THE CUREThe owner of a drugstore walks in to find a guy leaning heavily against a wall with an odd look on his

face.

The owner asks the sell's man "What's with that guy over there by the wall?“

The sell's man , "Well, he came in here at 7 A.M. to get something for his cough. I couldn't find the cough syrup, so I gave him an entire bottle of laxatives.“

The owner says, "You idiot! You can't treat a cough with laxatives!“

!!!! sell's man, "Oh yeah? Look at him—he's afraid to

cough !!!!

COUGH : DIAGNOSIS & MANAGEMENT

ACCP EVIDENCE BASED CLINICAL PRACTICE GUIDELINES

Dr.Sajid Nomani MD, MEM(USA)Peerless Hospital

Cough: Public Health Concern

Importance !!!• Cough is the most common presenting symptom

• The fourth most common symptom seen in PCP

• Acute cough accounted for 46 million GP’s visits

• Leads to decreased patient quality of life and decreased school and work productivity

• Chronic cough may account for up to 40% of visits to a Pulmonologist

Areas To Cover !!!

• Why do we Cough?

• Classification and Causes of Cough.

• The ACCP guidelines for diagnosis & Managment

What is a cough!!!

Coughing is the body's way

of removing foreign material or mucus

from the lungs & upper airway or of

reacting to an irritated airway

What is a cough!!!

• Cough is a 3-phase expulsive motor act characterized by an inspiratory effort (inspiratory phase), followed by a forced expiratory effort against a closed glottis (compressive phase) followed by opening of the glottis and rapid expiratory airflow (expulsive phase)

Pressure in the lungs rises to 100-300mmHg. Markedly positive intrathoracic pressure causes narrowing of the trachea.

Cough reflex!!!• Voluntarily or Involuntarily.

• Each cough is elicited by stimulation of relex arc

• Afferent and Efferent pathways.

• cough receptors

• Mechano recp-touch/displacment

• Chemo recp.- heat/acid

Cough Reflex !!!Impulses from the cough receptors

↓

via afferent limb vagus N.

↓

COUGH CENTER

↓

EFFERENT IMPLUSE GENERATED

↓ propagated

spinal motor : Expiratory muscles

Phrenic : Diaphragm

Vagus n. : Larynx,trachea,bronch

to the expiratory organs to produce

cough

• The afferent limb includes receptors within the sensory distribution of the trigeminal, glossopharyngeal, superior laryngeal, and vagus nerves.

• The efferent limb includes the recurrent laryngeal nerve and the spinal nerves.

What is the most common cause of cough???

1. Smoking

2. Infection

3. Asthma

4. Reflux

5. Occupation & Environmental Irritant.

Cough: What’s it good for ???

• Protect the airway from pathogens, particulates, food, other foreign bodies

• Clear the airways of accumulated secretions, particles

• Attract attention

• Signal displeasure

Complications of Cough!!!

• Result primarily from marked increase in intrathoracic pressure (> 300 mmHg) during cough

• Affect nearly every other organ system

• Disruption of surgical wounds

• Negative impact on quality of life, particularly in chronic cough

Complications of CoughCardiovascular 

Arterial hypotension Loss of consciousness Rupture of subconjunctival, nasal and anal veins Dislodgement/malfunctioning of intravascular catheters Bradyarrhythmias, tachyarrhythmias 

Neurologic Cough syncope Headache Cerebral air embolism CSF rhinorrhea Acute cervical radiculopathy Malfunctioning ventriculoatrial shunts Seizures Stroke due to vertebral artery dissection 

Gastrointestinal Gastroesophageal reflux events Hydrothorax in peritoneal dialysis Malfunction of gastrostomy button Splenic rupture Inguinal hernia 

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Complications of Cough !!!

Genitourinary Urinary incontinence Inversion of bladder through urethra 

Musculoskeletal From asymptomatic elevations of serum creatine phosphokinase to rupture of rectus abdominis muscles Rib fractures 

Respiratory Pulmonary interstitial emphysema, with potential risk of pneumatosis intestinalis, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, pneumothorax, subcutaneous emphysema Laryngeal trauma Tracheobronchial trauma (eg, bronchitis, bronchial rupture) Exacerbation of asthma Intercostal lung herniation 

Miscellaneous Petechiae and purpura Disruption of surgical wounds  Constitutional symptoms  Lifestyle changes Self-consciousness, hoarseness, dizziness Fear of serious disease Decrease in quality of life  

*

TOOLS!!!!• HISTORY / PHYSICAL EXAMINATION

• C-XRAY

• SPIROMETRY

• METHACHOLINE CHALLENGE TEST

• 24H.PH MONITORING

• BARIUM ESOPHAGOGRAPHY

• HRCT

ED……point of view!!!• R/O life threatning causes

• ABC

• Treatment

• Paroxysm of caugh

• lidocaine - 4 cc of 1% or 2% preservative-free nebulization

American College of Physicians 2006 Cough Guidelines• Evidence-based

• Includes guidelines for pediatric cough

• Should be used in conjunction with “clinical judgment

Grading of Recommendations !!

