Download Approach to Cough

Approach To The Patient With Cough
Case
• MKSAP 13 – Pulmonary Question #22
– A 47 yo black male is evaluated because of a 2-month
history of cough. Three months ago hypertension was
diagnosed, for which he takes HTCZ and benazepril. He
attributes his cough to the change of weather. He has a hx
of GERD that is well controlled on PPI. No hx of asthma.
– Which of the following would be the most appropriate
next step?
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CT scan of sinuses
pH probe
Methacholine challenge testing
Stop ACEI
Allergy testing
Cough By Duration
• Acute Cough < 3 weeks
• Sub acute Cough from 3 – 8 weeks
• Chronic Cough > 8 weeks
Irwin, R. S. et al. Chest 2006;129:1S-23S
Irwin R, Madison JM. The diagnosis and treatment of cough. N Engl J Med 2000; 343:1715–1721
Chronic cough algorithm for the
management of patients >= 15 years
Irwin, R. S. et al. Chest 2006;129:1S-23S
Evaluation Of Nonsmokers Presenting With
Chronic Cough
• If on ACEI discontinue ACEI
• Consider UACS, Asthma, GERD as most
common diagnoses
• Do not use the patient’s description of timing
of onset or production of sputum to diagnose
• The etiology of some cough syndromes is
multifactorial
Pratter MR. Overview of common causes of chronic cough: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):59S–62S
Chronic Cough Syndrome Caused By
Rhinosinus Disease
• Formerly labeled post nasal drip syndrome
• ACCP recommends calling this upper airway cough syndrome
• Ddx: Allergic rhinitis, postinfectious rhinitis, bacterial sinusitis,
rhinitis due to irritants, occupational, medicamentosa,
anatomic abnormalities
• Evaluation includes a combination of criteria, including
symptoms, physical examination findings, radiographic
findings, and, ultimately, the response to specific therapy
Pratter MR. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP
evidence-based clinical practice guidelines. Chest 2006; 129(suppl):63S–71S
Chronic Cough Syndrome Caused By
Rhinosinus Disease
• Draining into throat, need to clear throat, tickle in
throat, congestion, nasal discharge, hoarseness,
wheeze
• If obvious, treat with 1st generation A/D
• If not responsive, image sinuses
• Empiric therapy with 1st generation A/D
• An empiric trial of therapy aids in diagnosis
• An empiric trial of therapy should be given before
considering exhaustive work-up
Pratter MR, Brightling CE, Boulet LP, et al. An empiric integrative approach to the management of cough: ACCP evidence-based clinical practice
guidelines. Chest 2006; 129(suppl):222S–231S
Chronic Cough Syndrome Caused By
Rhinosinus Disease
• In the setting of the common cold;
– Treat with A/D, consider Naprosyn
– Nonsedating antihistamines do not work
– Even if productive of sputum do not use
antibiotics routinely
Cough And Asthma
• May be a symptom of asthma or a distinct entity,
cough variant asthma
• Spirometry with bronchodilator, and methacholine
challenge testing used to evaluate
• Treat with inhaled bronchodilator and inhaled
corticosteroids
• Can only diagnose this as cause if syndrome is
responsive to therapy
Cough And Asthma
• Consider sputum eosinophil level for steroid
responsiveness
• If not responsive or noncompliant, consider
leukotriene receptor antagonist
• May consider oral steroids if severe
Dicpinigaitis PV. Chronic cough due to asthma: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):75S–79S
Clinical Profile That Predicts That Chronic Cough Is Likely Due to
GERD Chronic cough
• Not exposed to environmental irritants nor a present smoker
• Not taking an angiotensin-converting enzyme inhibitor
• Chest radiograph is normal or shows nothing more than stable,
inconsequential scarring
• Symptomatic asthma has been ruled out:
• Cough has not improved with asthma therapy, or Methacholine
inhalation challenge is negative
• Upper airway cough syndrome due to rhinosinus diseases has
been ruled out: First-generation H1 -antagonist has been used
and cough failed to improve, and “Silent” sinusitis has been
ruled out
• Nonasthmatic eosinophilic bronchitis has been ruled out:
Properly performed sputum studies are negative, or
• Cough has not improved with inhaled/systemic corticosteroids
