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Cough gk



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  • 1. Cough Diagnosis and Management I’m Coughing my lungs up Doc.
  • 2. What is Cough? ‘A Cough is a forced expulsive manoevere, usually against a closed glottis and which is associated with a characteristic sound’
  • 3. Cough Mechanism Both chemical (e.g., capsaicin) and mechanical (e.g., particulates in air pollution) stimuli may initiate the cough reflex. The cough reflex involves a highly orchestrated series of involuntary muscular actions, with the potential for input from cortical pathways as well. The vocal cords adduct, leading to transient upper-airway occlusion. Expiratory muscles contract, generating positive intrathoracic pressures as high as 300 mm Hg. With sudden release of the laryngeal contraction, rapid expiratory flows are generated, exceeding the normal "envelope" of maximal expiratory flow seen on the flow-volume curve
  • 4. Classification of Cough Three Categories of Cough • Acute Cough = < 3 Weeks Duration • Subacute Cough = 3 – 8 Weeks Duration • Chronic Cough = > 8 Weeks Duration
  • 5. Acute Cough <3/52 Duration Differential Diagnosis • Upper Respiratory Tract infections: Viral syndromes, sinusitis viral / bacterial • URTI triggering exacerbations of Chronic Lung Disease eg Asthma/ COPD • Pneumonia • Left Ventricular Heart Failure • Foreign Body Aspiration
  • 6. Acute Cough Epidemiology • Symptomatic URTI – 2-5 per adults per year – 7-10 per child per year • 40-50% will have cough • Self medication common -£24million per year • 20% consult GP (2F:1M) • Most resolve within 2 weeks
  • 7. Duration of Cough in URTI Primary Care Setting No antecedent or chronic lung disease End of Week % Coughing 3 58 4 35 5 17 6 8 *Jones FJ and Stewart MA, Aust Family Physician Vol. 31, No. 10, October 2002 Sub-acute Cough -Post viral cough
  • 8. Managing Acute Cough “Don‟t just do something stand there.” Alice in Wonderland
  • 9. Managing Acute Cough Identify High Risk groups Acute Cough Can be 1st Indicator of Serious Disease eg Lung ca, TB, Foreign Body, Allergy, Interstitial Lung disease ‘Chronic cough always preceded by acute cough’.
  • 10. Red Flags in Acute Cough Symptoms • Haemoptysis • Breathlessness • Fever • Chest Pain • Weight Loss Signs Tachypnoea Cyanosis Dull chest Bronchial Breathing Crackles THINK pneumonia, lung cancer, LVF GET a CHEST X-Ray
  • 11. Treatment of Simple Acute Cough • Benign course -reassure • Cough can distress • Patients report OTC medication helpful • Voluntary cough suppression - linctuses/ drinks • Suppression of cough - dextromethorphan, menthol, sedating antihistamines & codeine
  • 12. Which Anti-tussive? Dextromorphan eg Benilyn non-drowsy 1 meta-analysis high dose 60mg beware combinations eg paracetomol Menthol Steam inhalation. Effect on reflex short lived Sedating Antihistamines danger sleepy - nocturnal cough Codeine or Pholcodeine No better than dextromorphan but more side-effects. Not recommended
  • 13. Sub-acute Cough 3-8 weeks Likely Diagnoses • Postinfectious • Bacterial Sinusitis • Asthma • Start of Chronic Cough • Don’t want to miss lung cancer ACTIONS •Examine Chest •Chest X-Ray if signs or smoker •Measure of airflow obstruction ie peak flow -one off peak flow -serial spirometry
  • 14. Post Infectious Cough A cough that begins with an acute respiratory tract infection and is not complicated* by pneumonia *Not complicated = Normal lung exam and normal chest X-ray Post Infectious cough will resolve without treatment Cause = Postnasal drip or Tracheobronchitis
  • 15. Chronic Cough Epidemiology Epidemiology difficult -acute vs chronic Cullinan 1992 Respir Med 86:143-9 n=9077 16% coughed on >50% days of year 13% coughed sputum on >50% days of year 54% were smokers
  • 16. Chronic Cough Epidemiology Associations with: Smoking (dose related) Pollutants (particulate PM10) -occupation Environmental irritants (eg cat dander) Asthma Reflux Obesity Irritable bowel syndrome Female
