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COUGH : A 360 degree Approach
- 1. COUGH : A 360o Approach Dr. (Mrs.) Chandra Jayasuriya FRCS,MD(Oto),DLO Consultant ENT Surgeon ENT Department National Hospital of Sri Lanka.
- 2. Statistics • Nearly 10% of the adult population have chronic cough • It’s less prevalent in Asia (2-7%) than in Europe (10-15%) and the USA (8-14%) • Nearly 3.6 Billion $ of money spent for OTC medications • The effects of chronic cough • Anxiety/Depression • Sleep disturbances • Incontinence • Rib fracture • Decreased quality of life
- 3. OBJECTIVES •Background: Chronic cough? •Common aetiologies •ENT Presentations •Chronic cough algorithm •Diagnostic tests •Cough suppression therapy •Paediatric cough
- 4. Cough is a defensive mechanism
- 5. COUGH? Cough is classified by duration • Acute cough <2 weeks • Protracted cough 2-4 weeks • Chronic cough >4weeks Specific cough Non specific cough Normal/Expected cough
- 6. 3 Q? Quality • Dry • Productive Duration • Tickle • Exacerbations Triggers • Present • Absent
- 8. Cough beyond 3As… • Refractory GORD • Neurogenic cough • Glottic insufficiency
- 10. Consultation Pyramid SLP Laryngologist Gastroenterologist Rhinologist/Allergist Pulmonologist Primary care physicians
- 14. i. First visit • Stop ACEI/ laryngeal irritants (Tobacco, caffeine) • CXR • Pulmonary Function Test (Methacholine Challenge Test—FEV1 reduces) • Maximal medical Rx-Rhinisinusitis(4/52) • Empirical acid reflux Rx (3/12) • PPIs & Prokinetics • Fibre Optic Laryngoscopy • Speech & Language Pathologist Referral • Cough suppressant therapy • Vocal hygiene advise • Stroboscopy if needed
- 15. Examination of Vocal cords
- 17. ii. Second visit(3/12) • Oral steroid trial • Respiratory referral • CT Chest • Bronchoscopy • Allergy test • NCCT -Nose+PNS • Superior laryngeal nerve block(Diagnostic+/-Therapeutic)
- 18. Cough beyond 3As… •Neurogenic cough •Glottic insufficiency • Refractory GORD
- 19. Refractory GORD • Still coughing? • BMI 35-40 • Obstructive Sleep Apnoea • Nocturnal arousals Refractory GORD
- 20. Refractory GORD…. • Due to pharyngeal irritation& oesophageal dilatation • Heart burn, Postprandial, nocturnal& recumbent cough • Investigation • PH impedance testing • UGIE • Oesophageal manometry • Antireflux surgery referral
- 21. Refractory GORD…. • Lifestyle modification • Gaviscone Advance(Alginic acid) • It forms a protective layer that floats on top of the contents of your stomach. This stops stomach acid escaping. • Gaviscon also contains an antacid that neutralizes excess stomach acid and reduces pain and discomfort. • PPI • Prokinetics
- 22. Cough beyond 3As… •Refractory GORD •Glottic insufficiency •Neurogenic cough
- 23. Neurogenic cough • Triggers(Odors, Temp) • Onset after URTI • “Tickle” in throat that proceeds cough • Dysphonia, dysphagia, globus, unilateral throat pain& laryngospasm • SLN block improvement
- 24. Neurogenic cough… • Pathophysiology unclear • Thought to be due to neuropathic vagal dysfunction • Diagnosis of exclusion at the first visit by the typical cough • But mostly responds to medications.. so identification important
- 26. Neurogenic cough Rx • 1st line neuromodulators (Gabapentin, Amitriptallin, Pregabalin) • 2nd line neuromodulators(Tramadol, Baclofen) • Superior Laryngeal Nerve block series
- 27. Superior Laryngeal Nerve Block (with steroid Lignocaine) • It’s a diagnostic as well as therapeutic measure Botox injection • In to vocal cords to paralyse Thyroarytenoid muscles • 50% reduction in cough severity at 8 weeks.
