approach to patient with chronic cough
TRANSCRIPT
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Approach to a patient withChronic Cough
Presented by-Dr. Debasish Bhowmick
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Usually defined as one lasting more than 8 weeks.
Key symptom of many important chronic respiratory diseases.
May be the sole presenting feature of a number of extra-pulmonary conditions.
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Cough Reflex: Afferent Pathway
Mechanical stimuli:– Rapidly adapting receptors
(RARs)– Slowly adapting stretch
receptors (SARs)
Chemical stimuli:–C-fibers
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Cough Reflex: Afferent Pathway• Vagus nerve is major
afferent pathway
• Stimuli arise from:– Ear– Pharynx– Larynx– Lungs– Tracheobronchial tree– Heart– Pericardium– Esophagus
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Efferent Pathway: 4 Phases
1. Inspiratory Phase
2. Compressive Phase
3. Expiratory Phase
4. Relaxation Phase
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History Cough characteristics / associations : Presence of post -nasal drip/catarrh/rhinitis
Worsened by posture / meals
Worse at night / in cold environments
Dry or productive
Associated wheeze / breathlessness Medications: ACE-I H/O Atopy Presence of other respiratory diseases
associated with cough (COPD,asthma,bronchiectasis etc.)
Age / Gender Smoking history Occupational history
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Physical Examination
Should look for:
Clubbing
Crepitation
Lymphadenopathy
Signs of lung collapse
Signs of pleural effusion
Horner’s syndrome etc.
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InvestigationsCXRSpirometryBronchial provocation testSputum testSinus imagingHRCT of chestBronchoscopyEndoscopy of upper GIT24 hr esophageal pH monitoring etc
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American College of Physicians 2006 Cough Guidelines
• Evidence-based
• Should be used in conjunction with “clinical judgment”
• Divides cough in adults by duration: acute, subacute, chronic
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Etiology of chronic cough in adults
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Differential Diagnosis
Top 4 in immunocompetent patient with normal CXR:
– Upper airway cough syndrome– Asthma– Gastroesophageal reflux disease– Non-asthmatic eosinophilic bronchitis
Chronic cough has two or more causes in 18 to 62 percent of patients, and three causes in up to 42 percent of patients.
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Upper Airway Cough Syndrome (UACS)
• Also called “Post-nasal drip syndrome” (PNDS)
• Mechanism: secretions from nose/sinuses stimulate upper airway cough receptors; inflammation increases receptor sensitivity
• Classic symptoms: “tickle” in throat; throat clearing, hoarseness, nasal congestion
• Cough may be the only symptom in ~ 20%
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Upper Airway Cough Syndrome (UACS)
• Signs (may be absent): inflamed nasal mucosa, secretions in posterior oropharynx
• Consider underlying causes: allergies, chronic sinusitis, overuse of alpha-agonist nasal sprays
• Diagnostic/Therapeutic trial: 1st generation anti-histamine/decongestant combination medication for 2 weeks
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Asthma• Mechanism: inflammatory mediators, mucus,
bronchoconstriction stimulate cough receptors
• Classic symptoms: intermittent wheeze
• Cough may be the only symptom in 7-57% patients - “Cough-variant asthma”
• Signs (often absent): expiratory wheezing on chest exam
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Asthma• Diagnostic tests:
– Spirometry, before and after bronchodilator: partially reversible airflow obstruction
– Methacholine inhalation challenge: positive
• Diagnostic/Therapeutic trial: inhaled corticosteroid + bronchodilator for
≥ 8 weeks
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Gastroesophageal Reflux Disease (GERD)
Acid reflux can stimulate the afferent limb of the cough reflex by irritating the upper respiratory tract without aspiration or by irritating the lower respiratory tract through aspiration
GERD can also cause chronic cough by stimulating an esophageal-bronchial cough reflex.
Daily heartburn and regurgitation suggest a GERD-induced chronic cough. These symptoms may be absent in “silent” GERD.
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A Vicious Cycle
COUGH
REFLUX INCREASED ABDOMINAL PRESSURE
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Gastroesophageal Reflux Disease (GERD)
• Classic symptoms: heartburn, sour taste in mouth
• Cough may be only symptom in 75% patients with chronic cough
• Diagnostic tests:– 24-hour esophageal pH
monitoring
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Gastroesophageal Reflux Disease (GERD)
• Diagnostic/Therapeutic trial: gastric acid suppression with proton pump inhibitor (e.g. omeprazole) for 2 months, ≥combined with diet and lifestyle modification
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Non-Asthmatic Eosinophilic Bronchitis (NAEB)
• Eosinophilic airway inflammation WITHOUT variable airflow obstruction or airway hyperresponsiveness.
• Diagnostic tests:- Spirometry: normal- Methacholine challenge: normal- Induced sputum: >3% eosinophils
• Diagnostic/Therapeutic trial: inhaled corticosteroid for 4 ≥weeks
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All that coughs is not UACS, asthma, GERD, or NAEB!
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ACE-inhibitor therapy
• Dry cough in 3-30% patients• Begins 1 week to 6 months after drug
started• Usually resolves 1-7 days after stopping
therapy, but can take 4 weeks• An ARB may be substituted for the ACE-I
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Continued on next slide…
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Chronic Cough, continued:
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Psychogenic/Habitual cough
Diagnosis of exclusion.Do not cough during sleep.Not awakened by cough.Do not cough during enjoyable distractions. Common triggers: changes in ambient
temperature; taking a deep breath; laughing; talking on the telephone for more than a few minutes; exposure to cigarette smoke, aerosol sprays or perfumes etc.
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Differentials with abnormal CXR
Any patient with chronic cough identified as having underlying structural
disease (on the basis of symptoms, signs and / or CXR) should be managed
according to recommended treatment guidelines or be referred to the
Respiratory Medicine Service for further assessment if needed.
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