COUGH! QUESTIONS Worst complication of cough T or F: can usually find 1 etiology T or F: GERD almost always symptomatic(heartburn) BONUS.

COUGH!

QUESTIONS

• Worst complication of cough• T or F: can usually find 1 etiology• T or F: GERD almost always

symptomatic(heartburn)

• BONUS

PERSISTENT COUGH

• Defined as lasting at least 3 weeks

• Some term cough subacute between 3 and 8 weeks

• >30 million physician visits annually

• first or fifth most common reason to see a doctor

• costs estimated at $30billion annually in U.S.

MECHANICS

• Intrathoracic pressure increases up to 300mmHg

• Expiratory velocity reaches 500mph.

• Helps to clear mucous

• BUT can cause complications

COMPLICATIONS

• headache

• dizziness

• musculoskeletal pain

• syncope

• urinary incontinence

• Rib fracture

• …….drives patient and everyone else crazy.

COUGH REFLEX

• Afferent arm

• lower respiratory tract upper respiratory tract—

• Includes pharynx, larynx, ear canal

pericardium

– esophagus

– diaphragm

– stomach

RECEPTORS

• Chemoreceptors respond to– acid

– heat

– capascin-like compounds

Mechanical receptors respond to

touch

COMMON CAUSES

• Post-nasal drip– Post infection

– Allergic and vasomotor rhinitis

• GERD

• Asthma

• Chronic bronchitis

• Eosinophillic bronchitis

• 25-50% ------multiple causes

POST-NASAL DRIP

• Probably most common cause

• allergic vs. vasomotor rhinitis

• sinusitis

• Symptoms:

• clearing throat

• sensation of mucous in back of throat

• nasal congestion

• dry mouth

• may be asymptomatic

• Exam

• nasal congestion, polyps, secretions

• throat: erythema, mucous, cobblestoning

POST-INFECTIOUS

• Many lump this with post-nasal drip as this symptom common for weeks post viral respiratory tract infection

• Can affect upper and/or lower respiratory tracts

• postulated enhance sensitivity of airways due to epithelial cell necrosis

• airway hyperresposiveness(RADS)

TREATMENT

• UPPER TRACT

• Intra-nasal corticosteroids

• antihistamines---systemic and intra-nasal

• Decongestants

• Anti-cholinergic nasal sprays

• LOWER TRACT

• Anti-cholinergics

• BOTH

• ? Anti-leukotriene rx

ASTHMA

• Considered second most common cause(disagree)

• “cough-variant” asthma

• may not wheeze or complain of dyspnea

• spirometry, even methacholine challenge may be negative

• ? Trial of therapy----

• e.g. beta2 agonist

• inhaled corticosteroids

• anti-leukotrienes

• oral steroids

GERD

• May be silent

• ENT exam frequently positive

• 24hr. pH monitor with even markers for cough

• barium swallow frequently negative

• ?trial of treatment– PPI

– elevate head of bed

– ?propulsive agent

DRUGS

• ACE inhibitors up to 15% of patients cough

• thought secondary to accumulation of bradykinin that normally

• degraded by ACE

• usually begins within 1 week of starting treatment

• resolves after 4 days to 4 weeks off therapy

• Beta blockers

• cough rare as isolated symptom

CHRONIC BRONCHITIS

• Defined as productive cough, “most days,” at least 3 months in 2 consecutive years

EOSINOPHILLIC BRONCHITIS

• Atopy• increased sputum eosinophils• active airway inflammation WITHOUT airway hyper-responsiveness• small series(20) chronic isolated cough without bronchodilator response:• bronchial biopsy: eosinophil infiltration in 16• most patients respond clinically to ICS

• 1 year after onset of symptoms(1 series)• 55% symptomatic with normal spirometry• 32% asymptomatic• 13% asthma

ODDMENTS

• Lung Ca

• laryngopharyngeal reflux

• anything that compresses airway, e.g.retrosternal mass

• irritation of ear canal

• pertussis

• tracheobronchiomalacia

• foreign body

WORK UPHISTORY

• Time course• prior episodes• initial symptom e.g. URI, recent respiratory infection or exposure• smoking history• asthma or other atopic history• productive? Color of sputum• time of day, e.g. nocturnal GERD • anything aggravating or relieving symptoms• recent medication changes• recent exposure to new potential allergens• prior pneumonia(possible bronchiectasis)• rhinitis history• AM dry mouth and/or nasal congestion

EXAM

• Ears--fluid, cerumen

• nose--polyps, erythema, secretions, blue or boggy turbinates

• throat--erythema, frothy secretions, cobblestoning

• neck--masses, stridor, adenopathy

• chest(of course) wheezes, rhonchi

TESTS

• All debatable

• chest radiograph

• spirometry

• sinus films

• pH monitor

IF DX NOT APPARENT…….

• Recommend treat for post nasal drip initially

• add anti-reflux measures if cough disabling

• cough suppressants

• anticholinergics

• oral corticosteroids

• ENT or allergy workup

• TIME