CoughDiagnosis and ManagementI’m Coughing my lungs up Doc.
What is Cough?‘A Cough is a forced expulsive manoevere,usually against a closed glottis and which isassociated with a char...
Cough MechanismBoth chemical (e.g., capsaicin) and mechanical (e.g.,particulates in air pollution) stimuli may initiate th...
Classification of CoughThree Categories of Cough• Acute Cough = < 3 Weeks Duration• Subacute Cough = 3 – 8 Weeks Duration•...
Acute Cough <3/52 DurationDifferential Diagnosis• Upper Respiratory Tract infections:Viral syndromes, sinusitis viral / ba...
Acute CoughEpidemiology• Symptomatic URTI– 2-5 per adults per year– 7-10 per child per year• 40-50% will have cough• Self ...
Duration of Cough in URTIPrimary Care SettingNo antecedent or chronic lung diseaseEnd of Week % Coughing3 584 355 176 8*Jo...
Managing Acute Cough“Don‟t just do somethingstand there.”Alice in Wonderland
Managing Acute CoughIdentify High Risk groupsAcute Cough Can be 1stIndicator of SeriousDiseaseeg Lung ca, TB, ForeignBody,...
Red Flags in Acute CoughSymptoms• Haemoptysis• Breathlessness• Fever• Chest Pain• Weight LossSignsTachypnoeaCyanosisDull c...
Treatment of Simple Acute Cough• Benign course -reassure• Cough can distress• Patients report OTCmedication helpful• Volun...
Which Anti-tussive?Dextromorphaneg Benilyn non-drowsy1 meta-analysishigh dose 60mgbeware combinations egparacetomolMenthol...
Sub-acute Cough 3-8 weeksLikely Diagnoses• Postinfectious• Bacterial Sinusitis• Asthma• Start of ChronicCough• Don’t want ...
Post Infectious CoughA cough that begins with an acuterespiratory tract infection and is notcomplicated* by pneumonia*Not ...
Chronic CoughEpidemiologyEpidemiology difficult -acute vs chronicCullinan 1992 Respir Med 86:143-9n=907716% coughed on >50...
Chronic CoughEpidemiologyAssociations with:Smoking (dose related)Pollutants (particulate PM10) -occupationEnvironmental ir...
Making the DiagnosisCommon DifferentialsGastro-OesophagealRefluxPost-nasal Drip-allergic rhinitis-bacterial sinusitisLung ...
Chronic CoughInvestigating Chronic CoughPurpose:• To exclude structural disease• To identify causeHowHistory & Examination...
BewareCough triggered by:change in temperaturescent, sprays, aerosols and exerciseindicateIncreased cough reflex sensitivi...
ACE-Inhibitors and ChronicCoughIncidence: 5-20%Onset: one week to six monthsMechanismBradykinin or Substance P increaseUsu...
Gastro-oesophageal RefluxGORD accounts alone or incombination for 10-40% ofchronic coughTwo Mechanismsa. Aspiration to lar...
Gastro-oesophageal RefluxSymptomsGI SymptomsIf Aspiration main mechanismHeart burnWaterbrash/ Sour tasteRegurgitationMorni...
Gastro-oesophageal RefluxReflux may be due to Medications or FoodsReflux may be due to Medications or FoodsDrugs and foods...
Gastro-oesophageal RefluxInvestigation• Oesophageal pH monitoring for 24 hours (+diary)– 95% sensitive and specific 95%• B...
Endoscopy can show GORD, but cannotconfirm GORD as the cause of cough.GED© Slice of Life and Suzanne S. StensaasGED
Gastro-oesophageal RefluxTreatmentTrial of Therapy• High dose twice daily PPI for min 8weeks• + prokinetic eg domperidone ...
Post-Nasal DripSymptoms:• ‘something dripping’• frequent throatclearing• nasal congestion /discharge• postureCauses• Aller...
Post Nasal Drip TreatmentOptions:1. Exclude /treat infection2. Nasal steroid for 8/523. Sedating antihistamines4. Antileuk...
Lung Diseases inc TobaccoFavouring Lung DiseaseShortness of breathWheezeSputum productionHaemoptysisChest signs eg crackles
Chest X-Rayand Differential of CoughNormal CXR• Gastro-oesophageal reflux• Post-nasal Drip• Smokers cough/ ChronicBronchit...