!

ACCP GRADING SYSTEM

• Quality of evidence

• Net benefit of the recommendation of diagnostic & therapeutic procedure

• Gr-A-Strong

• Gr-B-moderate

• Gr-C-weak

• Gr-E/A-strong expert openion

• Gr-E/B-moderate expert openion

Success Rate !!!• Cause of cough can be determined in

88 to 100% of cases

• Success rates with specific therapies range from

84 to 98%

Chest 1998;114(2):133s-181s

Thorax 1998;53:738-743

Categorization !!!

• Acute cough: < 3 weeks

• Subacute cough: 3-8 weeks

• Chronic cough: >8 weeks

ACUTE COUGH !!!

• Cough lasting less than 3 weeks

Key questions:

• 1. Is it life-threatening?

• 2. Are antibiotics needed?

Red flags: findings of particular concern

• Dyspnea….

• Hemoptysis….

• Resp. distress….

• Weight loss

• Risk factors for TB, HIV infection or other immune suppressed states

Acute Cough

History, Examination,

+/-investigations

Life-threatening Dx Non-Life-threatening dx

Pneumonia, severe exacerbation of asthma or COPD, PE, Heart Failure, other serious disease

Exacerbation of pre-existing condition

Environmental or Occupational

Infectious

1.URTI

2.LRTI

1.ASTHAMA2.Bronchiectasis

3.UACS4.COPD

Irwin R S et al. Chest 2006;129:1S-23S, American College of Chest Physicians

Causes and estimated frequencies of acute cough in the adult !!!

• Common

• Common cold

• Acute bacterial sinusitis

• Pertussis

• Exacerbations of COPD

• Allergic rhinitis

• Environmental irritant rhinitis

• Less common

• Asthma

• Congestive heart failure

• Pneumonia

• Aspiration syndromes

• Pulmonary embolism

Irwin RS et al. Chest 1998, 114:133S-181S

ACCP-GUIDELINES URTI• Common cold

• 1st gen. Antihistamine / Decongestant –BROMPHENARMINE+PSEUDOEPHEDRINE

(GR-A)

• In patients with cough and acute URTI,the diagnosis of bacterial sinusitis should not be made during the first week of symptoms. (gr-A)

• Clinical judgment is required to decide whether to institute antibiotic Therapy(GR-D)

ACCP-GUIDELINES LRTI• “Acute Bronchitis” Most bronchitis in otherwise healthy adults is caused by

viruses (rhinovirus, adenovirus, RSV) NO ANTIBIOTICS (gr-A)

Bacterial causes to consider:Mycoplasma pneumoniae, chlamydophila

pneumoniaeBordetella pertussis (whooping cough)

• R/O PNEUMONIA:C-xray (gr-B) Heart rate > 100 beats/min; respiratory rate > 24breaths/min oral body temperature > 38°C; chest examination findings

ACCP-GUIDELINES LRTI

• B-2-agonist bronchodilators should not be routinely used to alleviate cough. (GR-D)

• Acute bronchitis and wheezing + Cough

BETA 2-agonist bronchodilators Antitussive agents (GR-C)

Are we missing Pertussis???

• 75 adults, cough for more than 14 days

• Pertussis diagnosis based on culture

• 26% of adults had evidence of B. pertussis infection

• JAMA 1995;273:1044-1046

When to suspect & Whom to treat?

Suspect and treat if a clear cut history of

Exposure

Suspect and treat –if suggestive symptom

Treat contact

ACCP-GUIDELINES LRTI• whooping cough:

cough >2wks

Paroxysms of coughing+ /- posttussive vomiting

Inspiratory whooping sound• Dx-

• Nasopharyngeal aspirate/swab culture

• PCR-Not Recommended

• T/T Macrolides * 5days Isolation * 5days (gr-A)

Exacerbation of pre-existing condition !!!

