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
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
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 : DIAGNOSIS & MANAGEMENT
ACCP EVIDENCE BASED CLINICAL
• 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
Areas To Cover !!!
• Why do we Cough?
• Classification and Causes of Cough.
• The ACCP guidelines for diagnosis &
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
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)
Pressure in the lungs rises to 100-300mmHg. Markedly positive intrathoracic
pressure causes narrowing of the trachea.
• 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
Cough Reflex !!!
Impulses from the cough receptors
via afferent limb vagus N.
EFFERENT IMPLUSE GENERATED
spinal motor : Expiratory muscles
Phrenic : Diaphragm
Vagus n. : Larynx,trachea,bronch
to the expiratory organs to produce
What is the most common cause of cough???
5. Occupation & Environmental Irritant.
Cough: What’s it good for ???
• Protect the airway from pathogens,
particulates, food, other foreign bodies
• Clear the airways of accumulated secretions,
• Attract attention
• Signal displeasure
Complications of Cough!!!
• Result primarily from marked increase in
intrathoracic pressure (> 300 mmHg) during
• Affect nearly every other organ system
• Disruption of surgical wounds
• Negative impact on quality of life, particularly
in chronic cough
Complications of Cough
Loss of consciousness
Rupture of subconjunctival, nasal and anal veins
Dislodgement/malfunctioning of intravascular catheters
Cerebral air embolism
Acute cervical radiculopathy
Malfunctioning ventriculoatrial shunts
Stroke due to vertebral artery dissection
Gastroesophageal reflux events
Hydrothorax in peritoneal dialysis
Malfunction of gastrostomy button
Complications of Cough !!!
Inversion of bladder through urethra
From asymptomatic elevations of serum creatine phosphokinase to rupture of rectus
Pulmonary interstitial emphysema, with potential risk of pneumatosis intestinalis,
pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, pneumothorax,
Tracheobronchial trauma (eg, bronchitis, bronchial rupture)
Exacerbation of asthma
Intercostal lung herniation
Petechiae and purpura
Disruption of surgical wounds
Self-consciousness, hoarseness, dizziness
Fear of serious disease
Decrease in quality of life
ACUTE COUGH !!!
• Cough lasting less than 3 weeks
• 1. Is it life-threatening?
• 2. Are antibiotics needed?
Red flags: findings of particular concern
• Resp. distress….
• Weight loss
• Risk factors for TB, HIV infection or
other immune suppressed states
Life-threatening Dx Non-Life-threatening dx
exacerbation of asthma or
COPD, PE, Heart Failure,
other serious disease
Irwin R S et al. Chest 2006;129:1S-23S, American College of Chest Physicians
Causes and estimated frequencies of acute cough in the
• Common cold
• Acute bacterial
• Exacerbations of
• Allergic rhinitis
• Less common
• Congestive heart
Irwin RS et
al. Chest 19
• Common cold
• 1st gen. Antihistamine / Decongestant –
• 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)
• “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
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
• 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)
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
When to suspect & Whom to treat?
Suspect and treat if a clear cut history of
Suspect and treat –if suggestive symptom
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:
Subacute Cough !!!
• Cough lasting 3-8 week
• Usually resolve in 2 wks
• Sign of chronic cough!!!!!
1. Is it post-infectious?
2. If post-infectious, are antibiotics needed
New onset or exacerbation of pre-
Asthma BronchitisUACS GERD
Irwin R S et al. Chest 2006;129:1S-23S
2006 by American College of Chest
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
• Bronchial Hyperresponsivness
• Mucous hypersecration
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???
• 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
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.
• Several common cold in last 3-4 years.
• No other significant medical history.
• No medication
• House maker
• No harmful environmental exposure
• Regular workout
1) WHAT IS THE CAUSE OF HER COUGH???
Most common causes of chronic cough in patients
investigated in specialist clinics
McGarvey et al. Pulm Pharmacol Ther 2004
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
• Gastroesophageal reflux disease
• Non-asthmatic eosinophilic bronchitis
Can asthma be a possibility if a pre and
post-bronchodilator spirometry is completely
• (B) No
• COUGH MAY BE THE ONLY SYMPTOM IN
57% PATIENTS (DEPENDS ON STUDY)--
• Chest 1999;116(2):279-84
Back to the our patient!!!
Follow-up -8wks : Marked improvment!!!!
But still coughing specially at night and @
CONSIDER MULTIPLE Dx
PROTON PUMP INHIBITOR
LIMITED VIGOROUS EXERCISE
• ACID REF. VS NON ACID REF.
• Classic symptoms: heartburn,
sour taste in mouth
• Cough may be only symptom
• Diagnostic tests:
• 24-hour esophageal pH
• Barium Esophagography
• 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
• Acid suppression -proton pump inhibitor
IF FAIL----ANTIREFLUX SURGERY
↓ quality of life
Non-Asthmatic Eosinophilic Bronchitis
• 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
• Effects in 1-4wks
• Swictched to other agents.
• Restart ACE
• inhaled sodium cromoglycate,
Peter V. DicpinigaitisCHEST. january 2006;129(1_suppl):169S-173S.
• Occupational & enviromental cause-avoidance
slows decline in lung functionFEV1(%ofvalueatage25)
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
and susceptible to
stopping smoking can improve lung function by about 5% within a
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
I am sure you don’t want to miss this!!!
• All that coughs is
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