Left Ventricular Failure
Idiopathic Pulmonary Fibrosis
TB
Lung Cancer
Chest X-Rayand Differential of CoughNormal CXR• Gastro-oesophageal reflux• Post-nasal Drip• Smokers cough/ ChronicBronchit...
Smoking and the Healthy Lung
The Development ofChronic Bronchitis(Daily Cough)SmokingNeutrophil InfiltrationGoblet hyperplasia(mucous production)Releas...
Normal Spirometry and FlowVolume Loops
Normal Values• Depend on Age/ Sex / Height / Race• Tables and slide rules available• Asians decrease value by 7%• Afro-Car...
Obstructed SpirometryFEV1 reducedFVC largely preservedFEV1/FVC low <70%FEV1 =1.0„FVC‟ =2.0FEV1/FVC=50%FVC =3.0 FEV1/FVC=33%
Peak Flow MeasurementSingle or Repeated Measures
Definition of COPDChronic obstructive pulmonary diseaseis characterized by•airflow limitation that is not fully reversible...
Development of EmphysemaProteinases diffuse outNeutralised by Anti-proteinaseseg a1 Anti-trypsinIf balance incorrectalveol...
Stopping smokingslows decline in lung functionFEV1(%ofvalueatage25)100755025025 50 75Never smoked or notsusceptible to smo...
SYMPTOMScoughsputumdyspneaEXPOSURE TO RISKFACTORStobaccooccupationindoor/outdoor pollutionSPIROMETRYStep 1 Make Sure Patie...
All COPD PATIENTSStop Smoking -use Leeds Smoking Services GuidelinesShort-acting bronchodilator prn (see note 1)Annual flu...
See PulmonaryRehabilitation algorithmYesLong-acting beta agonistsalmeterol 50mcg bd (MDI/ accuhaler)or formoterol 12 mcg b...
Acute ManagementIncreaseshort actingbeta agonistfor duration ofexacerbationeg 2-8 puffsupto 4 hourly1st LineAntibioticamox...
Prevention of FutureExacerbationsIs theFEV1 <50% predictedandhas the patient had >2 exacerbations in the last 12months req...
Definition of asthmaDiagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92“A chronic inflammatory disorder of th...
Asthma• Variable airflow obstruction– Symptoms vary– Measurements of airflow obstruction vary• Associated with atopy (hayf...
AsthmaTriggers• Exercise• Fumes/ Smoke• Cold air• Oesophageal Reflux• OccupationalAllergens• Tree• Grass• Fungi• House dus...
Proving VariabilityLooking for 20% variationin PEFR or 15% in FEV11. Opportunistic single low peak flow in surgeryGive bro...
Peak Flow MeasurementSingle or Repeated Measures
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92Stepwise management ofasthma in adultsStep 1: Mild intermitte...
Case Study -CP 2007• 60yr retd Nurse• Chest infection 2002 inSpain -mild SOB since• Chest infection 2006 -hospitalised for...
ConclusionsAcute Cough < 3/52Usually URTICXR if worriedSymptomatic therapySubacute Cough 3-8/52Usually post-viralCXR if sm...
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Cough gk

  1. 1. CoughDiagnosis and ManagementI’m Coughing my lungs up Doc.
  2. 2. What is Cough?‘A Cough is a forced expulsive manoevere,usually against a closed glottis and which isassociated with a characteristic sound’
  3. 3. Cough MechanismBoth chemical (e.g., capsaicin) and mechanical (e.g.,particulates in air pollution) stimuli may initiate the coughreflex.The cough reflex involves a highly orchestrated series ofinvoluntary muscular actions, with the potential for inputfrom cortical pathways as well. The vocal cords adduct,leading to transient upper-airway occlusion. Expiratorymuscles contract, generating positive intrathoracic pressuresas high as 300 mm Hg. With sudden release of the laryngealcontraction, rapid expiratory flows are generated, exceedingthe normal "envelope" of maximal expiratory flow seen onthe flow-volume curve
  4. 4. Classification of CoughThree Categories of Cough• Acute Cough = < 3 Weeks Duration• Subacute Cough = 3 – 8 Weeks Duration• Chronic Cough = > 8 Weeks Duration
  5. 5. Acute Cough <3/52 DurationDifferential Diagnosis• Upper Respiratory Tract infections:Viral syndromes, sinusitis viral / bacterial• URTI triggering exacerbations of Chronic LungDisease eg Asthma/ COPD• Pneumonia• Left Ventricular Heart Failure• Foreign Body Aspiration
  6. 6. Acute CoughEpidemiology• Symptomatic URTI– 2-5 per adults per year– 7-10 per child per year• 40-50% will have cough• Self medication common -£24million peryear• 20% consult GP (2F:1M)• Most resolve within 2 weeks
  7. 7. Duration of Cough in URTIPrimary Care SettingNo antecedent or chronic lung diseaseEnd of Week % Coughing3 584 355 176 8*Jones FJ and Stewart MA, Aust FamilyPhysician Vol. 31, No. 10, October 2002Sub-acuteCough-Post viralcough
  8. 8. Managing Acute Cough“Don‟t just do somethingstand there.”Alice in Wonderland
  9. 9. Managing Acute CoughIdentify High Risk groupsAcute Cough Can be 1stIndicator of SeriousDiseaseeg Lung ca, TB, ForeignBody, Allergy, InterstitialLung disease‘Chronic cough alwayspreceded by acutecough’.
