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Optimum time to stop preoperatively?• 120 pts, cessation or 50% reduction 6-8 weeks prior
to THA and TKA• 18% vs 52% overall complication rate (p<0.0003)• 5% vs 31% wound complications (p<0.001)• 0% vs 10% cardiovascular complications (p<0.08)• 4% vs 15 % secondary surgery rate (p<0.07)
Can’t stop the medication?•Other medications may help•Cromolyn, baclofen, theophylline, local anesthetics, sulindac (COXi) and intermediate dose ASA (500 mg/day)
Hoofbeats...think horses, not zebras
Etiology of 99% of chronic cough cases can be identified in healthy, nonsmoking adults. – Immunocompetent, nonsmokers with normal chest x-ray not
Diagnosis based on:– Symptoms– PE findings (may be few/none)– Radiographic findings (may be few/none)– Response to specific treatment***
Treatment:– Avoidance of allergens/irritants– Treatment to block or reduce inflammation and secretions– Treatment of infection– Correction of structural alterations
Pratter MR. Chest 2006;129 (Suppl. 1): 220S–221S.
Upper Airway Cough Syndrome
• May consider empiric therapy based on suspicion of disease
• Consider diagnostic tests including CT sinus and allergy testing if suspicion is there despite lack of response
Upper Airway Cough Syndrome
Pratter MR. Chest 2006;129 (Suppl. 1): 220S–221S.
Cough Variant Asthma
• Don’t forget about asthma!• Physical exam and spirometry• If nondiagnostic, consider methacholine challenge
• Identified as etiology of chronic cough in 1989 by Gibson
• 10-30% of specialist referrals
(Brightling, 2006)
• Chronic cough in patient with• No symptoms or objective evidence of variable
airflow obstruction• Normal airway hyperresponsiveness• Sputum eosinophilia
• Often associated with exposure to occupational sensitizer or inhaled allergen
• Corticosteroid responsive
Eosinophilic Bronchitis
(Gibson, 1989)
Induced sputum studies
• Technique: patient inhales increasingly concentrated hypertonic saline: 3%, 4% then 5% in sequence for 5 min each via ultrasonic nebulizer after premedication with bronchodilator
• Expectorated sputum collected, then dispersed, filtered and spun,cells evaluated
corticosteroid response good good (if eos) good (if eos)
sputum eosinophilia always usually usually
bronchial biopsy eosinophilia
very common common common
mast cells in AW sm. muscle
no yes yes
(Brightling, 2006)
Treatment…•If causal allergen or occupational sensitizer identified… avoidance•Inhaled corticosteroids (budesonide 400 mcg inhaled BID best studied) •Oral antihistamines or leukotriene modifiers need more study•Rarely, oral corticosteroids needed
Typically, initial insult or etiology resolves, but cough remains.
• Preponderance of females, especially peri- or postmenopausal (up to 80% of referrals in some cough clinics)
• Females generally have heightened cough reflex
(McGarvey, 2005)
Pathophysiology…•Inflammatory/neuropathic changes in sensory nerves (post-insult)•Repetitive mechanical and physical effects of coughing can enhance airway inflammation•Airway inflammation and remodeling can increase cough reflex sensitivity•“Cough hypersensitivity syndrome”?
Maybe coming soon?• Retrospective series and case reports:
• Pregabalin• Baclofen• Botulinum toxin
• Further studies needed
(Altman, 2015)
Idiopathic cough
Psychogenic cough
• AKA habitual cough or tic cough• Nonproductive, tinny or harsh cough• Severe frequency up to Q2-3 seconds• NOT during sleep, enjoyable activities• Diagnosis of exclusion only• Psychological evaluation or psychiatric
Recognizing the Etiology of Cough and Institution of the Appropriate Treatment
46
6 Year-Old Girl With Chronic DryCough of 10 Weeks DurationHistory• Dry cough occurs almost daily, no present wheeze.• Sight chest tightness and dyspnea with exertion.• Nocturnal awakening several times a month with cough.• History of “croup” with wheezing in past.• URI’s several times a year associated with wheezing that improves
with SABAs.• No reported nasal symptoms or heartburn• No prior history of food allergy or eczema (AD)
Family History• Father and one sibling have asthma• Mother and another sibling have Allergic rhinitisMedication History• OTC cough and cold medications, without benefit
47
Case 1 continued
Physical Exam• Well nourished girl, alert and cooperative who appears normal
except for her intermittent coughing• Nasal membranes pale but not swollen or wet, no discharge or post
nasal drip• No sinus tenderness• Chest clear to auscultation: no wheezes rales or rhonchi• No organomegaly or abdominal tenderness
Differential diagnosis might includea) Asthmab) Habit coughc) GERDd) Vocal cord dysfunctione) Rhinosinusitisf) All of the above
Global Initiative for Asthma. Global strategy for asthma management and prevention. 2006;1:16-25.Grayson MH, Holtzman MJ. 14 Respiratory Medicine, II Asthma, ACP Medicine Online, 2002.
