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Cough.accp

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  • 1. THE CURE The 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 !!!!
  • 2. COUGH : DIAGNOSIS & MANAGEMENT ACCP EVIDENCE BASED CLINICAL PRACTICE GUIDELINES Dr.Sajid Nomani MD, MEM(USA) Peerless Hospital
  • 3. Cough: Public Health Concern
  • 4. 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
  • 5. Areas To Cover !!! • Why do we Cough? • Classification and Causes of Cough. • The ACCP guidelines for diagnosis & Managment
  • 6. 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
  • 7. 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)
  • 8. Pressure in the lungs rises to 100-300mmHg. Markedly positive intrathoracic pressure causes narrowing of the trachea.
  • 9. 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
  • 10. 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
  • 11. What is the most common cause of cough??? 1. Smoking 2. Infection 3. Asthma 4. Reflux 5. Occupation & Environmental Irritant.
  • 12. 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
  • 13. 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
  • 14. Complications of Cough Cardiovascular 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 Irwin,RS,Boulet,LP,Cloutier,MM,etal.Managingacough asadefensemechanismandasasymptom.Aconsensus panelreportoftheAmericanCollegeofChestPhysicians. Chest1998;114(suppl2):133S.
  • 15. 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 *
  • 16. TOOLS!!!! • HISTORY / PHYSICAL EXAMINATION • C-XRAY • SPIROMETRY • METHACHOLINE CHALLENGE TEST • 24H.PH MONITORING • BARIUM ESOPHAGOGRAPHY • HRCT
  • 17. ED……point of view!!! • R/O life threatning causes • ABC • Treatment • Paroxysm of caugh • lidocaine - 4 cc of 1% or 2% preservative-free nebulization
  • 18. American College of Physicians 2006 Cough Guidelines • Evidence-based • Includes guidelines for pediatric cough • Should be used in conjunction with “clinical judgment
  • 19. 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
  • 20. 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
  • 21. Categorization !!! • Acute cough: < 3 weeks • Subacute cough: 3-8 weeks • Chronic cough: >8 weeks
  • 22. ACUTE COUGH !!! • Cough lasting less than 3 weeks Key questions: • 1. Is it life-threatening? • 2. Are antibiotics needed?
  • 23. Red flags: findings of particular concern • Dyspnea…. • Hemoptysis…. • Resp. distress…. • Weight loss • Risk factors for TB, HIV infection or other immune suppressed states
  • 24. 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.ASTHAMA 2.Bronchiectasis 3.UACS 4.COPD Irwin R S et al. Chest 2006;129:1S-23S, American College of Chest Physicians
  • 25. 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 19 98, 114:133S- 181S
  • 26. 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)
  • 27. 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 pneumoniae Bordetella 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
  • 28. 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)
  • 29. 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
  • 30. When to suspect & Whom to treat? Suspect and treat if a clear cut history of Exposure Suspect and treat –if suggestive symptom Treat contact
  • 31. 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)
  • 32. 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
  • 33. 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
  • 34. SUBACUTE COUGH Post-infectious Non-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
  • 35. 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
  • 36. Algorithmic approach to subacute cough.
  • 37. 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
  • 38. Chronic Cough !!! • Cough lasting longer than 8 weeks • Causes • GERD • Asthma • Post nasal drip • COPD • Bronchogenic carcinoma • TB • ILD • ACE inhibitor
  • 39. 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
  • 40. 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
  • 41. 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???
  • 42. Most common causes of chronic cough in patients investigated in specialist clinics McGarvey et al. Pulm Pharmacol Ther 2004
  • 43. 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
  • 44. 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
  • 45. ACCP-GUIDELINES UACS • Diagnostic/Therapeutic trial: 1st generation A/D combination(gr-B) • 1st gen. Antihistamine / Decongestant – BROMPHENARMINE+PSEUDOEPHEDRINE*2wks (GR-A) • Sinus Imaging
  • 46. Back to the our patient!!! • BROMPHENARMINE+PSEUDOEPHEDRINE * 2 WKs FOLLOW-UP: No improvement !!! NEXT—ASSESMENT /PLAN??? 1) SPIROMETRY 2) START EMPERIC TREATMENT
  • 47. 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
  • 48. ACCP-GUIDELINES ASTHMA • Diagnostic tests: Spirometry :before and after Bonchodilator Methacholine inhalation challenge:
  • 49. 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
  • 50. Question??? Can asthma be a possibility if a pre and post-bronchodilator spirometry is completely normal? • (A)Yes • (B) No
  • 51. • COUGH MAY BE THE ONLY SYMPTOM IN 57% PATIENTS (DEPENDS ON STUDY)-- “COUGH-VARIANT ASTHMA” • Chest 1999;116(2):279-84
  • 52. 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
  • 53. Gastroesophageal Reflux Disease!!!
  • 54. 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
  • 55. 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
  • 56. 8 WEEKS LATER…….. • COUGH GONE COMPLETELY Dx : • COUGH VARIENT ASTHAMA .NON REFLUX GERD
  • 57. 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
  • 58. 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
  • 59. Stopping smoking slows decline in lung functionFEV1(%ofvalueatage25) 100 75 50 25 0 25 50 75 Never smoked or not susceptible to smoke Adapted from: Fletcher et al, Br Med J 1977. Stopped at 65 Stopped at 45 Smoked regularly and susceptible to its effects Death Age (years) stopping smoking can improve lung function by about 5% within a few months.
  • 60. 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
  • 61. I am sure you don’t want to miss this!!! • All that coughs is not UACS, asthma, GERD, or NAEB
  • 62. 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 Chest1998;114(2):133s-181s
  • 63. I am open forDiscussion / Questions