- 28. Superior laryngeal nerve block • The SLN block can be done as an office procedure • Originally used by anaesthetist for awake intubation • A 50:50 solution of steroid and lidocaine is injected into the internal branch of the SLN at the thyrohyoid membrane.
- 29. Cough beyond 3As… •Glottic insufficiency •Refractory GORD •Neurogenic cough
- 30. Glottic insufficiency • Gap on fibre optic laryngoscopy
- 31. Glottic insufficiency... • Causes for incomplete glottic closure • Vocal cord lesions (Nodules, cysts, polyps and tumours) • Vocal cord palsy-adductor palsy • Neurological-CVA
- 32. Glottic insufficiency • RX-Underlying cause Nodule Cyst Polyp Tumour
- 33. • Vocal fold augmentation is a reasonable option It gives bulkiness to the vocal cord. • Injection laryngoplasty • Medialization thyroplasty • Tracheostomy with a cuffed tube is the last resort to prevent aspiration.
- 34. Injection laryngoplasty & Medialization thyroplasty
- 36. Other common causes • Chronic Laryngitis • Upper Airway Cough Syndrome • Tuberculosis • OSA • Laryngo Pharyngeal Reflux (LPR)
- 37. Laryngo Pharyngeal Reflux (LPR) • Irritation of the larynx from stomach contents which reflux back up into the throat • People may not even have GORD symptoms like heart burn or regurgitation.
- 38. LPR : • Recurrent or persistent hoarseness, especially in the morning • A history of persistent throat clearing • Halitosis • Hypersialorrhea • Globus (Feeling lump in throat)
- 39. FOL findings •Posterior laryngitis •Contact ulcer of larynx •Saliva- String sign •Vocal cord granuloma •Subglottic stenosis
- 40. RX OF LPR •Life style modification •PPI Regimen •Prokinetic drug •Anti reflux surgery-Nisssen fundoplication
- 41. Life style modifications…. •Water treatment •Weight reduction. •Elevate the head of the bed 4-6 inches. •Avoid tight clothing. •Stop smoking & drinking alcohol.
- 42. Water treatment:
- 43. Other common causes • Laryngo Pharyngeal Reflux (LPR) • Upper Airway Cough Syndrome • Tuberculosis • OSA •Chronic Laryngitis
- 44. Chronic Laryngitis Causes- • Infectious (TB) • Environmental pollutants • Toxic products-smoking • Ethanol • Inhaled steroids (Candidal laryngitis) •Autoimmune
- 45. Presents: •Loss of voice, Hoarseness and dysphonia •Chronic cough •Neck muscle tension & spasm
- 46. Supportive Measures • Hydration with about 2 liters of fluid/day • Steam inhalation or room humidifier • Identification and avoidance of environmental and occupational sensitizers. • Avoidance of active & passive smoking
- 47. Other common causes • Laryngo Pharyngeal Reflux (LPR) • Chronic Laryngitis • Tuberculosis • OSA •Upper Airway Cough Syndrome
- 48. Upper Airway Cough Syndrome • Due to secretions from postnasal space stimulate upper airway causing cobble stone appearance • Have frequent throat clearing, hoarseness, • Cough may be the only symptom in nearly 20%
- 49. Upper Airway Cough Syndrome…… • Allergic Rhinitis • Bacterial rhinosinusitis • Fungal ball in sinuses • Occupational rhinitis (Chemical irritants) • Rhinitis medicamentoza due to prolonged use of nasal decongestents. • Gestational rhinitis
- 50. Allergic rhinitis • Caused by allergen (IgE mediated) • Presents with • Nasal discharge • Nasal congestion • Sneezing • Itching • Allergy test (Skin prick tests & IgE level) • Rx • Avoidance of allergen if known • Topical steroids
- 51. Fungal ball in sinuses. • Unilateral fungal sinusitis with fungal ball • Cacosmia, postnasal drip and cough • Very common cause for cough and asthma due to aspiration
- 52. Other common causes •Tuberculosis • Laryngo Pharyngeal Reflux (LPR) • Chronic Laryngitis • Upper Airway Cough Syndrome • Obstructive Sleep Apnoea(OSA)
