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Cough Diagnosis and Management Dr Paul Plant Consultant Chest Physician I’m Coughing my lungs up Doc. Areas To Cover • Why do we Cough? • Classification and Causes of Cough – Acute – Subacute – Chronic • When and How to Investigate • Management • Case Study What is Cough? ‘A Cough is a forced expulsive manoevere, usually against a closed glottis and which is associated with a characteristic sound’ Classification of Cough Three Categories of Cough • Acute Cough = < 3 Weeks Duration • Subacute Cough = 3 – 8 Weeks Duration • Chronic Cough = > 8 Weeks Duration Acute Cough Acute Cough <3/52 Duration Differential Diagnosis • Upper Respiratory Tract infections: Viral syndromes, sinusitis viral / bacterial • URTI triggering exacerbations of Chronic Lung Disease eg Asthma/ COPD • Pneumonia • Left Ventricular Heart Failure • Foreign Body Aspiration Acute Cough Epidemiology • Symptomatic URTI – 2-5 per adults per year – 7-10 per child per year • 40-50% will have cough • Self medication common -£24million per year • 20% consult GP (2F:1M) • Most resolve within 2 weeks Duration of Cough in URTI Primary Care Setting No antecedent or chronic lung disease End of Week 3 4 5 6 % Coughing 58 Sub-acute 35 Cough 17 8 -Post viral cough *Jones FJ and Stewart MA, Aust Family Physician Vol. 31, No. 10, October 2002 Managing Acute Cough “Don’t just do something stand there.” Alice in Wonderland Managing Acute Cough Identify High Risk groups Acute Cough Can be 1st Indicator of Serious Disease eg Lung ca, TB, Foreign Body, Allergy, Interstitial Lung disease ‘Chronic cough always preceded by acute cough’. Red Flags in Acute Cough • • • • • Symptoms Haemoptysis Breathlessness Fever Chest Pain Weight Loss Signs Tachypnoea Cyanosis Dull chest Bronchial Breathing Crackles THINK pneumonia, lung cancer, LVF GET a CHEST X-Ray Treatment of Simple Acute Cough • Benign course -reassure • Cough can distress • Patients report OTC medication helpful • Voluntary cough suppression linctuses/ drinks • Suppression of cough dextromethorphan, menthol, sedating antihistamines & codeine Which Anti-tussive? Dextromorphan Sedating Antihistamines eg Benilyn non-drowsy 1 meta-analysis high dose 60mg beware combinations eg paracetomol danger sleepy - nocturnal cough Menthol Steam inhalation. Effect on reflex short lived Codeine or Pholcodeine No better than dextromorphan but more side-effects. Not recommended Sub-Acute Cough Sub-acute Cough 3-8 weeks Likely Diagnoses • Postinfectious • Bacterial Sinusitis • Asthma • Start of Chronic Cough ACTIONS •Examine Chest •Chest X-Ray if signs or smoker •Measure of airflow obstruction ie peak flow -one off peak flow -serial • Don’t want to miss lung cancer spirometry Post Infectious Cough A cough that begins with an acute respiratory tract infection and is not complicated* by pneumonia *Not complicated = Normal lung exam and normal chest X-ray Post Infectious cough will resolve without treatment Cause = Postnasal drip or Tracheobronchitis Chronic Cough Case Study -CP 2007 • 60yr retd Nurse • Chest infection 2002 in Spain -mild SOB since • Chest infection 2006 hospitalised for 4/7 antibiotics / steroids • SOB and dry cough since • No variation • 4 lots of AB and steroids from GP plus tiotropium & oxis -no help for cough • Wt climbing • More SOB over 9/12 • Ex-smoker 30 pack yrs • FEV1 0.97 43% What else would you like to know? What causes can you think of? Chronic Cough Epidemiology Epidemiology difficult -acute vs chronic Cullinan 1992 Respir Med 86:143-9 n=9077 16% coughed on >50% days of year 13% coughed sputum on >50% days of year 54% were smokers Chronic Cough Epidemiology Associations with: Smoking (dose related) Pollutants (particulate PM10) -occupation Environmental irritants (eg cat dander) Asthma Reflux Obesity Irritable bowel syndrome Female Making the Diagnosis Common Differentials Lung Disease -normal CXR -abnormal CXR Gastro -Oesophageal Reflux Post-nasal Drip -allergic rhinitis -bacterial sinusitis Non-structural ACE-Inhibitors Tobacco Habit Cough Chronic Cough Investigating Chronic Cough Purpose: • To exclude structural disease • To identify cause How History & Examination inc occupation & Spirometry ALWAYS GET A CHEST X-RAY IN