49
Study Results• Chest X-ray: normal, no hyperinflation, no infiltrates• Peak flow: 100% of predicted• Spirometry: within normal limits, Normal flow/volume
loop• Exhaled NO: 31 ppb (elevated) • Sinus imaging: not indicated given absence of upper
respiratory symptoms• Skin tests positive to dust mite
The AAAAI and ACAAI Recognize and Endorse the 2011 American Thoracic Society Guidelines
“…measurement of airway inflammation, using FeNO, is a paradigm change in asthma diagnosis and management “
“…it provides a perspective otherwise unavailable to the clinician”
ACAAI/AAAAI Joint Work Group
FeNO Significantly ELEVATED in Asthma
• FeNO levels significantly increased in both asthma groups
• FeNO levels significantly higher in patients with allergic asthma versus patients with nonallergic asthma
Zietkowski et al. J Investig Allergol Clin Immunol. 2006;16(4):239-246.
FeN
O,
pp
b
P=0.0001160
140
120
100
80
60
40
Nonallergic asthma
n=45
Allergic asthma
n=56
Healthy volunteers
n=39
0
20
P=0.0001P=0.0001
FeNO For Assessment of Chronic Cough
FeNO significantly higher in asthmatics with chronic cough compared with healthy volunteers (P=0.007) and non-asthmatic patients with chronic cough (P=0.0014)
Chatkin et al. Am J Respir Crit Care Med. 1999; 159(6): 1810-1813..
FeNO Interpretation: Patients with suspected asthma
Question 2Which course of therapy is most appropriate?
A) Watch and wait approach; Reassurance, Instructions to call if symptoms worsen and make f/u visit in 1 month
B) Broad spectrum antibiotic for URI to cover atypical organisms such as mycoplasma or chlamydia
C) Albuterol MDI q4h PRN as monotherapy
D) Single entity controller asthma medication I.e. inhaled corticosteroid (ICS) or Leukotriene Receptor Antagonost (LTRA) along with albuterol MDI PRN and/or pre exercise.
E) Combination therapy with an ICS and Long Acting Beta Agonist (LABA) to control both exercise induced bronchospasm and cough due to airway inflammation
RESULTS OF THERAPEUTICCHOICES
CHOICE A) Watch and Wait (Poor choice)
• 3 weeks later, mother still reports persistent cough increased by recent heavy dust exposure; wheezing is now observed
RESULTS OF THERAPEUTICCHOICESCHOICE B) BROAD SPECTRUM ANTIBIOTIC (poor choice)
• Dry cough persists without change after completion of 2 week antibiotic course
• No fever, myalgia or discolored sputum,
• Mother returns for reevaluation and change in therapy
• FENO 31 ppb (still elevated)
• Elevated exhaled NO indicative of eosinophilic inflammation rather than neutrophilic inflammation associated with infection
RESULTS OF THERAPEUTICCHOICES
CHOICE C) PRN ALBUTEROL MDI as sole therapy (Poor Choice)
• Minimal decrease in daytime cough. Nocturnal awakening 3x/month
• Exercise induced cough prevented with albuterol MDI pretreatment
• FeNO 30 (Still elevated) Initial impression of asthma was appropriate
• BUT:PRN albuterol only helpful in preventing EIB and controlling the bronchospastic aspect of cough and inadequate in controlling underlying bronchial inflammation as indicated by elevated exhaled NO level
RESULTS OF THERAPEUTICCHOICESD) Daily ICS plus PRN Albuterol MDI (BEST Choice)
• Cough subsided, No further nocturnal awakening
• FeNO 7 ppb
• Mild Persistent Asthma is the most likely diagnosis
• Cough in an atopic child with elevated exhaled NO suggests atopic asthma despite normal peak flow and spirometry or impulse oscillometry
• Allergic asthma is likely because of sensitization to mite
• Maintenance asthma controller [ICS (preferred) or LTRA] is recommended
Kim CK et al. Clin Exp Allergy. 2003;33:1409-1414.
Malmberg LP et al. Thorax. 2003;58:494-499.
Guilbert TW et al. N Engl J Med. 2006;354:1985-1997.
RESULTS OF THERAPEUTICCHOICESE) ICS +LABA (Over-treatment: Poor Choice)
• Mother informed at Pharmacy that Insurance Company would not pay for a combination ICS/LABA drug for patient who had not tried and failed a single entity controller
• Mother would not pay for drug out of pocket and returned to office for alternative therapy
• Physician chastised by Quality Control HMO Director for prescribing a ICS/LABA for mild persistent asthma, when a less expensive single entity controller has been shown to be equally efficacious and less expensive!
Friedman et al. Curr Med Res Opin 2007;23:427-434
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