  • 17. Making the Diagnosis Common Differentials Gastro -Oesophageal Reflux Post-nasal Drip -allergic rhinitis -bacterial sinusitis Lung Disease -normal CXR -abnormal CXR Non-structural ACE-Inhibitors Tobacco Habit Cough
  • 18. Chronic Cough Investigating Chronic Cough Purpose: • To exclude structural disease • To identify cause How History & Examination inc occupation & Spirometry ALWAYS GET A CHEST X-RAY IN CHRONIC COUGH
  • 19. Beware Cough triggered by: change in temperature scent, sprays, aerosols and exercise indicate Increased cough reflex sensitivity and Not just seen in Asthma. Esp GORD, infection and ACEI
  • 20. ACE-Inhibitors and Chronic Cough Incidence: 5-20% Onset: one week to six months Mechanism Bradykinin or Substance P increase Usually metabolized by ACE) PGE2 accumulates and vagal stimulation. Treatment: switch to Angiotensin II Receptor Blockers (ARBs)
  • 21. Gastro-oesophageal Reflux GORD accounts alone or in combination for 10-40% of chronic cough Two Mechanisms a. Aspiration to larynx/ trachea b. Acid in distal oesophagus stimulates vagus and cough reflex
  • 22. Gastro-oesophageal Reflux Symptoms GI Symptoms If Aspiration main mechanism Heart burn Waterbrash/ Sour taste Regurgitation Morning Hoarseness If Vagal - NO GI symptoms Cough Features Throat clearing Worse at night / rising On eating Reflex hypersensitivity CXR -normal or hiatus hernia Spirometry normal
  • 23. Gastro-oesophageal Reflux Reflux may be due to Medications or FoodsReflux may be due to Medications or Foods Drugs and foods thatDrugs and foods that reducereduce lower esophageallower esophageal sphincter (LES) pressure and can cause increasedsphincter (LES) pressure and can cause increased reflux include:reflux include: TheophyllineTheophylline ChocolateChocolate OralOral ββ adrenergic agonistsadrenergic agonists CaffeineCaffeine NSAIDsNSAIDs PeppermintPeppermint Ascorbic acidAscorbic acid AlcoholAlcohol Calcium Channel BlockersCalcium Channel Blockers FatFat
  • 24. Gastro-oesophageal Reflux Investigation • 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 cannot confirm GORD as the cause of cough. GED © Slice of Life and Suzanne S. Stensaas GED
  • 26. Gastro-oesophageal Reflux Treatment Trial of Therapy • High dose twice daily PPI for min 8weeks • + prokinetic eg domperidone or metoclopramide • Eliminate contributing drugs. • Baclofen rarely Improves in 75-100% of cases
  • 27. Post-Nasal Drip Symptoms: • ‘something dripping’ • frequent throat clearing • nasal congestion / discharge • posture Causes • Allergic rhinitis • Non-allergic rhinitis • Vasomotor rhinitis • Chronic bacterial sinusiits
  • 28. Post Nasal Drip Treatment Options: 1. Exclude /treat infection 2. Nasal steroid for 8/52 3. Sedating antihistamines 4. Antileukotrienes eg montelukast 5. Saline lavage 6. ENT opinion
  • 29. Lung Diseases inc Tobacco Favouring Lung Disease Shortness of breath Wheeze Sputum production Haemoptysis Chest signs eg crackles
  • 30. Chest X-Ray and Differential of Cough Normal CXR • Gastro-oesophageal reflux • Post-nasal Drip • Smokers cough/ Chronic Bronchitis • Asthma • COPD • Bronchiectasis • Foreign body Abnormal 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-Ray and Differential of Cough Normal CXR • Gastro-oesophageal reflux • Post-nasal Drip • Smokers cough/ Chronic Bronchitis • Asthma • COPD • Bronchiectasis • Foreign body
  • 36. Smoking and the Healthy Lung
  • 37. The Development of Chronic Bronchitis (Daily Cough) Smoking Neutrophil Infiltration Goblet hyperplasia (mucous production) Release of Proteinases
  • 38. Normal Spirometry and Flow Volume 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 Spirometry FEV1 reduced FVC largely preserved FEV1/FVC low <70% FEV1 =1.0 „FVC‟ =2.0 FEV1/FVC=50% FVC =3.0 FEV1/FVC =33%
  • 41. Peak Flow Measurement Single or Repeated Measures
  • 42. Definition of COPD Chronic obstructive pulmonary disease is characterized by •airflow limitation that is not fully reversible. FEV1always <80% with •airflow limitation that is usually progressive •associated with an abnormal inflammatory response to noxious particles or gases.