CHRONIC COUGH Beware Cough triggered by: change in temperature scent, sprays, aerosols and exercise indicate Increased cough reflex sensitivity and Not just seen in Asthma. Esp GORD, infection and ACEI ACE-Inhibitors and Chronic Cough Incidence: 5-20% Onset: one week to six months Mechanism Bradykinin or Substance P increase Usually metabolized by ACE) PGE2 accumulates and vagal stimulation. Treatment: switch to Angiotensin II Receptor Blockers (ARBs) Gastro-oesophageal Reflux GORD accounts alone or in combination for 10-40% of chronic cough Two Mechanisms a. Aspiration to larynx/ trachea b. Acid in distal oesophagus stimulates vagus and cough reflex Gastro-oesophageal Reflux Symptoms Cough Features GI Symptoms Throat clearing Worse at night / rising On eating Reflex hypersensitivity If Aspiration main mechanism Heart burn Waterbrash/ Sour taste Regurgitation Morning Hoarseness CXR -normal or hiatus hernia Spirometry normal If Vagal - NO GI symptoms Gastro-oesophageal Reflux Reflux may be due to Medications or Foods Drugs and foods that reduce lower esophageal sphincter (LES) pressure and can cause increased reflux include: Theophylline Oral β adrenergic agonists NSAIDs Ascorbic acid Calcium Channel Blockers Chocolate Caffeine Peppermint Alcohol Fat Gastro-oesophageal Reflux Investigation • Oesophageal pH monitoring for 24 hours (+diary) – 95% sensitive and specific 95% • Ba swallow not sensitive enough • Endoscopy - may confirm but false -ve rate Endoscopy can show GORD, but cannot confirm GORD as the cause of cough. © Slice of Life and Suzanne S. Stensaas GED GED Gastro-oesophageal Reflux Treatment Trial of Therapy • High dose twice daily PPI for min 8weeks • + prokinetic eg domperidone or metoclopramide • Eliminate contributing drugs. • Baclofen rarely Improves in 75-100% of cases Post-Nasal Drip Symptoms: • ‘something dripping’ • frequent throat clearing • nasal congestion / discharge • posture Causes • Allergic rhinitis • Non-allergic rhinitis • Vasomotor rhinitis • Chronic bacterial sinusiits Post Nasal Drip Treatment Options: 1. Exclude /treat infection 2. Nasal steroid for 8/52 3. Sedating antihistamines 4. Antileukotrienes eg montelukast 5. Saline lavage 6. ENT opinion Lung Diseases inc Tobacco Favouring Lung Disease Shortness of breath Wheeze Sputum production Haemoptysis Chest signs eg crackles Chest X-Ray and Differential of Cough Normal CXR • Gastro-oesophageal reflux • Post-nasal Drip • Smokers cough/ Chronic Bronchitis • Asthma • COPD • Bronchiectasis • Foreign body Abnormal CXR • • • • • Left ventricular failure Lung cancer Infection/ TB Pulmonary fibrosis Pleural effusion Left Ventricular Failure Idiopathic Pulmonary Fibrosis TB Lung Cancer Chest X-Ray and Differential of Cough Normal CXR • Gastro-oesophageal reflux • Post-nasal Drip • Smokers cough/ Chronic Bronchitis • Asthma • COPD • Bronchiectasis • Foreign body Smoking and the Healthy Lung The Development of Chronic Bronchitis (Daily Cough) Smoking Neutrophil Infiltration Goblet hyperplasia (mucous production) Release of Proteinases Normal Spirometry and Flow Volume Loops Normal Values • • • • Depend on Age/ Sex / Height / Race Tables and slide rules available Asians decrease value by 7% Afro-Caribbean decrease by 13% • Report results as Absolute and % predicted • Normal is 80-120% Obstructed Spirometry FEV1 reduced FVC largely preserved FEV1/FVC low <70% FEV1 =1.0 ‘FVC’ =2.0 FEV1/FVC=50% FVC =3.0 =33% FEV1/FVC Peak Flow Measurement Single or Repeated Measures Definition of COPD Chronic obstructive pulmonary disease is characterized by •airflow limitation that is not fully reversible. FEV1always <80% with •airflow limitation that is usually progressive •associated with an abnormal inflammatory response to noxious particles or gases. Development of Emphysema Proteinases diffuse out Neutralised by Antiproteinases eg a1 Anti-trypsin If balance incorrect alveolar walls destroyed FEV1 (% of value at age 25) Stopping smoking slows decline in lung function Smoked regularly and susceptible to its effects 100 Never smoked or not susceptible to smoke 75 Stopped at 45 50 25 Stopped at 65 Death 0 25 50 Age (years) Adapted from: Fletcher et al, Br Med J 1977. 