Transcript
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Cough
Lakshmi Durairaj, MD
Division of Pulmonary, Critical Careand Occupational Medicine
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Cough
54 yo woman with cough X 3 months Cough is intermittent but awakens her at night and
cause urinary incontinence
Mostly dry cough
PMH: HTN, DMII, Hyperlipidemia
Meds: Lisinopril, glyburide, atorvastatin
Soc: Non-smoker, homemaker
ROS: Occasional heartburn, occasional wheeze Exam: Normal nasal mucosa, clear lungs
Test: Chest X-ray is normal
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Questions
Common causes of cough?
Diagnosis plan?
Effective treatments?
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Neural Pathway for Cough
Voluntary and involuntarycontrol
Location of coughreceptors?
Airway, lung parenchyma Tympanic membrane
Esophagus
Pericardium
Chung and Pavord: Lancet 2008
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How do we cough?
3 Phases of cough
Inspiration
Force of cough dependent on inspired volume
Forced expiration against closed glottis
Opening of glottis with rapid expiration
Requires intact:
Diaphragm, glottis and inspiratory/expiratory
muscles
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Differential of cough
Acute < 3 weeks
Common cold, allergic rhinitis, acute bacterialsinusitis, pertussis
Pneumonia, PE, COPD exacerbation, CHF Sub-acute 3 8 weeks
Post infectious, pertussis, bacterial sinusitis,asthma
Chronic > 8 weeks
UACS, asthma, GERD, ACEI, bronchitis
Irwin, Diagnosis and Treatment of Cough, NEJM 2000
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Acute cough
Upper resp tract infection (URI)
Most common cause (usually viral)
Tx: Sedating, 1st gen antihistamine
(brompheniramine + pseudoephedrine)
Allergic rhinitis
Tx:
Avoid allergen(s)
Non-sedating antihistamines loratadine,
fexofenadine, cetirizine
Irwin, Diagnosis and Treatment of Cough, NEJM 2000
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Pratter, M. R. et al. Chest 2006;129:222S-231S
The acute cough algorithm for the management of patients aged >= 15 years
Pratter MR. Chest 2006
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Acute cough
Pneumonia 3rd most common cause
In the absence of
Abnormal vitals (P > 100, RR > 24, T > 38 C)
Chest examination (crackles, egophony, fremitus) No further testing is needed
Pulmonary embolism - Not common
Risk factors: immobilization, surgery, malignancy
Physical findings: tachycardia, hypoxia, pleural rub
Chest CT or perfusion scan
Anticoagulation
Irwin, Diagnosis and Treatment of Cough, NEJM 2000
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Subacute cough
Post infectious cough (3-8 weeks)
Begins with URI and resolves spontaneously
Ask about associated symptoms
Post-nasal drainage, reflux, wheeze
Treatment
Mild impairment - inhaled ipratropium
Moderate impairment - inhaled corticosteroids
Severe impairment short course oral corticosteroids
If nothing else works - dextromethorphan or codeine
ACCP Diagnosis and Management of Cough 2006
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Chronic cough
Common causes - 95% of chronic cough
UACS (34%), asthma (28%), GERD (18%),
chronic bronchitis or ACE inhibitor use
Less common
Lung cancer, sarcoidosis, Tb, broncholith
More than one cause often present
18-93% more than one condition present
ACCP Diagnosis and Management of Cough 2006
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Upper airway cough syndrome
Previously called post-nasal drip Drainage of secretions from nose or sinuses into
pharynx
Up to 20% of patients unaware of drainage
Hx: tickle in throat, hoarseness, clearing
Exam: Nasal drainage, cobblestone pharynx
DDx: allergic, non-allergic, post-infections,
vasomotor, sinusitis Tx: sedating antihistamine and pseudoephedrine
If no response consider sinus imaging
ACCP Diagnosis and Management of Cough 2006
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Cough-variant Asthma
Cough with triggers, seasonalallergies
Exam: occasional wheezing
Dx:
Spirometry: Obstructive pattern
Fev1
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Gastroesophageal reflux
Hx: heartburn, regurgitation, dysphagia,hoarseness Silent = no GI symptoms up to 75%
Non-smoker, no asthma, no ACEI
Path: Aspiration into larynx
Direct stimulation of esophageal cough receptor
Phx: Nothing specific on physical exam
Laryngoscopy - red arytenoids, mucosal edema
ACCP Diagnosis and Management of Cough 2006
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Reflux disease
Dx:
Trial of treatment (see Tx below)
Not helpful: pH probe, manometry,
esophogram
Tx:
Anti-reflux treatment even if symptom free
Elevate head of bed 4-6 inches
Dietary avoidance: coffee, chocolate, high fat foods
H2 blockers or proton pump inhibitors
ACCP Diagnosis and Management of Cough 2006
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Angiotensin converting enzyme
inhibitor induced cough Incidence
5-35% of patients on ACEI cough
0-3% chronic cough are on ACEI
Class effect and not dose dependent
Hx: Dry, hacking, paroxysmal cough
Occurs hours to months after 1st dose
Tx:
Removal of medication: 4 weeks typical but up to 3months for resolution
May re-challenge if compelling reason for ACEI