- 53. Tuberculosis • CXR and Sputum AFB are standard Ix in chronic cough
- 54. Other common causes • Laryngo Pharyngeal Reflux (LPR) • Chronic Laryngitis • Upper Airway Cough Syndrome • Tuberculosis •OSA
- 55. Obstructive Sleep Apnoea • It’s a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort. • It is characterized by recurrent episodes of upper airway collapse during sleep
- 56. Sleep-related breathing disorder continuum Snoring UARS Hypopneas ApneasObesity – Hypoventilation
- 57. Epworth sleepiness scale & Sleep study
- 59. Management of OSA Weight reduction
- 60. OSA Treatment Positive Airway Pressure Poor Compliance (40%) Surgery Variable outcomes (30-70%) Oral Appliance Limited Application Sleep position
- 61. Life threatening causes of acute cough
- 62. Bronchogenic Carcinoma • One of the common cancer worldwide and is the leading cancer-related cause of death in both men and women • Persistent cough • Haemoptysis may be a warning sign • Urgent pulmonary referral+/- Bronchoscopy+ CT Chest
- 64. Cough suppression therapy •3 Q? Quality • Dry • Productive Duration • Tickle • Exacerbations Triggers • Present • Absent
- 65. Cough suppression therapy • By Speech& Language pathologist • Individualized sessions • Education on cough reflex • Techniques to reduce laryngeal irritation
- 66. Cough suppression therapy… • Increase hydration • Cough suppressant exercises • Psycho educational counselling • Voice therapy techniques
- 67. Summary of Adult cough.. • Cough is a common and frustrating symptom • When successful- Grateful patients • Always have an algorithm • Asthma, Allergy, Acid reflux (3As) • Consider less common causes( Refractory GORD, Neurogenic, glottic insufficiency) • Don’t forget Speech& Language Pathologist. • Cough suppressant therapy) • Voice therapy
- 68. PAEDIATRIC COUGH
- 69. •COUGH? •Cough is classified by duration • Acute cough <2 weeks • Protracted cough 2-4 weeks • Chronic cough >4weeks Specific cough Non specific cough Normal/ Expected cough
- 70. • Common causes of cough in adults are not common in children • Age and the clinical settings need to be considered • Children with OSA and cough…treatment according to sleep guidelines
- 71. Aetiologies CONGENITAL • Laryngomalacia • Laryngeal cleft • Tracheo bronchomalacia • Tracheo-oesophageal fistula • Oesophageal atresia • Vocal cord paralysis • Double aortic arch
- 72. Aetiologies… INFECTIOUS • Chronic Rhinosinusitis • Laryngotracheitis • Chronic Bronchitis • Tuberculosis • Mycoplasma INFLAMMATORY • Cough variant asthma • Bronchial Asthma • Allergy • GORD • Chronic aspiration
- 73. Aetiologies… TRAUMATIC • Foreign body inhalation • Fractures • Intubation trauma SYSTEMIC • Primary ciliary dyskinesia • Habit cough • Cystic fibrosis
- 74. • Most common diagnoses when CXR&PFT normal… • BA • Protracted bronchitis • Most common in ENT office • Infectious ones • Airway hypersensitivity • GORD • FB inhalation
- 75. PAEDIATRIC COUGH • Timeline: Sudden Vs Chronic and Gradual • Time of day: Diurnal Vs Constant • Associated with seasonal allergies or activity • Association with food intake, type and time • Nature of the cough: Dry Vs productive, Thin Vs thick sputum
- 76. Evaluation • Signs of aspiration • Immunization status • Neonatal infections • Medications
- 77. • Allergic symptoms • Trauma/Intubations • Neuro developmental abnormalities • Tobacco exposure
- 78. Examination… • Overall developmental status, appearance • Eyes: Allergic shiners, Allergic conjunctivitis • Nose: Allergic salute, Polyps, Turbinates, mucous drainage • Neck: Masses, lymphadenopathy • Lungs: Cardiac, Chest wall
- 79. Allergic signs.
