PROBLEMS IN ETIOLOGY PROBLEMS IN ETIOLOGY AND DIAGNOSIS OF COUGH AND DIAGNOSIS OF COUGH AND CHRONIC COUGHAND CHRONIC COUGH

Muhammad FachriMuhammad Fachri

FKK UMJ – RSIJ Sukapura, RSIJ Pondok KopiFKK UMJ – RSIJ Sukapura, RSIJ Pondok Kopi

2

IntroductionIntroduction

The impact of cough on health is substantial. The impact of cough on health is substantial. It can :It can :

(1) be important defens mechanism that helps clear (1) be important defens mechanism that helps clear

excessive secretions and foreign material from excessive secretions and foreign material from

airwaysairways

(2) be important factor in the spread of infection (2) be important factor in the spread of infection

(3) present as one the common symptoms for which(3) present as one the common symptoms for which

patient seek medical attention. patient seek medical attention.

How Common is CoughHow Common is Cough

Cough is one of the most common complaints for Cough is one of the most common complaints for which patients seek medical attentionwhich patients seek medical attention

29,5 million US population visit for cough (1998) 29,5 million US population visit for cough (1998) 3,6% of all physician visit 3,6% of all physician visit

Chronic cough being reported by 3–40% of the population (Europe)

One of most common reasons for new visit to One of most common reasons for new visit to

pulmonologist and respirologistspulmonologist and respirologists

Chronic Cough PhysiologyChronic Cough Physiology

Each cough occurs through the stimulation of a Each cough occurs through the stimulation of a complex reflex arc. complex reflex arc.

Cough receptors exist : Cough receptors exist : 1. In the epithelium of the upper and lower 1. In the epithelium of the upper and lower

respiratory tracts respiratory tracts 2. Pericardium2. Pericardium3. Esophagus3. Esophagus4. Diaphragm4. Diaphragm5. Stomach. 5. Stomach.

Chronic Cough PhysiologyChronic Cough Physiology

Mechanical cough receptorsMechanical cough receptors

Can be stimulated by triggers such as touch or Can be stimulated by triggers such as touch or displacement. displacement.

Chemical receptorsChemical receptors

Sensitive to noxious gases or fumes. Sensitive to noxious gases or fumes. Laryngeal and tracheobronchial receptorsLaryngeal and tracheobronchial receptors

Respond to both mechanical and chemical Respond to both mechanical and chemical stimuli. stimuli.

An effective

cough have been classified as inspiratory, compressive, and expiratory.

Chronic Cough PhysiologyChronic Cough Physiology

Cough - HistoryCough - History

Some controversy over definitionsSome controversy over definitions Arguably the bestArguably the best

AcuteAcute : less than 3 weeks: less than 3 weeks Sub acuteSub acute : 3 to 8 weeks : 3 to 8 weeks ChronicChronic : more than 8 weeks: more than 8 weeks

ACCP Evidence-Based Clinical Practice Guidelines CHEST 2006

I.I. Common CausesCommon Causesa. Chronic Upper airways a. Chronic Upper airways cough cough syndromesyndromeb. Cough and common coldb. Cough and common coldc. Asthmac. Asthmad. GERDd. GERDe. Bronchitise. Bronchitisf. Bronchiectasisf. Bronchiectasisg. Post Infection coughg. Post Infection coughh. Lung Tumorsh. Lung Tumors

I.I. Cough in the Cough in the immunocompromised immunocompromised

II.II. Uncommon causesUncommon causesIII.III. Unresolved cough Unresolved cough

(Idiopathic cough)(Idiopathic cough)

Etiology of CoughEtiology of Cough

i. Cough and aspiration

j. ACE inhibitor induced

k. Psychogenic coughl. ILDm.Occupational and

enviroment causesn. Tuberculosis and

other infectiono. Peritoneal dialysis

and cough

ACCP Evidence-Based Clinical Practice Guidelines CHEST 2006

Etiology of chronic coughEtiology of chronic cough

Eur Respir J 2004; 24: 481-492

Etiology of Chronic CoughEtiology of Chronic Cough

The most common etiology of The most common etiology of chronic cough are :chronic cough are :1. Upper airway cough syndrome 1. Upper airway cough syndrome (UACS) due to a variety of (UACS) due to a variety of

rhinosinus conditionsrhinosinus conditions2. Asthma2. Asthma3. Nonasthmatic eosinophilic 3. Nonasthmatic eosinophilic

bronchitis (NAEB)bronchitis (NAEB)4. Gastroesophageal reflux disease 4. Gastroesophageal reflux disease

(GERD) (GERD)