75 Step 1 Make Sure Patient Has COPD EXPOSURE TO RISK FACTORS tobacco occupation indoor/outdoor pollution SYMPTOMS cough sputum dyspnea SPIROMETRY REMEMBER: •Only 1/3 smokers get COPD •Need 15 pack years min •Asthma/ Bronchiectasis Chronic Disease Management Main Algorithm All COPD PATIENTS Stop Smoking -use Leeds Smoking Services Guidelines Short-acting bronchodilator prn (see note 1) Annual flu vaccination 5 yearly pneumonia vaccination (see note 2) Encourage regular exercise (5x 30mins walking at breathless pace per week) Maintain weight in healthy range Is patient breathless walking on level ground at a normal pace? YES – LONG-ACTING BRONCHODILATOR CAN PATIENT USE AN MDI? Yes No Long-acting beta agonist salmeterol 50mcg bd (MDI/ accuhaler) or formoterol 12 mcg bd (turbohaler) (see note 3) Plus short acting bronchodilator prn Longacting anticholinergic Tiotropium 18mcg od (see note 3) Plus short acting beta agonist prn (breathe actuated or dry powder) £30 No benefit Stop longacting drug and try the alternative £34 Partial Response Add ipratropium bromide 40 mcg qds via MDI + spacer (see notes 3 & 4) £43 £47 See Pulmonary Rehabilitation algorithm Partial Response Add shortacting beta agomist 2puffs qds via breathe-actuated inhaler or dry powder device (see note4) Acute Management Increase short acting beta agonist 1st Line Antibiotic for duration of exacerbation eg 2-8 puffs upto 4 hourly amoxycillin 250-500mg tds or doxycycline 100mg bd for 1 week (see note 6) Steroids Prednisolone 30mg od for 1 week No Improvement at 1 week 2nd line antibiotic if sputum still purulent ciprofloxacin 750mg bd (Half maintenance theophylline dose) (see note 7) Continue prednisolone 30mg od upto 2 weeks maximum Prevention of Future Exacerbations Is the FEV1 <50% predicted and has the patient had >2 exacerbations in the last 12 months requiring oral steroids or antibiotics? No No additional therapy Yes Add budesonide 400mcg bd or fluticasone 500mcg bd. If on a longacting beta agonist -prescribe as symbicort 200/6 2 clicks bd or seretide 500 1 click bd (cheaper than separates) (see note 8) >2 exacerbations in next 12 months after starting the above add carbocisteine 750mg bd (see note 9) Definition of asthma “A chronic inflammatory disorder of the airways … in susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.” Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92 Asthma • Variable airflow obstruction – Symptoms vary – Measurements of airflow obstruction vary • • • • • Associated with atopy (hayfever, eczema, urticaria) Occupational links eg bakers, isocyanates, wood-dust Dry cough, worse at night Episodic breathlessness Effects all ages Asthma Allergens • Tree • Grass • Fungi • House dust mite • Pets • Occupational Triggers • Exercise • Fumes/ Smoke • Cold air • Oesophageal Reflux • Occupational Proving Variability Looking for 20% variation in PEFR or 15% in FEV1 1. Opportunistic single low peak flow in surgery Give bronchodilator and repeat in 20 mins Give trial of therapy and repeat next visit 2. Opportunistic single normal peak flow in surgery Measure on subsequent visits -hope for variability naturally Home peak flow measurements Induce an asthma attack! -histamine challenge Peak Flow Measurement Single or Repeated Measures Stepwise management of asthma in adults Step 5: Continuous or frequent use of oral steroids Step 4: Persistent poor control Step 3: Add-on therapy Step 2: Regular preventer therapy Step 1: Mild intermittent asthma Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Case Study -CP 2007 • 60yr retd Nurse • Chest infection 2002 in Spain -mild SOB since • Chest infection 2006 hospitalised for 4/7 antibiotics / steroids • SOB and dry cough since • No variation • 4 lots of AB and steroids from GP plus tiotropium & oxis -no help for cough • Wt climbing • More SOB over 9/12 • Ex-smoker 30 pack yrs • FEV1 0.97 43% What else would you like to know? History positional /reflux What causes can you think of? COPD Obesity with Reflux 8/52 omeprazole 20mg bd + domperdone 10mg tds asymptomatic Conclusions Acute Cough < 3/52 Usually URTI CXR if worried Symptomatic therapy Subacute Cough 3-8/52 Usually post-viral CXR if smoker or worried Chronic Cough >3/12 CXR and Spirometry Consider GORD Post -Nasal Drip Lung - Abnormal CXR - Normal CXR (asthma/ COPD)