Essential work-up of chronic cough...COPD/bronchitis Bronchiectasis Eosinophilic bronchitis Pertussis, TB Lungcancer Pulmfibrosis Rhinologic Chronic sinusitis Allergic rhinitis/PND
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UCSF Voice and Swallowing CenterUniversity of California, San Francisco
vyvy.young@ucsf.edu
Essential work-up of chronic coughVyVy N. Young, MDAssociate Professor, Dept of Otolaryngology –Head and Neck Surgery
UCSF Voice and Swallowing Center
Disclosure
None personally
Spouse: - Olympus America Inc. (consultant) - Instrumentarium (royalties/holder of intellectual property rights)- Freundenberg (consultant) - Reflux Gourmet LLC (stock shareholder)
UCSF Voice and Swallowing Center
Objective
Review essential workup of chronic coughNOT treatment of chronic cough
UCSF Voice and Swallowing Center
Chronic CoughOne of the most common reasons that patients seek ambulatory medical treatment1
Prevalence: 9-33% worldwideAnnual US spendings on cough: $3.6B2
1Irwin RS, et al. Chest. 1998 Aug;114(2 Suppl):133S-181S2Altman KW, Irwin RS. Otolaryngol Head Neck Surg. 2011 Mar;144(3):348-52
UCSF Voice and Swallowing Center
Chronic Cough
Duration = 8 weeks- 3-8 weeks may be still
infectious/inflammatory PertussisAtypical PNA Viral Bronchitis
Spectrum of laryngeal hyperfunction/hypersensitivity- Throat clearing- Chronic cough- Cough paroxysms with post-
tussive emesis.
UCSF Voice and Swallowing Center
Reflux
Asthma
Allergies
“Roundabout” illness
UCSF Voice and Swallowing Center
Etiology of Chronic Cough
Irwin RS. Chest, 2006; 129:80S-94SIrwin RS et al. Chest 1998; 114(suppl 2):133S-181S
Pulmonary Cough variant asthmaCOPD/bronchitisBronchiectasisEosinophilic bronchitisPertussis, TBLung cancerPulm fibrosis
RhinologicChronic sinusitisAllergic rhinitis/PND
EsophagealGERD/LPREsophageal abn/dysphagia
Systemic/environmentalMeds: ACE inhibitors, ARBs, AdvairSmokingCF, sarcoidosis, GPADehydration
Laryngeal/neurologicNeurogenic cough“Hypersensitivity” syndromesGlottic insufficiencyLesionParadoxical vocal fold motionPost viral vagal neuropathy
Habitual
UCSF Voice and Swallowing Center
Etiology of Chronic Cough
Irwin RS. Chest, 2006; 129:80S-94SIrwin RS et al. Chest 1998; 114(suppl 2):133S-181S
Pulmonary Asthma (cough variant) COPD/bronchitisBronchiectasisEosinophilic bronchitisPertussis, TBLung cancerPulm fibrosis
Rhinologic/AllergicChronic sinusitisAllergic rhinitis/PND
EsophagealGERD/LPREsophageal abn/dysphagia
Systemic/environmentalMeds: ACE inhibitors, ARBs, AdvairSmokingCF, sarcoidosis, GPADehydration
Laryngeal/neurologicNeurogenic cough“Hypersensitivity” syndromesGlottic insufficiencyLesionParadoxical vocal fold motionPost viral vagal neuropathy
Habitual
UCSF Voice and Swallowing Center
Rational approach to evaluation/treatment
Many algorithms proposedUse one that makes sense to you
LPR
Asthma Sinusitis
Allergic rhinitis
Post URI
UCSF Voice and Swallowing Center
Algorithm for chronic cough – option 1
Courtesy of Dr. JP Giliberto(UWash) and
Dr. Lyndsay Madden (Wake Forest)
UCSF Voice and Swallowing Center
Algorithm for chronic cough – option 2
Courtesy of Dr. Tom Carroll (Brigham&Women’s
UCSF Voice and Swallowing Center
Algorithm for chronic cough – option 3
Altman KW et al. Otolaryngol Head Neck Surg. 2011;144(3):348-52
UCSF Voice and Swallowing Center
Algorithm for chronic cough – option 4
Gibson P, et al. Chest. 2016;149(1):27-44
UCSF Voice and Swallowing Center
Algorithm for chronic cough – option 5
UCSF Voice and Swallowing Center
What’s your first step(s)?
So many options… Make sure common problems have been addressed first
UCSF Voice and Swallowing Center
Essential work-upFirst visit
D/C ACE-inhibitorsD/C laryngeal irritants- Tobacco, caffeine, EtOHHydration
Order CXR if not done previously
Laryngoscopy (+/- stroboscopy)
- Look for glottic insufficiency- Look for paradoxical VF motionSpeech language pathologist (SLP) - Cough suppression/
management therapy- Vocal hygiene
UCSF Voice and Swallowing Center
If you’re really lucky…You will see something cool AND it may be the cause of the cough
Glottic insufficiency- Vocal fold atrophy- Vocal fold hypomobility
Paradoxical VF motion
Thickened mucus
Or something else… Video courtesy of Dr. JP Giliberto
UCSF Voice and Swallowing Center
Essential work-upFirst visit
If allergy/sinus symptoms: - Maximal medical tx x 4 weeks- Saline rinse, nasal steroids,
antihistamines, possible abx
Consider empiric acid suppression- At least 12 weeks- PPI 40mg daily, H2RB qhs,
alginate after meals & qhs
Then reassess 3 mos later- Cough gone:
Wean treatments
- Cough persists: Move on to other possibilities
UCSF Voice and Swallowing Center
Next stepsDepends on associated symptoms and your suspicion for underlying etiology
Potential additional workup:
Pulm referral- PFTs, chest CT, bronchoscopy, eval for Pertussis?Allergy testingSinus CT without contrastReflux testing- pH/impedance, manometry- TNE/EGD- Eval for anti-reflux surgery
UCSF Voice and Swallowing Center
Next steps
“Neurogenic cough” can be hard to diagnosis – treatment may be diagnostic and therapeutic
Superior laryngeal nerve blockNeuromodulators- Neurontin, pregabalin, TCA’s- Tramadol, baclofen
UCSF Voice and Swallowing Center
The Cough Wheel
From Ch 9 Chronic Cough, Plural Publishing 2019, TL Carroll Ed
Where to start?
How long to try?
One at a time? All at once?
UCSF Voice and Swallowing Center
Summary: essential workup of chronic coughHow to know which way to go?
Don’t forget the obvious- ACE inhibitors- Hydration- CXR- TobaccoHave a logical approach- Checklist- AlgorithmBe guided by pt’s symptomsBe willing to think outside the box
UCSF Voice and Swallowing Center
Patient SLP RTENT GISurg
Neuro GIAllergy Gen SurgPulm
Multi-disciplinary team = IDEAL Working as a team
to take care of our patients!
UCSF Voice and Swallowing Center
Questions?vyvy.young@ucsf.edu
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