ACCP Evidence-Based Clinical Practice Guidelines CHEST 2006; 129:1S–23S

ACCP Evidence-Based Clinical Practice Guidelines CHEST 2006

ACCP Evidence-Based Clinical Practice Guidelines

“ In patients with chronic cough and a normal chest roentgenogram finding who are nonsmokers and are not receiving therapy with an angiotensin-converting enzyme (ACE) inhibitor, the diagnostic approach should focus on the detection and treatment of UACS (formerly called PNDS), asthma, NAEB, or GERD, alone or in combination. This approach is most likely to result in a high rate of success in achieving cough resolution. (Level Evidence B) “

CHEST 2006; 129:1S–23S

ACCP Evidence-Based Clinical Practice Guidelines

“ In all patients with chronic cough, regardless of clinical signs or symptoms, because UACS (formerly called PNDS), asthma, and GERD each may present only as cough with no other associated clinical findings (ie, “silent PNDS,” “cough variant asthma,” and “silent GERD”), each of these diagnoses must be considered. (Level Evidence : B) “

CHEST 2006; 129:1S–23S

Evaluation of Chronic Evaluation of Chronic CoughCough

HistoryHistory

PhysicalPhysical Oropharyngeal mucous or cobblestone Oropharyngeal mucous or cobblestone

appearance suggests postnasal-drip appearance suggests postnasal-drip syndromesyndrome

““silent” postnasal-drip syndromesilent” postnasal-drip syndrome

Evaluation of Chronic Evaluation of Chronic CoughCough

Heartburn and regurgitation suggest Heartburn and regurgitation suggest Gastroesophageal reflux diseaseGastroesophageal reflux disease ““silent”GERD in up to 75% of patientssilent”GERD in up to 75% of patients

Wheezing suggests asthmaWheezing suggests asthma ““silent”asthma (cough variant asthma) silent”asthma (cough variant asthma)

in up to 57% of casesin up to 57% of cases

Evaluation of Chronic Evaluation of Chronic CoughCough

Where to startWhere to start CXR: normal is consistent with PND, CXR: normal is consistent with PND,

GERD, asthma, chronic bronchitis. GERD, asthma, chronic bronchitis. Unlikely : bronchogenic carcinoma, Unlikely : bronchogenic carcinoma, sarcoid, TB and bronchiectasissarcoid, TB and bronchiectasis

Since PND syndromes are most Since PND syndromes are most common---start therecommon---start there Sinusitis or rhinitis of the following Sinusitis or rhinitis of the following

varieties: nonallergic, allergic, varieties: nonallergic, allergic, postinfectious, vasomotor, drug-induced postinfectious, vasomotor, drug-induced and environmental-irritant inducedand environmental-irritant induced

DIAGNOSIS OF CHRONIC COUGH

DIAGNOSIS OF CHRONIC COUGH

Cough and Post Nasal Drip Cough and Post Nasal Drip (UACS)(UACS)

UACS (Upper Airway Cough Syndrome)UACS (Upper Airway Cough Syndrome)

Secondary to a variety of rhinosinus conditionSecondary to a variety of rhinosinus condition Underlying reasons for postnasal drip include allergic, Underlying reasons for postnasal drip include allergic,

perennial nonallergic, and vasomotor rhinitis; acute perennial nonallergic, and vasomotor rhinitis; acute nasopharyngitis; and sinusitis nasopharyngitis; and sinusitis

Symptoms of postnasal drip include frequent nasal Symptoms of postnasal drip include frequent nasal discharge, a sensation of liquid dripping into the back of the discharge, a sensation of liquid dripping into the back of the throat, and frequent throat clearingthroat, and frequent throat clearing

Diagnosis of UACS is determined by considering a Diagnosis of UACS is determined by considering a combination of symptoms, physical finding, sinus imaging combination of symptoms, physical finding, sinus imaging and respons to therapyand respons to therapy

Cough and asthmaCough and asthma

Cough and (Cough Variant) Cough and (Cough Variant) AsthmaAsthma

Suggested when the patient is atopic or has a Suggested when the patient is atopic or has a family history of asthma family history of asthma

Cough may be seasonal, may follow an upper Cough may be seasonal, may follow an upper respiratory tract infection, or may worsen upon respiratory tract infection, or may worsen upon exposure to triggersexposure to triggers

Airways hyperreactivity can be demonstrated Airways hyperreactivity can be demonstrated by bronchoprovocation testing. However, in a by bronchoprovocation testing. However, in a patient with persistent cough, the presence of patient with persistent cough, the presence of reversible airflow obstruction or a positive reversible airflow obstruction or a positive bronchoprovocation test does not necessarily bronchoprovocation test does not necessarily prove that the cough is secondary to asthmaprove that the cough is secondary to asthma

the best way to confirm asthma as a cause of the best way to confirm asthma as a cause of cough is to demonstrate improvement in the cough is to demonstrate improvement in the cough with appropriate therapy for asthmacough with appropriate therapy for asthma