  • 43. Development of Emphysema Proteinases diffuse out Neutralised by Anti- proteinases eg a1 Anti-trypsin If balance incorrect alveolar walls destroyed
  • 44. Stopping smoking slows decline in lung function FEV1(%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)
  • 45. SYMPTOMS cough sputum dyspnea EXPOSURE TO RISK FACTORS tobacco occupation indoor/outdoor pollution SPIROMETRY Step 1 Make Sure Patient Has COPD  REMEMBER: •Only 1/3 smokers get COPD •Need 15 pack years min •Asthma/ Bronchiectasis
  • 46. All COPD PATIENTS Stop Smoking -use Leeds Smoking Services Guidelines Short-acting bronchodilator prn (see note 1) Annual flu vaccination 5 yearly pneumonia vaccination (see note 2) Encourage regular exercise (5x 30mins walking at breathless pace per week) Maintain weight in healthy range Is patient breathless walking on level ground at a normal pace? Chronic Disease Management Main Algorithm YES – LONG-ACTING BRONCHODILATOR
  • 47. See Pulmonary Rehabilitation algorithm Yes Long-acting beta agonist salmeterol 50mcg bd (MDI/ accuhaler) or formoterol 12 mcg bd (turbohaler) (see note 3) Plus short acting bronchodilator prn No Longacting anticholinergic Tiotropium 18mcg od (see note 3) Plus short acting beta agonist prn (breathe actuated or dry powder) No benefit Stop longacting drug and try the alternative Partial Response Add ipratropium bromide 40 mcg qds via MDI + spacer (see notes 3 & 4) Partial Response Add shortacting beta agomist 2puffs qds via breathe-actuated inhaler or dry powder device (see note4) CAN PATIENT USE AN MDI? £30 £43 £34 £47
  • 48. Acute Management Increase short acting beta agonist for duration of exacerbation eg 2-8 puffs upto 4 hourly 1st Line Antibiotic amoxycillin 250-500mg tds or doxycycline 100mg bd for 1 week (see note 6) Steroids Prednisolone 30mg od for 1 week No Improvement at 1 week 2nd line antibiotic if sputum still purulent ciprofloxacin 750mg bd (Half maintenance theophylline dose) (see note 7) Continue prednisolone 30mg od upto 2 weeks maximum
  • 49. Prevention of Future Exacerbations Is the FEV1 <50% predicted and has the patient had >2 exacerbations in the last 12 months requiring oral steroids or antibiotics? No No additional therapy Yes Add budesonide 400mcg bd or fluticasone 500mcg bd. If on a longacting beta agonist -prescribe as symbicort 200/6 2 clicks bd or seretide 500 1 click bd (cheaper than separates) (see note 8) >2 exacerbations in next 12 months after starting the above add carbocisteine 750mg bd (see note 9)
  • 50. Definition of asthma Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92 “A chronic inflammatory disorder of the airways … in susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, 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. Asthma Triggers • Exercise • Fumes/ Smoke • Cold air • Oesophageal Reflux • Occupational Allergens • Tree • Grass • Fungi • House dust mite • Pets • Occupational
  • 53. Proving Variability Looking for 20% variation in PEFR or 15% in FEV1 1. Opportunistic single low peak flow in surgery Give bronchodilator and repeat in 20 mins Give trial of therapy and repeat next visit 2. Opportunistic single normal peak flow in surgery Measure on subsequent visits -hope for variability naturally Home peak flow measurements Induce an asthma attack! -histamine challenge
  • 54. Peak Flow Measurement Single or Repeated Measures
  • 55. Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Stepwise management of asthma in adults Step 1: Mild intermittent asthma Step 5: Continuous or frequent use of oral steroids Step 4: Persistent poor control Step 3: Add-on therapy Step 2: Regular preventer therapy
  • 56. Case Study -CP 2007 • 60yr retd Nurse • Chest infection 2002 in Spain -mild SOB since • Chest infection 2006 - hospitalised for 4/7 antibiotics / steroids • SOB and dry cough since • No variation • 4 lots of AB and steroids from 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 to know? History positional /reflux What causes can you think of? COPD Obesity with Reflux 8/52 omeprazole 20mg bd + domperdone 10mg tds - asymptomatic
  • 57. Conclusions Acute Cough < 3/52 Usually URTI CXR if worried Symptomatic therapy Subacute Cough 3-8/52 Usually post-viral CXR if smoker or worried Chronic Cough >3/12 CXR and Spirometry Consider GORD Post -Nasal Drip Lung - Abnormal CXR - Normal CXR (asthma/ COPD)