Pulmonary - Cough

7/27/2019 Pulmonary - Cough

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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



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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



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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



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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



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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



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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



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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



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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



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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



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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



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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.

Pulmonary - Cough

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