Download Chronic Cough

Cough - differential diagnosis:
It’s not all asthma!
Dr Chris Davies MD FRCP
Consultant Physician
RBH / Dunedin Hospital
Reading
Prevalence
• 3 - 40 %
• 7% has significant inpact on QoL
• Primary care survey
• 14% men
• 10% women
report coughing on > 50% days of year
Cough - Definition
• acute
• (subacute
• chronic
< 3 weeks
3 - 8 weeks)
< 8 weeks
Cough - Definition
• Acute: Causes?
Cough - Definition
• Acute: Causes?
– Infections
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Viral
Bronchitis
Pneumonia
Whooping cough
– Non-infectious
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Asthma/COPD flares
Environmental exposures
Drugs
Foreign body etc
Miscellaneous
Mechanisms
Pathophysiology
• Cough reflex sensitive
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Atmospheric changes
perfumes
ACE I
GORD
Causes of cough
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Causes of cough
smoking
lung disorders (> 50%)
chronic cough syndromes
drugs - ACE Inhibitors
mediastinal masses
cardiac
upper GI
neurological
idiopathic & psychogenic
Causes of Chronic Cough
Syndromes?
Causes of Chronic Cough
Syndromes
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Gastro-oesophageal reflux
Rhinosinusitis (postnasal drip)
Asthma – cough variant
Eosinophilic bronchitis
• Chronic tonsillar enlargement
• Angiotensin-converting enzyme inhibitor
medications
Impact of Chronic Cough
Impact of Chronic Cough
• Physical
– Cough syncope
– Chest pain
– Urinary incontinence
• Psychological
– Social exclusion
– Marital dysharmony
– Depression
Impact of Chronic Cough
• Physical
– Cough syncope
– Chest pain
– Urinary incontinence
• Psychological
– Social exclusion
– Marital dysharmony
– Depression
Chronic cough
Chronic cough – how to approach?
• Red flag symptoms
• Urgent CXR and pathway
Chronic cough – how to approach?
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haemoptysis
chest pain
weight loss
night sweats
progressive/persistent
symptoms (esp cough)
• heavy smoking history
• asbestos exposure
CXR - Urgent pathway
CXR - Urgent pathway
Initial strategy
Ask about
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dry or productive (? purulent)
other respiratory symptoms e.g. SOB & wheeze
nasal symptoms & sensation of post-nasal drip
dyspepsia & waterbrash
history of atopic illness or severe LRTI
history of heart disease
drugs taken
smoking history
occupation, pets, hobbies
When to order a chest x-ray?
• In the absence of Red flag symptoms
– All chronic cough (> 8 weeks duration)
– X-ray abnormal – treat ± refer
But usually…..
Other tests
• Spirometry – in all chronic cough pts
– Usually normal
– may be normal in cough variant asthma but
may be changes in flow volume loop
Spirometry
Flow volume loops
• Flow (l/min)
• Volume (l)
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(a) normal
(b) asthma
(c) emphysema
(d) restrictive
(e) upper airway
obstruction
Chest x-ray “normal”?
• Is there a possible lung disease?
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Asthma
COPD
Bronchiectasis
Early lung fibrosis
• Gastro-oesophageal reflux (GORD) ?
• Rhinosinusitis with post nasal drip (PND) ?
• Stop ACE inhibitors if possible
Chronic Cough – the majority…
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GORD +/- laryngopharngeal reflux
Rhinosinusitis/PND
Cough variant asthma with BHR
Eosinophilic bronchitis
and finally…
• Unexplained Chronic Cough Syndrome
Clues in the history
• Asthma
Clues in the history
• Asthma
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Nocturnal, exposure to cold, exercise, aerosols
May be symptoms of wheeze, sputum
Family history, atopy, pets
May be a previous response to steroids
little/no variable airflow obstruction
• Eosinophilic bronchitis
– Very similar….
Clues in the history
• GORD
Clues in the history
• GORD
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with or after meals
on phonation / laughter
10 - 30 minutes after getting out of bed
Often not at night unless severe
Postural – e.g in car, sitting on phone
laryngopharngeal reflux – throat clearing
Wheeze afterwards - aspiration
May get dysfunctional respiratory symptoms
GORD - pathophysiology
• Acid and non-acid reflux
– Lower sphincter
• Mornings – after rising
• Post prandial – 10 mins later
– Hiatus Hernia
– Gastrointestinal dysmotility
– Diaphragmatic movement
• Talking
• Telephone
Clues in the history
• Post nasal drip
Clues in the history
• Post nasal drip
– May be no nasal or upper airway symptoms
– May be sensation of drip or throat clearing
– No ‘test’ – treatment trial may be 1st line of
intervention
But which is the cause?