  10. 10. Red Flags in Acute CoughSymptoms• Haemoptysis• Breathlessness• Fever• Chest Pain• Weight LossSignsTachypnoeaCyanosisDull chestBronchial BreathingCracklesTHINK pneumonia, lung cancer, LVFGET a CHEST X-Ray
  11. 11. Treatment of Simple Acute Cough• Benign course -reassure• Cough can distress• Patients report OTCmedication helpful• Voluntary cough suppression -linctuses/ drinks• Suppression of cough -dextromethorphan, menthol,sedating antihistamines &codeine
  12. 12. Which Anti-tussive?Dextromorphaneg Benilyn non-drowsy1 meta-analysishigh dose 60mgbeware combinations egparacetomolMentholSteam inhalation. Effect onreflex short livedSedating Antihistaminesdanger sleepy - nocturnal coughCodeine or PholcodeineNo better than dextromorphanbut more side-effects. Notrecommended
  13. 13. Sub-acute Cough 3-8 weeksLikely Diagnoses• Postinfectious• Bacterial Sinusitis• Asthma• Start of ChronicCough• Don’t want to misslung cancerACTIONS•Examine Chest•Chest X-Ray if signs or smoker•Measure of airflow obstructionie peak flow -one offpeak flow -serialspirometry
  14. 14. Post Infectious CoughA cough that begins with an acuterespiratory tract infection and is notcomplicated* by pneumonia*Not complicated = Normal lung exam and normal chest X-rayPost Infectious cough will resolve without treatmentCause = Postnasal drip or Tracheobronchitis
  15. 15. Chronic CoughEpidemiologyEpidemiology difficult -acute vs chronicCullinan 1992 Respir Med 86:143-9n=907716% coughed on >50% days of year13% coughed sputum on >50% days of year54% were smokers
  16. 16. Chronic CoughEpidemiologyAssociations with:Smoking (dose related)Pollutants (particulate PM10) -occupationEnvironmental irritants (eg cat dander)AsthmaRefluxObesityIrritable bowel syndromeFemale
  17. 17. Making the DiagnosisCommon DifferentialsGastro-OesophagealRefluxPost-nasal Drip-allergic rhinitis-bacterial sinusitisLung Disease-normal CXR-abnormal CXRNon-structuralACE-InhibitorsTobaccoHabit Cough
  18. 18. Chronic CoughInvestigating Chronic CoughPurpose:• To exclude structural disease• To identify causeHowHistory & Examination inc occupation& SpirometryALWAYS GET A CHEST X-RAYIN CHRONIC COUGH
  19. 19. BewareCough triggered by:change in temperaturescent, sprays, aerosols and exerciseindicateIncreased cough reflex sensitivityand Not just seen in Asthma.Esp GORD, infection and ACEI
  20. 20. ACE-Inhibitors and ChronicCoughIncidence: 5-20%Onset: one week to six monthsMechanismBradykinin or Substance P increaseUsually metabolized by ACE)PGE2 accumulates and vagal stimulation.Treatment: switch to Angiotensin II ReceptorBlockers (ARBs)
  21. 21. Gastro-oesophageal RefluxGORD accounts alone or incombination for 10-40% ofchronic coughTwo Mechanismsa. Aspiration to larynx/ tracheab. Acid in distal oesophagusstimulates vagus and coughreflex
  22. 22. Gastro-oesophageal RefluxSymptomsGI SymptomsIf Aspiration main mechanismHeart burnWaterbrash/ Sour tasteRegurgitationMorning HoarsenessIf Vagal - NO GI symptomsCough FeaturesThroat clearingWorse at night / risingOn eatingReflex hypersensitivityCXR -normal or hiatusherniaSpirometry normal
