Cough 101

Recommended Reading

•The Diagnosis and Treatment of Cough Richard S. Irwin and J. Mark Madison NEJM Volume 343, Number 23 Pages 1715-1721. December 2000

•Diagnosis and Management of Cough Executive Summary. ACCP Evidence-Based Clinical Practice Guidelines Chest Volume 129 Supplement 2006

Recommended Reading

•Prevalence, pathogenesis, and causes of chronic coughKian F. Chung and Ian D. PavordLancet 371(9621):Pages 1364-74 April 2008

•Management of chronic coughIan D. Pavord and Kian F. ChungLancet 371(9621):Pages 1375-84 April 2008

Recommended Reading

•Concise Clinical Review: Controversies in the Evaluation and Management of Chronic CoughSurinder S. BirringAm J Resir Crit Care Med 183(6)Pages 708-715 March 2011

Cough 101

• Acute cough– Lasting less than 3 weeks

• Sub-acute– Lasting 3-8 weeks

• Chronic cough– Lasting 8 weeks or more

Cough is the most common reason patients seek medical attention in the United States

Acute Cough

• Duration less than 3 weeks• Most commonly due to:

1. Upper respiratory tract infection2. Lower respiratory tract infection3. Pulmonary embolism

Acute Cough

• Duration less than 3 weeks• Most commonly due to:

1. Upper respiratory tract infection2. Lower respiratory tract infection3. Pulmonary embolism

Acute cough algorithm for the management of patients ≥ 15 years of age with cough lasting

< 3 weeks

Irwin R S et al. Chest 2006;129:1S-23S

©2006 by American College of Chest Physicians

Cough and Pulmonary Embolism

• Which of the following statements are true about cough and acute PE

a) Cough associated with PE is usually productive

b) Cough is present in 50% of patients with PE

c) Cough is the predominant symptom in some patients with PE

d) The severity of cough predicts the extent of thromoboembolism in patients with PE

Cough and Pulmonary Embolism

• Which of the following statements are true about cough and acute PE

a) Cough associated with PE is usually productive

b) Cough is present in 50% of patients with PE

c) Cough is the predominant symptom in some patients with PE

d) The severity of cough predicts the extent of thromoboembolism in patients with PE

Life-threatening causes of acute cough

High index of suspicion in the elderly because classic signs/symptoms may be absent

Pulmonary embolism Heart Failure Pneumonia

Subacute cough algorithm for the management of patients ≥ 15 years of age with cough

lasting 3 to 8 weeks

Irwin R S et al. Chest 2006;129:1S-23S

©2006 by American College of Chest Physicians

Subacute cough algorithm for the management of patients ≥ 15 years of age with cough

lasting 3 to 8 weeks

Irwin R S et al. Chest 2006;129:1S-23S

©2006 by American College of Chest Physicians

Post-infectious cough

• Cough more than 3 weeks following an upper or lower respiratory tract infection

• Usually resolves in 4 weeks

• Anti-tussive medications and steroids can help with symptoms

Chronic Cough• Chronic cough of undetermined etiology

accounts for 10-40% of a pulmonologist’s outpatient practice

How good can we be at making a diagnosis?

• Studies show that the etiology of chronic cough can be determined by a well-trained pulmonologist…..

a) Less than 50% of the time

b) 60-70% of the time

c) 70-80% of the time

d) 80-90% of the time

e) 90-100% of the time

How good can we be at making a diagnosis?

• Studies show that the etiology of chronic cough can be determined by a well-trained pulmonologist…..

a) Less than 50% of the time

b) 60-70% of the time

c) 70-80% of the time

d) 80-90% of the time

e) 90-100% of the time

How good can we be at making a diagnosis?

• Studies show that the etiology of chronic cough can be determined by a well-trained pulmonologist…..

a) Less than 50% of the time

b) 60-70% of the time

c) 70-80% of the time

d) 80-90% of the time

e) 90-100% of the time

Can you cure your patient?

• Studies show that treatment success rates for chronic cough can be as high as…..

a) Less than 50%

b) 50-60%

c) 60-70%

d) 70-85%

e) 85-100%

Can you cure your patient?

