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  • 1. CoughDiagnosis and ManagementI’m Coughing my lungs up Doc.
  • 2. What is Cough?‘A Cough is a forced expulsive manoevere,usually against a closed glottis and which isassociated with a characteristic sound’
  • 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. Classification of CoughThree Categories of Cough• Acute Cough = < 3 Weeks Duration• Subacute Cough = 3 – 8 Weeks Duration• Chronic Cough = > 8 Weeks Duration
  • 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. 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. 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. Managing Acute Cough“Don‟t just do somethingstand there.”Alice in Wonderland
  • 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. Red Flags in Acute CoughSymptoms• Haemoptysis• Breathlessness• Fever• Chest Pain• Weight LossSignsTachypnoeaCyanosisDull chestBronchial BreathingCracklesTHINK pneumonia, lung cancer, LVFGET a CHEST X-Ray
  • 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. 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. 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. 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. 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. Chronic CoughEpidemiologyAssociations with:Smoking (dose related)Pollutants (particulate PM10) -occupationEnvironmental irritants (eg cat dander)AsthmaRefluxObesityIrritable bowel syndromeFemale
  • 17. Making the DiagnosisCommon DifferentialsGastro-OesophagealRefluxPost-nasal Drip-allergic rhinitis-bacterial sinusitisLung Disease-normal CXR-abnormal CXRNon-structuralACE-InhibitorsTobaccoHabit Cough
  • 18. Chronic CoughInvestigating Chronic CoughPurpose:• To exclude structural disease• To identify causeHowHistory & Examination inc occupation& SpirometryALWAYS GET A CHEST X-RAYIN CHRONIC COUGH
  • 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. 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. 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. 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. 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. 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. Endoscopy can show GORD, but cannotconfirm GORD as the cause of cough.GED© Slice of Life and Suzanne S. StensaasGED
  • 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. Post-Nasal DripSymptoms:• ‘something dripping’• frequent throatclearing• nasal congestion /discharge• postureCauses• Allergic rhinitis• Non-allergic rhinitis• Vasomotor rhinitis• Chronic bacterialsinusiits
  • 28. Post Nasal Drip TreatmentOptions:1. Exclude /treat infection2. Nasal steroid for 8/523. Sedating antihistamines4. Antileukotrienes egmontelukast5. Saline lavage6. ENT opinion
  • 29. Lung Diseases inc TobaccoFavouring Lung DiseaseShortness of breathWheezeSputum productionHaemoptysisChest signs eg crackles
  • 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. Left Ventricular Failure
  • 32. Idiopathic Pulmonary Fibrosis
  • 33. TB
  • 34. Lung Cancer
  • 35. Chest X-Rayand Differential of CoughNormal CXR• Gastro-oesophageal reflux• Post-nasal Drip• Smokers cough/ ChronicBronchitis• Asthma• COPD• Bronchiectasis• Foreign body
  • 36. Smoking and the Healthy Lung
  • 37. The Development ofChronic Bronchitis(Daily Cough)SmokingNeutrophil InfiltrationGoblet hyperplasia(mucous production)Release of Proteinases
  • 38. Normal Spirometry and FlowVolume Loops
  • 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. Obstructed SpirometryFEV1 reducedFVC largely preservedFEV1/FVC low <70%FEV1 =1.0„FVC‟ =2.0FEV1/FVC=50%FVC =3.0 FEV1/FVC=33%
  • 41. Peak Flow MeasurementSingle or Repeated Measures
  • 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. Development of EmphysemaProteinases diffuse outNeutralised by Anti-proteinaseseg a1 Anti-trypsinIf balance incorrectalveolar wallsdestroyed
  • 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. 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. 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. 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. 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. 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. 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. 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. AsthmaTriggers• Exercise• Fumes/ Smoke• Cold air• Oesophageal Reflux• OccupationalAllergens• Tree• Grass• Fungi• House dust mite• Pets• Occupational
  • 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. Peak Flow MeasurementSingle or Repeated Measures
  • 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. 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. 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)