  23. 23. Gastro-oesophageal RefluxReflux may be due to Medications or FoodsReflux may be due to Medications or FoodsDrugs and foods thatDrugs and foods that reducereduce lower esophageallower esophagealsphincter (LES) pressure and can cause increasedsphincter (LES) pressure and can cause increasedreflux include:reflux include:TheophyllineTheophylline ChocolateChocolateOralOral ββ adrenergic agonistsadrenergic agonists CaffeineCaffeineNSAIDsNSAIDs PeppermintPeppermintAscorbic acidAscorbic acid AlcoholAlcoholCalcium Channel BlockersCalcium Channel Blockers FatFat
  24. 24. Gastro-oesophageal RefluxInvestigation• Oesophageal pH monitoring for 24 hours (+diary)– 95% sensitive and specific 95%• Ba swallow not sensitive enough• Endoscopy - may confirm but false -ve rate
  25. 25. Endoscopy can show GORD, but cannotconfirm GORD as the cause of cough.GED© Slice of Life and Suzanne S. StensaasGED
  26. 26. Gastro-oesophageal RefluxTreatmentTrial of Therapy• High dose twice daily PPI for min 8weeks• + prokinetic eg domperidone or metoclopramide• Eliminate contributing drugs.• Baclofen rarelyImproves in 75-100% of cases
  27. 27. Post-Nasal DripSymptoms:• ‘something dripping’• frequent throatclearing• nasal congestion /discharge• postureCauses• Allergic rhinitis• Non-allergic rhinitis• Vasomotor rhinitis• Chronic bacterialsinusiits
  28. 28. Post Nasal Drip TreatmentOptions:1. Exclude /treat infection2. Nasal steroid for 8/523. Sedating antihistamines4. Antileukotrienes egmontelukast5. Saline lavage6. ENT opinion
  29. 29. Lung Diseases inc TobaccoFavouring Lung DiseaseShortness of breathWheezeSputum productionHaemoptysisChest signs eg crackles
  30. 30. Chest X-Rayand Differential of CoughNormal CXR• Gastro-oesophageal reflux• Post-nasal Drip• Smokers cough/ ChronicBronchitis• Asthma• COPD• Bronchiectasis• Foreign bodyAbnormal CXR• Left ventricular failure• Lung cancer• Infection/ TB• Pulmonary fibrosis• Pleural effusion
  31. 31. Left Ventricular Failure
  32. 32. Idiopathic Pulmonary Fibrosis
  33. 33. TB
  34. 34. Lung Cancer
  35. 35. Chest X-Rayand Differential of CoughNormal CXR• Gastro-oesophageal reflux• Post-nasal Drip• Smokers cough/ ChronicBronchitis• Asthma• COPD• Bronchiectasis• Foreign body
  36. 36. Smoking and the Healthy Lung
  37. 37. The Development ofChronic Bronchitis(Daily Cough)SmokingNeutrophil InfiltrationGoblet hyperplasia(mucous production)Release of Proteinases
  38. 38. Normal Spirometry and FlowVolume Loops
  39. 39. 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%
  40. 40. Obstructed SpirometryFEV1 reducedFVC largely preservedFEV1/FVC low <70%FEV1 =1.0„FVC‟ =2.0FEV1/FVC=50%FVC =3.0 FEV1/FVC=33%
  41. 41. Peak Flow MeasurementSingle or Repeated Measures
  42. 42. Definition of COPDChronic obstructive pulmonary diseaseis characterized by•airflow limitation that is not fully reversible.FEV1always <80% with•airflow limitation that is usually progressive•associated with an abnormal inflammatoryresponse to noxious particles or gases.