Irwin, RS Chronic cough due to gastroesophageal reflux disease: ACCP evidencebased clinical practice guidelines. Chest 2006;129(suppl),80S-94S
Cough Associated With GERD
• Suspected by clinical profile
• Treat if suspected, even if they are otherwise
asymptomatic
• Cannot rule out on clinical profile
• Cannot rule out GERD as cause of cough until it is
fully treated/evaluated
• Esophageal pH probe is the most sensitive and
specific test for acid reflux
Cough Associated With GERD
• Normal esophagoscopy does not rule out
GERD
• Barium esophography is the test of choice to
evaluate for non-acid reflux cough complex
• Esophageal manometry may be useful
Rudolph C, Mazur L, Liptak G, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children:
recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 2001;
32(suppl):S1–S31
Cough Associated With GERD
• If initial treatment fails, escalate therapy (mixed
modalities)
• Evaluate for effective therapy
• Lifestyle changes
– Anti-reflux diet that includes no > 45 g of fat in 24 h and no
coffee, tea, soda, chocolate, mints, citrus products,
including tomatoes, or alcohol, no smoking, and limiting
vigorous exercise that will increase intraabdominal
pressure
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Spectrum of Options for Treating Chronic Cough Due to
GERD
Anti-reflux medical therapy
Diet
Lifestyle changes
Smoking
Exercising
Consuming alcohol
Medications
– Acid suppression - PPI, PPI/BID, H2 blockers
– Prokinetic
Address risk factors/Treat other causes of cough
Treat comorbid conditions
– Obesity
– Obstructive sleep apnea
– Consider changing medications for comorbid conditions
Anti-reflux surgery
Irwin, RS Chronic cough due to gastroesophageal reflux disease: ACCP evidence-based clinical practice guidelines.
Chest 2006;129(suppl),80S-94S
Nonasthmatic Eosinophilic Bronchitis
• Common cause of cough 10-30% cases
• Diagnosed by ruling out asthma and showing
induced sputum/bronchial wash eosinophilia, or
response to ICS
• Evaluate for allergen or occupational cause
• Avoidance is treatment of choice if cause found
Brightling CE. Chronic cough due to nonasthmatic eosinophilic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(
Nonasthmatic Eosinophilic Bronchitis
• Treat with inhaled corticosteroids
• If firmly diagnosed and not responsive
consider burst of oral systemic steroids
• Evaluate for reduction of eosinophilia
• vs Asthmamast cells
biopsy
Brightling CE. Chronic cough due to nonasthmatic eosinophilic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(
Features
Eosinophilic
Bronchitis
Classic Asthma
Cough-Variant
Asthma
Sx
Cough and upper
airway
Dyspnea, cough,
wheeze
Isolated cough
Atopy
No increase
common
Common
Airway
Absent
hyperresponsiveness
Present
Present
Response BD
Absent
Good
Good
Response ICS
Good
Good
Good
Sputum eos
Always
Usually
Usually
Bronchial bx eos
Very common
Common
Common
Mast cells in airway
smooth muscle
No
Yes
Yes
Subacute cough algorithm for the
management of patients >= 15 years
Irwin, R. S. et al. Chest 2006;129:1S-23S
Post-infectious Cough
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<8 weeks
CXR normal
Resolves on its own
Postviral airway inflammation, bronchial
hyperresponsiveness, mucus hypersecretion,
impaired mucociliary clearance
Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):95S–103S
Braman SS. Chronic cough due to chronic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):104S–115S
Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):72S–74S
Post-infectious Cough
• No antibiotics unless sinusitis or Bordetella
pertussis
• Consider trial of ipratropium to attenuate
cough
• If this does not work consider trial of ICS
• If severe paroxysms – prednisone 30-40mg
short finite period, only when GERD, asthma,
UACS ruled out
Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):95S–103S
Braman SS. Chronic cough due to chronic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):104S–115S
Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):72S–74S
Post-infectious Cough
• Codeine or Dextromethorphan when other
measures fail
• Paroxysms of coughing posttussive vomit and
inspiratory whoop
• Order nasopharyngeal aspirate or cx for B.