Chronic Cough -- GERDChronic Cough -- GERD

EtiologyEtiology Gross aspiration including pulmonary Gross aspiration including pulmonary

aspiration syndromes, abscess, chronic aspiration syndromes, abscess, chronic bronchitis, bronchiectasis, and pulmonary bronchitis, bronchiectasis, and pulmonary fibrosisfibrosis

Laryngeal inflammationLaryngeal inflammation Vagally mediated distal esophageal-Vagally mediated distal esophageal-

tracheobronchial reflextracheobronchial reflex

When GERD is cause of chronic cough, up When GERD is cause of chronic cough, up to 75% of patients have no GI symptomsto 75% of patients have no GI symptoms

Chronic Cough -- GERDChronic Cough -- GERD

24-h esophageal pH monitoring is 24-h esophageal pH monitoring is bestbest

Esophageal pH monitoring, Esophageal pH monitoring, ideally performed with event ideally performed with event markers to allow correlation of markers to allow correlation of cough with esophageal pH, is cough with esophageal pH, is generally considered the optimal generally considered the optimal diagnostic study, with a sensitivity diagnostic study, with a sensitivity exceeding 90 percentexceeding 90 percent

Cough and Non Asthmatic Cough and Non Asthmatic Eosinophilic BronchitisEosinophilic Bronchitis

Chronic cough due to ACE Chronic cough due to ACE InhibitorsInhibitors

A nonproductive cough is a complication of treatment A nonproductive cough is a complication of treatment with angiotensin converting enzyme (ACE) with angiotensin converting enzyme (ACE) inhibitors,inhibitors,

Oocuring in 3 to 20 percent of patients treated with Oocuring in 3 to 20 percent of patients treated with these agents these agents

Pathogenesis seems be an accumulation of Pathogenesis seems be an accumulation of inflammatory mediators: bradykinin, substance P inflammatory mediators: bradykinin, substance P and/or prostaglandinsand/or prostaglandins

Chronic cough due to ACE Chronic cough due to ACE InhibitorsInhibitors

ACE inhibitor-induced cough has the following general ACE inhibitor-induced cough has the following general featuresfeatures

usually begins within one week of instituting therapy, usually begins within one week of instituting therapy, but the onset can be delayed up to six monthsbut the onset can be delayed up to six months

It typically resolves within one to four days of It typically resolves within one to four days of discontinuing therapy, but can take up to four weeksdiscontinuing therapy, but can take up to four weeks

It generally recurs with rechallenge, either with the same It generally recurs with rechallenge, either with the same or a different ACE inhibitoror a different ACE inhibitor

It is generally not accompanied by airflow obstruction It is generally not accompanied by airflow obstruction

DON’T FORGETDON’T FORGET

TuberculosisTuberculosis BronchiectasisBronchiectasis Chronic BronchitisChronic Bronchitis Lung tumorLung tumor Occ and Env exposureOcc and Env exposure ILDILD othersothers

CONCLUSIONCONCLUSION

The most common etiology of chronic cough are UACS, The most common etiology of chronic cough are UACS, Asthma, GERD and NAEB Asthma, GERD and NAEB

In patients with chronic cough and a normal chest roentgenogram finding who are nonsmokers and are not receiving therapy with an angiotensin-converting enzyme (ACE) inhibitor, the diagnostic approach should focus on the detection and treatment of UACS (formerly called PNDS), asthma, NAEB, or GERD, alone or in combination

THANK YOUTHANK YOU

Cough and Non Cough and Non Asthmatic Eosinophilic Asthmatic Eosinophilic

BronchitisBronchitis Patients with this disorder demonstrate atopic Patients with this disorder demonstrate atopic tendencies, with elevated sputum eosinophils and tendencies, with elevated sputum eosinophils and active airway inflammation in the absence of active airway inflammation in the absence of airway hyperresponsivenessairway hyperresponsiveness

bronchial mucosal biopsies are required to bronchial mucosal biopsies are required to definitively diagnose eosinophilic bronchitisdefinitively diagnose eosinophilic bronchitis

a trial of therapy is usually performed without a trial of therapy is usually performed without biopsy, since most patients respond well to biopsy, since most patients respond well to inhaled corticosteroidsinhaled corticosteroids

One year follow-up of 367 patients with normal One year follow-up of 367 patients with normal lung function and eosinophilic inflammation noted lung function and eosinophilic inflammation noted that:that:

55 percent remained symptomatic with normal lung 55 percent remained symptomatic with normal lung function, function,

32 percent were free of symptoms32 percent were free of symptoms 13 percent developed asthma 13 percent developed asthma