  43. 43. Development of EmphysemaProteinases diffuse outNeutralised by Anti-proteinaseseg a1 Anti-trypsinIf balance incorrectalveolar wallsdestroyed
  44. 44. Stopping smokingslows decline in lung functionFEV1(%ofvalueatage25)100755025025 50 75Never smoked or notsusceptible to smokeAdapted from: Fletcher et al, Br Med J 1977.Stopped at 65Stopped at 45Smoked regularlyand susceptible toits effectsDeathAge (years)
  45. 45. SYMPTOMScoughsputumdyspneaEXPOSURE TO RISKFACTORStobaccooccupationindoor/outdoor pollutionSPIROMETRYStep 1 Make Sure Patient Has COPDREMEMBER:•Only 1/3 smokers getCOPD•Need 15 pack years min•Asthma/ Bronchiectasis
  46. 46. All COPD PATIENTSStop Smoking -use Leeds Smoking Services GuidelinesShort-acting bronchodilator prn (see note 1)Annual flu vaccination5 yearly pneumonia vaccination (see note 2)Encourage regular exercise (5x 30mins walking at breathless pace per week)Maintain weight in healthy rangeIs patient breathless walking on level ground at a normal pace?Chronic Disease ManagementMain AlgorithmYES – LONG-ACTING BRONCHODILATOR
  47. 47. See PulmonaryRehabilitation algorithmYesLong-acting beta agonistsalmeterol 50mcg bd (MDI/ accuhaler)or formoterol 12 mcg bd (turbohaler)(see note 3)Plus short acting bronchodilator prnNoLongacting anticholinergicTiotropium 18mcg od(see note 3)Plus short acting beta agonist prn(breathe actuated or dry powder)No benefitStop longacting drug and try thealternativePartial ResponseAdd ipratropium bromide 40mcg qds via MDI + spacer(see notes 3 & 4)Partial ResponseAdd shortacting beta agomist 2puffsqds via breathe-actuated inhaler ordry powder device(see note4)CAN PATIENT USE AN MDI?£30 £43£34 £47
  48. 48. Acute ManagementIncreaseshort actingbeta agonistfor duration ofexacerbationeg 2-8 puffsupto 4 hourly1st LineAntibioticamoxycillin250-500mg tdsor doxycycline100mg bd for1 week(see note 6)SteroidsPrednisolone30mg od for 1weekNoImprovementat 1 week2nd line antibiotic ifsputum stillpurulentciprofloxacin 750mgbd(Half maintenancetheophylline dose)(see note 7)Continueprednisolone 30mgod upto 2 weeksmaximum
  49. 49. Prevention of FutureExacerbationsIs theFEV1 <50% predictedandhas the patient had >2 exacerbations in the last 12months requiring oral steroids or antibiotics?NoNo additionaltherapyYesAdd budesonide 400mcg bd or fluticasone500mcg bd.If on a longacting beta agonist -prescribe assymbicort 200/6 2 clicks bd or seretide 5001 click bd (cheaper than separates)(see note 8)>2 exacerbations in next 12 monthsafter starting the aboveadd carbocisteine 750mg bd(see note 9)
  50. 50. Definition of asthmaDiagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92“A chronic inflammatory disorder of the airways …in susceptible individuals, inflammatory symptomsare usually associated with widespread but variableairflow obstruction and an increase in airwayresponse to a variety of stimuli. Obstruction is oftenreversible, either spontaneously or with treatment.”
  51. 51. 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
  52. 52. AsthmaTriggers• Exercise• Fumes/ Smoke• Cold air• Oesophageal Reflux• OccupationalAllergens• Tree• Grass• Fungi• House dust mite• Pets• Occupational
  53. 53. Proving VariabilityLooking for 20% variationin PEFR or 15% in FEV11. Opportunistic single low peak flow in surgeryGive bronchodilator and repeat in 20 minsGive trial of therapy and repeat next visit2. Opportunistic single normal peak flow in surgeryMeasure on subsequent visits -hope for variabilitynaturallyHome peak flow measurementsInduce an asthma attack! -histamine challenge
  54. 54. Peak Flow MeasurementSingle or Repeated Measures
  55. 55. Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92Stepwise management ofasthma in adultsStep 1: Mild intermittent asthmaStep 5: Continuous or frequentuse of oral steroidsStep 4: Persistent poor controlStep 3: Add-on therapyStep 2: Regular preventer therapy
  56. 56. Case Study -CP 2007• 60yr retd Nurse• Chest infection 2002 inSpain -mild SOB since• Chest infection 2006 -hospitalised for 4/7antibiotics / steroids• SOB and dry cough since• No variation• 4 lots of AB and steroidsfrom 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 toknow?History positional /refluxWhat causes can you think of?COPDObesity with Reflux8/52 omeprazole 20mg bd +domperdone 10mg tds -asymptomatic
  57. 57. ConclusionsAcute Cough < 3/52Usually URTICXR if worriedSymptomatic therapySubacute Cough 3-8/52Usually post-viralCXR if smoker orworriedChronic Cough >3/12CXR and SpirometryConsiderGORDPost -Nasal DripLung - Abnormal CXR- Normal CXR(asthma/ COPD)

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