Consider angiotensin receptor blocker as alternative
ACCP Diagnosis and Management of Cough 2006
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Chronic bronchitis
Productive sputum > 3 months / 2 years
Hx: active/passive current/previous smoking
occupation Tx:
Avoidance of exposure
90-94% of cough resolves after cessation
Resolves in 4 weeks 54% of the time Consider
2 agonist for dyspnea
Ipratropium for mucous production
ACCP Diagnosis and Management of Cough 2006
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Duration of cough
Acute (< 3 weeks)
Life-threatening
PE, CHF,
Pneumonia,
COPDE
Non-life-threatening
URTI
Sub-Acute (3-8 weeks)
Post infectious
Pneumonia, bronchitis
Non-post infectious
Same work up as
chronic cough
Chronic (> 8 weeks)
See next slide
URTI = upper respiratory tract infection
COPDE = COPD exacerbation
ACCP Diagnosis and Management of Cough 2006
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Chronic Cough
History,
examination,Chest X-ray
A cause is
suggested
Investigate
and treat
1. Upper Airway Cough Syndrome (UACS)
Empiric treatment
2. Asthma
(spirometry, bronchodilator reversibility
or bronchoprovocation challenge) or
Empiric treatment
3. Gastroesophageal Reflux Disease (GERD)
Empiric treatment
Discontinue
Smoking
ACE-I
Inadequate
Response
No
Response
ACCP Diagnosis and Management of Cough 2006
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questions?
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Cough case #1
35 yo male presents with 5 weeks of cough Cough is dry and worse at night and when on the
phone
No nasal drainage, dyspnea or wheezing
He had the flu about 2 months ago for 1 week
Meds: None
Social: Works as telephone operator, no
smoking Physical: Normal, no nasal drainage, nowheezing
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Cough case #1
What is the most likely cause of cough
Based on time frame (3-8 weeks) and antecedent
URTI post infectious cough most likely
What are the treatment options? Mild impairment inhaled albuterol
Moderate impairment inhaled corticosteroids
Severe impairment short course oral corticosteroids
If nothing else works dextromethorphan or codeine
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Cough case #2
56 yo female with cough for the last 3 years Paroxysms of cough lasting up to 2 min
Productive, clear sputum, most days of the month
No nasal drainage, no heartburn
Meds: Albuterol BID, escitalopram daily Soc: Smokes 1-1.5 ppd for 30 years
Physical: Normal: no nasal drainage, normallung auscultation
PFTs: FEV1/FVC 0.56, FEV1 65%, nobronchodilator change
CXR: Normal, without infiltrates or hyperinflation
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Cough case #2
What is the most likely cause of hercough?
COPD with chronic bronchitis
What is the next step intreatment/diagnosis?
Smoking cessation
Follow up after at least 4 weeks of abstinencefrom smoking
Consider ipratropium for cough
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Cough case #3
54 yo female with 1.5 years of cough Cough is intermittent but paroxysmal
Will awaken her at night
Urinary incontinence
Often dry cough but occasionally productive PMH: HTN, DMII, Hyperlipidemia
Meds: Lisinopril, glyburide, atorvastatin
Soc: Non-smoker, homemaker
ROS: Occasional heartburn, occasional wheeze Physical: Normal nasal mucosa, clear lungs
Test: Chest X-ray is normal
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Cough case #3
What is the most likely cause of cough in
this patient?
Multifactorial ACEI, UACS, Asthma, GERD
What is the next best single intervention?
Stop the ACEI for at least 4-8 weeks and
advise nonpharmacologic measures of GERD
prevention
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Case #3 continued
Returns in 8 weeks
Less paroxysms of cough but still having nocturnal
symptoms and incontinence
She reports an increase nasal drainage She denies any seasonal allergies
What do you suspect and recommend now?
UACS
1st generation antihistamine and decongestant (A/D)
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Case #3 continued
She calls in 3 weeks to say that she is
sleeping better (day and night) but the
cough is only slightly better
What do you suspect and do next?
Counsel about reflux reduction and prescribe
a PPI
After 8 weeks she is without cough;Hooray!
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When to ask for help
Concerning red flag symptoms
Weight loss
Hemoptysis
Night sweats Difficult symptom control
Uncertain etiology
Who do you ask for help from? Pulmonary
Otolaryngology
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Conclusion
Cough is very common presentingsymptom
Causes are different depending onduration
Chronic cough in nonsmokers is mostlikely due to UACS, asthma, GERD,chronic bronchitis or ACEI
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Further Reading
Chung KF, Pavord, ID: Prevalence,pathogenesis and causes of chroniccough. Lancet 2008; 371: 1364-1374
Irwin, Diagnosis and Treatment of Cough,NEJM 2000; 343:23:1715-1721
ACCP Evidence-Based Clinical Practice
Guidelines. Chest 2006;129:222S-231S Executive Summary and Empiric IntegrativeApproach of the Management of Cough.
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