pertussis
• IgG/IgA for presumptive diagnosis
• Erythromycin, 5 day isolation
Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):95S–103S
Braman SS. Chronic cough due to chronic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):104S–115S
Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):72S–74S
Acute cough algorithm for the
management of patients >= 15 years
Irwin, R. S. et al. Chest 2006;129:1S-23S
Chronic cough algorithm >15yrs
Irwin, R. S. et al. Chest 2006;129:1S-23S
Irwin R, Boulet L-P, Cloutier MM, et al. Managing cough as a defense mechanism and as a symptom: a consensus panel report of the
American College of Chest Physicians. Chest 1998; 114(suppl):133S–181S
Cough stimulus
• Afferent limb of cough reflex
• Sensory receptors stimulated
• Mucus volume, production, consistency, ciliary
action
• Neural brainstem elements
• Spinal motoneurons innervate respiratory
muscles
Suppressant Therapy
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Old term - non-specific therapy
Peripheral antitussive agents
Centrally acting antitussive agents
Inhibit efferent limb and paralytic agents
When cough is elevated over what is required
to defend airways
• No evidence that therapy prevents cough
Suppressant Therapy
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Short-term basis
Symptomatic relief
Etiology of cough is unknown
Specific therapy requires time to become
effective
• Specific therapy ineffective, ie inoperable lung
cancer
Drugs that alter mucocillary factors
• Conflicting study data on Guaifenesin,
Ipratropium, Tiotropium, and Acetylcysteine
• Few drugs suppress cough consistently
• In chronic bronchitis mucolytics are not
recommended
• In URI or chornic bronchitis the only
anticholinergic recommended is ipratropium
bromide
Peripheral antitussive agents
• Suppress excitability of sensory receptors
• 2 drugs recommended by evidence based guidelines
in ACCP
• Not available in US
• Benzonatate - Tetracaine congener with antitussive
properties
• Topical anesthetic action on the respiratory stretch
receptors
Centrally acting antitussive agents
• Work on brainstem CNS
• Chronic bronchitis codeine and
dextromethorphan recommended for shortterm relief
• Cough secondary to URI limited efficacy, not
recommended
Inhibit efferent limb and paralytic agents
• In patients with chronic or acute cough requiring
symptomatic relief, drugs that affect the efferent
limb of the cough reflex are NOT RECOMMENDED
– Baclofen - decreased cough secondary to ACE-inhibitor in
one study, not yet tested in DBPCT
• During intubation with GETA neuromuscluar blocking
agents such as succinylcholine recommended to
suppress coughing
Protussive effects – increase cough
clearance
• Bronchitis – hypertonic saline solution
recommended short term basis to increase
cough clearance
Case
• MKSAP 13 – Pulmonary Question #22
– A 47 yo black male is evaluated because of a 2-month
history of cough. Three months ago hypertension was
diagnosed, for which he takes HTCZ and benazepril. He
attributes his cough to the change of weather. He has a hx
of GERD that is well controlled on PPI. No hx of asthma.
– Which of the following would be the most appropriate
next step?
•
•
•
•
•
CT scan of sinuses
pH probe
Methacholine challenge testing
Stop ACEI
Allergy testing
Referral To A Cough Specialist
• If no cause is found with previous algorithmic
approach referral is appropriate
• Most involved evaluations involve specialists;
GI, ENT, Pulmonary, Cardiology
• Consider pulmonary consult for assistance if
needed
Questions