• Studies show that treatment success rates for chronic cough can be as high as…..

a) Less than 50%

b) 50-60%

c) 60-70%

d) 70-85%

e) 85-100%

Chronic Cough- Etiology• In non-smoking adults with a normal

CXR who are not taking ACE inhibitors, chronic cough is almost always due to which of the following 3 conditions?

a) Congestive Heart Failureb) Upper Airway Cough Syndrome (UACS)c) Asthmad) Gastroesophageal reflux disease (GERD)e) Chronic Bronchitis

Chronic Cough- Etiology• In non-smoking adults with a normal

CXR who are not taking ACE inhibitors, chronic cough is almost always due to which of the following 3 conditions?

a) Congestive Heart Failureb) Upper Airway Cough Syndrome (UACS)c) Asthmad) Gastroesophageal reflux disease (GERD)e) Chronic Bronchitis

Etiology of Chronic Cough

= UACS + NAEB ?

Chronic Cough sometimes has more than one cause

1 = single cause of cough

2 = 2 causes of cough

3 = 3 causes of cough

Causes of Cough in Children and Adults

= UACS

Guideline for Evaluating Chronic Cough

• A systematic, diagnostic approach has been validated in immunocompetent patients- 5 step plan:

– Step 1: Review history and exam focusing on the most common causes of chronic cough

– Step 2: Order a CXR in nearly all patients

(except perhaps young non-smokers with presumed UACS)

Guideline for Evaluating Chronic Cough

– Step 3: Do not order additional tests in present smokers or patients taking ACE inhibitors until the response to smoking cessation or drug discontinuation for at least 4 weeks can be assessed. Cough due to smoking or ACE inhibitors should improve substantially or disappear during this time-frame of abstinence.

– Step 4: Order additional diagnostic tests or embark on empiric treatment

Tests for evaluating Chronic Cough

Guideline for Evaluating Chronic Cough

– Step 5: Determine the cause(s) of cough by observing which specific therapy eliminates cough as a complaint.• If the evaluation suggests more than one

possible cause, initiate treatment in the same sequence that the abnormalities were discovered

• Since cough can be simultaneously caused by more than one condition, do NOT stop therapy that appears to be partially successful; rather, sequentially add to it.

Guideline for Evaluating Chronic Cough

Step 1 Step 2 Step 3

Step 4 Step 5

Upper Airway Cough Syndrome

Upper Airway Cough Syndrome

• Common cause of chronic cough in all age groups– Second most common cause in children– Most common cause in adults and the elderly

• In addition to cough, UACS can also cause– Wheeze– Dyspnea

Upper Airway Cough Syndrome

• Clues to UACS– History of

• Need to frequently clear their throat• Friend/relative notices that the patient frequently

clears their throat• Sensation of dripping into throat• Nasal symptoms

– Physical Exam demonstrating• Secretions in nose or oropharynx• Cobblestone appearance of mucosa

Causes of Upper Airway Cough Syndrome

UACS

• Diagnosis of UACS as a cause of cough is established when:

a) frequent throat clearing is elicited from the history

b) cobblestoning and phlegm are present on physical examination of the posterior pharyxnx

c) cough responds favorably to specific therapy aimed at eliminating the drip

UACS• Diagnosis of UACS as a cause of cough

is established when:a) frequent throat clearing is elicited from

the historyb) cobblestoning and phlegm are present

on physical examination of the posterior pharyxnx

c) cough responds favorably to specific therapy aimed at eliminating the drip

UACS-Sinusitis

Treatment-Sinusitis

• Antibiotics directed against H. Flu, S. Pneumonia, oral anaerobes

• Oral antihistamine/decongestant x 3 weeks• Intranasal decongestant for maximum of 5

days– e.g. oxymetazoline 2 sprays each nostril bid

x 3 days only

Treatment- Allergic Rhinitis

• Allergen avoidance

• Intranasal steroid

• Antihistamine

• Antihistamine/decongestant

• Allergen immunotherapy

Nasal Steroids

Antihistamines

Treatment- other UACS

• Perennial non-allergic, post-infectious, environmental irritant, vasomotor rhinitis

– Antihistamine/decongestant– Intranasal steroids– Intranasal ipratropium bromide for vasomotor rhinitis– Non-histamine mediated rhinitidies do not respond

as well to newer generation H1-antagonists; try older ones with anti-cholinergic activity

Asthma• Second most common cause of cough in

adults

• Clues that chronic cough is due to asthma:– Episodic wheezing, dyspnea– Reversible airflow obstruction– Bronchial hyperresponsiveness

