– Symptoms of heartburn or sour taste in mouth
– Reflux demonstrated by• 24-hour pH-impedance monitoring • Barium x-ray
• Cough is the only symptom of GERD in 40-75% of patients with chronic cough due to GERD
GERD
• Cough due to GERD occurs most commonly while patients are awake and upright, and usually does not occur or is not noted during the night
• Diagnosis of GERD as cause of chronic cough requires resolution of cough with GERD treatment
Treatment- GERD• Intensive anti-reflux medical regimen:
– Diet is most important factor• High protein, low fat anti-reflux diet• 3 meals per day• Avoid food, drinks, and meds that lower esophageal
sphincter pressure• NPO between meals and 2 hours prior to reclining• Improve compliance by referring to dietician and
monitoring weight at follow-up visit
– Elevate head of bed 4 inches– Proton pump inhibitors
Notable points:• Successful treatment for GERD takes on average 161-179
days, vs. 67-70 days for cough due to PNDS or asthma
Treatment- GERD
– Successful treatment for GERD takes on average 161-179 days, vs. 67-70 days for cough due to UACS or asthma
– Continue treatment for at least 3 months after cough has disappeared as a complaint, then gradually discontinue it
– If medical therapy fails• Consider OSA• Consider offending med
(CCB, nitrate, progesterone, theo)• Consider surgery
Algorithm for the management of patients ≥ 15 years of age with cough lasting > 8 weeks
Irwin R S et al. Chest 2006;129:1S-23S©2006 by American College of Chest Physicians
ACE inhibitor cough• Accounts for 2% of cases of chronic cough• Non-productive, irritating, tickling, scratching
sensation in the throat• Can occur after 1st dose, or weeks to months
later• Usually will recur with switch to any other ACE
inhibitor• Diagnosis is confirmed when cough
disappears after drug in discontinued
Bronchogenic Carcinoma
Bronchogenic Carcinoma
• Cough is a common symptom of lung cancer, but lung cancer is NOT a common cause of chronic cough
• Suspicion for cancer as a cause of cough should be heightened
– If CXR shows a central lesion– In cigarette smokers who develop a new
cough that persists or have a change in character of their chronic cough
Cough 102
Unexplained Chronic Cough
• Middle aged females around the onset of menopause
• Onset triggered by a viral illness, Bordetella pertussis, basidiomycetous fungi
• Concomitant anxiety and depression (due to the chronic, persistent cough)
• *psychogenic cough is extremely rare
Pathogenesis of Unexplained Chronic Cough
• Cough reflex hypersensitivity– Increased sensitivity to cough challenge with
capsaicin– Increased density of sensory nerve fibers in
the airways– Increased TRPV-1 receptor expression on
sensory c-fibers
Cough reflex hypersensitivity
Increased density of sensory nerve fibers in the airways
Increased TRPV-1 receptor expression on sensory c-fibers
Cough hypersensitivity syndrome
• Chronic cough > 2 months duration
• Minimal or no sputum production
• One or more cough reflex triggers (cold air, speech, eating, odors such as perfumes)
• Urge to cough (tickle or itch) located in throat
• Adverse impact of cough on QOL
• Positive cough reflex challenge test (e.g. capsaicin)
Non-specific Anti-tussives
– Codeine 30-60 mg
– Dextromethorphan 60 mg
– Diphenhydramine 25-50 mg
– Benzonatate (Tessalon pearls)• 100-200 mg tid prn, maximum 600 mg/d
– Down-regulate neural activity– amitriptyline
– gabapentin
Cough hypersensitivity syndrome
New concepts in the management of chronic cough
• Obstructive sleep apnea
• Tonsillar enlargement
• Autoimmune disease (hypothyroidism)
• Basidomycetous fungi