• COPD: always consider bacterial infection

• Asthma: try to identify the underlying cause (exposure, viral URTI, viral LRTI, other)

• Bronchiectasis: always consider bacterial infection (gram negative rods, staph. aureus, organisms resistant to antibiotics)

• Upper airway cough syndrome (UACS)

• Environmental or occupational exposure: allergens, irritants

Subacute Cough !!!

• Cough lasting 3-8 week• Usually resolve in 2 wks

• Sign of chronic cough!!!!!

Key questions:

1. Is it post-infectious?

2. If post-infectious, are antibiotics needed

SUBACUTE COUGH

Post-infectiousNon-postinfectious

History and Physical Exam

Pneumonia and other serious diseases

New onset or exacerbation of pre-existing condition

Workup same as chronic cough

Pertussis

Bronchitis

Asthma BronchitisUACS GERD

NAEB AECB

Irwin R S et al. Chest 2006;129:1S-23S 2006 by American College of Chest Physicians

Post Infectious Cough !!!

Min 3 wks - < 8 wks

• A cough that begins with an acute respiratory tract infection and is not complicated by pneumonia

• Post Infectious cough will resolve without treatment

CAUSE :

• UACS

• GERD

• ASTHMA

• Bronchial Hyperresponsivness

• Mucous hypersecration

Algorithmic approach to subacute cough.

ACCP-GUIDELINES

• Ipratropium inhalation• Corticosteroid Inhalation• For severe paroxysm of Cough

• Prednisone-40mg/day (gr-C)

if fails• Codeine & Dextromethorphan

• R/O UACS /GERD /ASTHMA

Chronic Cough !!!• Cough lasting longer than 8 weeks• Causes

• GERD• Asthma• Post nasal drip• COPD• Bronchogenic carcinoma• TB• ILD• ACE inhibitor

Lets Dx this lady…..

61 yo female c/o cough * 2 years, usually dry; sometime Productive of white foamy material. Worse with exercise, cold air, mildly hoarseness in voice.

What else would you like to know???

Relevant History…..• Reports postnasal drip and throat clearing. • Had sinus problems as child requiring drainage.• Often awakened at night due to cough

• Worse with exercise, cold air

Physical Exam:Vitals - Normal• General: mod.overweight, NAD,

• HEENT: NAD

• CHEST: normal br.pattern, normal percussion, inspection, palpation. Normal breath sounds bilaterally. No wheezes, crackles, rhonchi,

• CV: Normal S1 S2, no murmurs, gallops, or rubs

• Abdomen: soft, nontender, no masses,/organomegaly

• Ext: no clubbing or edema. • Neuro-normal

PMx:

• Several common cold in last 3-4 years.

• No other significant medical history.

• No medication

Sx :

• Non-smoker

• House maker

• No harmful environmental exposure

• Regular workout

1) WHAT IS THE CAUSE OF HER COUGH???

2) PLAN???

Most common causes of chronic cough in patients

investigated in specialist clinics

McGarvey et al. Pulm Pharmacol Ther 2004

Top 4 causes!!!

• Account for the etiologic cause of chronic cough in 92-100% of immunocompetent, nonsmoking patients with normal CXR.

• Upper airway cough syndrome

• Asthma

• Gastroesophageal reflux disease

• Non-asthmatic eosinophilic bronchitis

Upper Airway Cough Syndrome!!!

Symptoms:

• ‘something dripping’

• frequent throat clearing

• nasal congestion / discharge

• Hoarness

Causes

• Allergic rhinitis

• Non-allergic rhinitis

• Vasomotor rhinitis

• Chronic bacterial sinusiits

Mechanism: secretions from nose/sinuses stimulate upper airway cough receptors; inflammation increases receptor sensitivity

ACCP-GUIDELINES UACS• Diagnostic/Therapeutic trial:

1st generation A/D combination(gr-B)• 1st gen. Antihistamine / Decongestant –

BROMPHENARMINE+PSEUDOEPHEDRINE*2wks

(GR-A)

• Sinus Imaging

Back to the our patient!!!

• BROMPHENARMINE+PSEUDOEPHEDRINE * 2 WKs

FOLLOW-UP: No improvement !!!

NEXT—ASSESMENT /PLAN???