• Confirmed by resolution of cough with asthma treatment

Cough Variant Asthma• 30-60% of patients presenting with

chronic cough that was due to asthma had cough as their ONLY symptom

Non-asthmatic Eosinophilic Bronchitis (NAEB)

•Normal CXR

•Normal spirometry

•Normal methacholine challenge

•Sputum eosinophilia

•Treatment- inhaled corticosteroids

Treatment- Asthma

• Inhaled corticosteroid

• ICS/LABA combination

• Oral steroids for empiric trial of efficacy is not recommended since oral steroids may improve cough resulting from any inflammatory disease

GERD• Suspect GERD when…

– Symptoms of heartburn or sour taste in mouth

– Reflux demonstrated by• 24-hour pH-impedance monitoring • Barium x-ray

• Cough is the only symptom of GERD in 40-75% of patients with chronic cough due to GERD

GERD

• Cough due to GERD occurs most commonly while patients are awake and upright, and usually does not occur or is not noted during the night

• Diagnosis of GERD as cause of chronic cough requires resolution of cough with GERD treatment

Treatment- GERD• Intensive anti-reflux medical regimen:

– Diet is most important factor• High protein, low fat anti-reflux diet• 3 meals per day• Avoid food, drinks, and meds that lower esophageal

sphincter pressure• NPO between meals and 2 hours prior to reclining• Improve compliance by referring to dietician and

monitoring weight at follow-up visit

– Elevate head of bed 4 inches– Proton pump inhibitors

Notable points:• Successful treatment for GERD takes on average 161-179

days, vs. 67-70 days for cough due to PNDS or asthma

Treatment- GERD

– Successful treatment for GERD takes on average 161-179 days, vs. 67-70 days for cough due to UACS or asthma

– Continue treatment for at least 3 months after cough has disappeared as a complaint, then gradually discontinue it

– If medical therapy fails• Consider OSA• Consider offending med

(CCB, nitrate, progesterone, theo)• Consider surgery

Algorithm for the management of patients ≥ 15 years of age with cough lasting > 8 weeks

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

ACE inhibitor cough• Accounts for 2% of cases of chronic cough• Non-productive, irritating, tickling, scratching

sensation in the throat• Can occur after 1st dose, or weeks to months

later• Usually will recur with switch to any other ACE

inhibitor• Diagnosis is confirmed when cough

disappears after drug in discontinued

Bronchogenic Carcinoma

Bronchogenic Carcinoma

• Cough is a common symptom of lung cancer, but lung cancer is NOT a common cause of chronic cough

• Suspicion for cancer as a cause of cough should be heightened

– If CXR shows a central lesion– In cigarette smokers who develop a new

cough that persists or have a change in character of their chronic cough

Cough 102

Unexplained Chronic Cough

• Middle aged females around the onset of menopause

• Onset triggered by a viral illness, Bordetella pertussis, basidiomycetous fungi

• Concomitant anxiety and depression (due to the chronic, persistent cough)

• *psychogenic cough is extremely rare

Pathogenesis of Unexplained Chronic Cough

• Cough reflex hypersensitivity– Increased sensitivity to cough challenge with

capsaicin– Increased density of sensory nerve fibers in

the airways– Increased TRPV-1 receptor expression on

sensory c-fibers

Cough reflex hypersensitivity

Increased density of sensory nerve fibers in the airways

Increased TRPV-1 receptor expression on sensory c-fibers

Cough hypersensitivity syndrome

• Chronic cough > 2 months duration

• Minimal or no sputum production

• One or more cough reflex triggers (cold air, speech, eating, odors such as perfumes)

• Urge to cough (tickle or itch) located in throat

• Adverse impact of cough on QOL

• Positive cough reflex challenge test (e.g. capsaicin)

Non-specific Anti-tussives

– Codeine 30-60 mg

– Dextromethorphan 60 mg

– Diphenhydramine 25-50 mg

– Benzonatate (Tessalon pearls)• 100-200 mg tid prn, maximum 600 mg/d

– Down-regulate neural activity– amitriptyline

– gabapentin

Cough hypersensitivity syndrome

New concepts in the management of chronic cough

• Obstructive sleep apnea

• Tonsillar enlargement

• Autoimmune disease (hypothyroidism)

• Basidomycetous fungi