• All (asthma, GOR, PND) may exhibit no
other symptoms of the disorder
• All are common & frequently co-exist
• Positive predictive value of characteristic
symptoms is limited (40 - 60%)
• Multiple causes (20 - 60%)
Empirical trials of treatment
• Can be diagnostic tool in chronic cough
• Guided by most likely cause/best guess
once know spirometry and CXR normal
• Treat with relatively high dose & prolonged
duration e.g. 4-6 weeks each
GORD
• PPI ( eg Omeprazole 20 - 40 mg bd,
8 weeks)
• Consider adding ranitidine too
• dietary advice, lifestyle modification
• Add prokinetics and antacids
Cough variant asthma
• (inhaled beta-2 agonists) – don’t usually help
• inhaled steroids (400 mcg BDP bd, 8 weeks)
– Work in eosinophilic bronchitis too
• Oral steroids ?
– e.g. Prednisolone 30mg daily – 10-14 days
Rhinosinusitis/PND
• nasal steroids (for ≈ 2 months)
– Correct technique essential
• nasal decongestants (short term only)
• Older generation antihistamines e.g.
promethazine (Phenergan®)
Still coughing?
• No response –
– treat other cough syndromes in turn
• Partial response
– escalate treatment(s)
Still coughing?
• No response – treat other cough syndromes in
turn
• Partial response – escalate treatment
– Asthma – Monteleukast, Theophylline, short course
oral steroids
– GOR – Alginate (5-10 ml qds), double dose PPI, H2
blocker e.g ranitidine, pro-kinetic e.g. domperidone
or metoclopramide tds
– PND – antihistamine & decongestant, high strength
nasal steroid, saline douches
Still coughing?
• No response – treat other cough syndromes in
turn
• Partial response – escalate treatment
– Asthma – Monteleukast, Theophylline, short course
oral steroids
– GOR – Alginate (5-10 ml qds), double dose PPI, H2
blocker e.g ranitidine, pro-kinetic e.g. domperidone
or metoclopramide tds
– PND – antihistamine & decongestant, high strength
nasal steroid, saline douches
Still coughing?
• No response – treat other cough syndromes in
turn
• Partial response – escalate treatment
– Asthma – Monteleukast, Theophylline, short course
oral steroids
– GOR – Alginate (5-10 ml qds), double dose PPI, H2
blocker e.g ranitidine, pro-kinetic e.g. domperidone
or metoclopramide tds
– PND – antihistamine & decongestant, high strength
nasal steroid, saline douches
But has it really worked?
• Patients may have difficulty confirming
improvement
• Objective scores…
But has it really worked?
• Patients may have difficulty confirming
improvement
• Objective scores…
• Consider withdrawing and/or reducing
treatment & monitor symptoms 4 weeks
Leicester Cough Questionnaire. © 2001.
Birring S S et al. Thorax 2003;58:339-343
Chronic cough
History when seen
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Cough 8 years
Possibly started with infection
Dry
Worse when gets up and when lies down
Worse winter
Worse laughter
History when seen
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Breathless stairs
Wheeze coughing not otherwise
No GORD or post nasal symptoms
Tried salbutamol / PPI ?dose
Examination – few crackles L base
Spiro/bloods normal
History when seen
• Given BCM again and PPI
• HRCT
Pitfalls
• Inadequate treatment trial
– duration
– strength
– compliance
• Multiple causes
• Variability of chronic cough
When to refer?
• A number of factors will influence this –
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Confidence in continuing treatment trials
Time consuming for GP
Patient pressure that ‘something is wrong’
Partner pressure
‘Secondary care’ investigations
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Repetition of history
Examination
Spirometry (variability)
Review imaging
In depth discussion about causes/treatment
Further empirical trials
Tests
‘Secondary care’ investigations
• High resolution CT scan of lungs
– Often important after trials to
– A) reassure patient nothing more serious
– B) identify any structural cause
‘Secondary care’ investigations
• GORD Tests?
– OGD – often no oesophagitis
– 24 hour oesophageal pH monitoring
– Oesophageal manometry
– May not correlate with symptoms
‘Secondary care’ investigations
• Bronchial challenge test
– High NPV, low PPV
• Induced sputum (eosinophils)
• Nitric oxide
– Reduces in response to steroids
• CT sinuses
• Nasendoscopy
Heart-sinks or Unexplained Chronic
Cough Syndrome
Unexplained Chronic Cough
Syndrome
• Can be due to:
– 1. Inadequate assessment
– 2. Poor Compliance treatments
– 3. Ineffective treatment
• These patients probably have a
“hypersensitive cough reflex”
Unexplained Chronic Cough
Syndrome
• Typically
– Middle aged women – perimenopausal
– Often triggered by infection
– Increased anxiety/depression levels
Unexplained Chronic Cough
Syndrome
• Treatments are limited…stop as much as possible
• Opiates
• act centrally & locally on OP-3 receptor
• usually codeine linctus or pholcodine initially
• side effects a problem
• SALT / Physiotherapy
• Local anaesthetics (nebulised lignocaine)
• Gabapentin/TCADs
– RCT
– Maximal dose tolerated
Summary
• chronic cough is common
• limited number of common causes
• diagnosis is difficult but therapeutic trials are often
effective – careful explanation helpful for patients
• secondary care approach may require multispeciality input
• 80 - 90% of patients improve (eventually!)
• UCCS – may require novel treatments