1) SPIROMETRY

2) START EMPERIC TREATMENT

ASTHMA!!!• Mechanism: inflammatory mediators, mucus,

bronchoconstriction stimulate cough receptors

• CH.cough always consider as a potential couse (gr-B)

• Classic symptoms: intermittent wheeze

• Signs (often absent): expiratory wheezing on chest exam

ACCP-GUIDELINES ASTHMA

• Diagnostic tests:

Spirometry :before and after Bonchodilator

Methacholine inhalation challenge:

ACCP-GUIDELINES ASTHMA

• Diagn./Therapeutic trial: Antiasmatic rg.

• ICS+ Inh. bronchodilator (gr-A)

↓

• Refractory cough→Airway inflamation assessment

↓

• Leukotriene Recep.antagonist

↓ (gr-B)

• Systemic corticosteroid *2wks

↓

• ICS

Question???Can asthma be a possibility if a pre and

post-bronchodilator spirometry is completely normal?

• (A)Yes

• (B) No

• COUGH MAY BE THE ONLY SYMPTOM IN 57% PATIENTS (DEPENDS ON STUDY)-- “COUGH-VARIANT ASTHMA”

• Chest 1999;116(2):279-84

Back to the our patient!!!

Follow-up -8wks : Marked improvment!!!!

But still coughing specially at night and @

exsercise ??

NEXT—ASSESMENT /PLAN???

CONSIDER MULTIPLE Dx

ANTIREFLUX DIET

PROTON PUMP INHIBITOR

PROKINETIC THERAPY

LIMITED VIGOROUS EXERCISE

Gastroesophageal Reflux Disease!!!

ACCP-GUIDELINES• ACID REF. VS NON ACID REF.

• Classic symptoms: heartburn, sour taste in mouth

• Cough may be only symptom in 75%

• Diagnostic tests:

• 24-hour esophageal pH probe (best)

• Barium Esophagography

ACCP-GUIDELINES

GERD• ANTIREFLUX DIET

No > 45 g of fat in 24 h/ no coffee, tea, soda, chocolate, mints, citrus products, including tomatoes,or alcohol, no smoking

• limiting vigorous exercise that will increase intraabdominal pressure

• Acid suppression -proton pump inhibitor

-prokinetic therapy

IF FAIL----ANTIREFLUX SURGERY

24h.ph--+ve

GERD sugs.symp

3mo.therapy

↓ quality of life

8 WEEKS LATER……..

• COUGH GONE COMPLETELY

Dx :

• COUGH VARIENT ASTHAMA .NON REFLUX GERD

Non-Asthmatic Eosinophilic Bronchitis

(NAEB)• Eosinophilic airway inflammation WITHOUT variable airflow

obstruction or airway hyperresponsiveness

• Consider Occupation related cause

• Diagnostic tests:- Cxray : normal- Spirometry: normal- Methacholine challenge: normal- Induced sputum / bronchial wash fluid : >3% eosinophils

• Diagn/Therap. Trial: inhaled corticosteroid ≥ 4 wks• : avoidance of occup.sensitizer

Other causes!!!• ACE-inhibitor—Dsicontinue(gr-A)

• Effects in 1-4wks• Swictched to other agents.• Restart ACE• inhaled sodium cromoglycate,

theophylline,Baclofen (gr-B) Peter V. DicpinigaitisCHEST. january 2006;129(1_suppl):169S-173S.

• Smoking—cesasation

• Occupational & enviromental cause-avoidance

Stopping smokingslows decline in lung function

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Adapted from: Fletcher et al, Br Med J 1977.

Stopped at 65

Stopped at 45

Smoked regularlyand susceptible to

its effects

Death

Age (years)

stopping smoking can improve lung function by about 5% within a few months.

Last Question ????A 67 y/o man,heavy smoker , complains of 12 weeks of

non-productive cough. He’s had a couple of “colds” this winter. He has no current nasal or sinus symptoms, rarely has heartburn, and never wheezes. He’s on no meds. Vitals and physical exam are normal. Your next step would be:

A)Prescribe a 1st generation antihistamine/decongestant

B) Prescribe an inhaled corticosteroid for asthma

C) Counseling for smoking

D)Order a chest x-ray

E) All of the above

I am sure you don’t want to miss this!!!

• All that coughs is not UACS, asthma, GERD, or NAEB

Therapeutic trials: When to expect a response?

• Smoking cessation: up to 4 weeks

• ACE-inhibitor discontinuation: up to 4 weeks

• Upper airway cough syndrome: up to 2-3 weeks

• Asthma: up to 6-8 weeks

• GERD: up to 8-12 weeks

• Eosinophilic bronchitis: up to 3-4 weeks

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Thank

you…

..I am open forDiscussion / Questions