- 80. Ancillary testing • FBC/Eosinophil count • Sputum culture • Nasal smear • TB skin test/PPD • Chloride Sweat test • Pulmonary Function Test
- 81. Cough pointers
- 82. Cough pointers
- 83. Look for cough pointers,CXR changes,Abnormal spirometry, Neurodev issues, Feeding issues, Malnutrition, Recurrent Lower RTI, Chest wall deformities, clubbing, Abnormal auscultation, Classic cough characteristics, Fail to respond to treatment . No features above Specific cough,Features of other specific diagnosis(BA), CSLD WET COUGH DRY COUGH Features of protracted Bacterial Bronchitis Non specific cough, No features of specific diagnosis Antibiotics Watchful waiting & review Continue trial of Steroid therapy American college of chest physician algorythm Ix and Rx according to the diagnosis
- 84. Case 1: • 3 year old male underwent tubes placement for recurrent ear infection. Presents for post op appointment. • Mom reports cough for past 4 weeks. • Cough is intermittent, dry and sporadic. • No other symptoms • Started with cold 1 month ago. • Doesn’t have nasal drainage & congestion.
- 85. • Examination • Healthy • Grommet Tubes functional. • No wheezing/ Rhinorrhoea
- 86. What do you do? •NOTHING
- 87. Look for cough pointers,CXR changes,Abnormal spirometry, Neurodev issues, Feeding issues, Malnutrition, Recurrent Lower RTI, Chest wall deformities, clubbing, Abnormal auscultation, Classic cough characteristics, Fail to respond to treatment . No features above Specific cough,Features of other specific diagnosis(BA), CSLD WET COUGH DRY COUGH Features of protracted Bacterial Bronchitis Non specific cough, No features of specific diagnosis Antibiotics Watchful waiting & review Continue trial of therapy American college of chest physician algorythm Ix and Rx according to the diagnosis
- 88. Case 2: • 6 month old full term male referred for persistent cough and wheeze • RSV Bronchiolitis at 3 months of age requiring hospital admission • Cough is intermittent and dry. • No associated with feeds • Wheezing present • No nasal drainage/ congestion
- 89. Examination • Healthy, No rhinorrhoea. No stridor/ retraction • Scattered wheeze • What do you do? • Cough pointer present • Wheeze suggest intrathoracic airway issue.
- 90. What do you do? • Bronchoscopy • Tracheo bronchomalacia with left mainstem compression • Start Budesonide neb 0.5mg BD • Pulmonary referral
- 91. Look for cough pointers,CXR changes,Abnormal spirometry, Neurodev issues, Feeding issues, Malnutrition, Recurrent Lower RTI, Chest wall deformities, clubbing, Abnormal auscultation, Classic cough characteristics, Fail to respond to treatment . No features above Specific cough,Features of other specific diagnosis(BA), CSLD WET COUGH DRY COUGH Features of protracted Bacterial Bronchitis Non specific cough, No features of specific diagnosis Antibiotics Watchful waiting & review Continue trial of therapy American college of chest physician algorythm Ix and Rx according to the diagnosis
- 92. Case 3: • 2 year old female presents with cough for 4 weeks • Wet cough, during day time, worse at night • Also had chronic mouth breathing and congestion • Started with clear drainage, but now discoloured for past 2 weeks. • Snores, but no apnoeas, sleep restfully
- 93. Examination • Discoloured drainage and crusting in anterior nose • Oral cavity examination shows yellow drainage in the pharynx • No wheezing/rhonchi • What do you do?
- 94. • Protracted Bacterial Bronchitis and Chronic Adenoiditis • Start Antibiotics • Nasal saline drops for 1 month
- 95. Look for cough pointers,CXR changes,Abnormal spirometry, Neurodev issues, Feeding issues, Malnutrition, Recurrent Lower RTI, Chest wall deformities, clubbing, Abnormal auscultation, Classic cough characteristics, Fail to respond to treatment . No features above Specific cough, Features of other specific diagnosis(BA), CSLD WET COUGH DRY COUGH Features of protracted Bacterial Bronchitis Non specific cough, No features of specific diagnosis Antibiotics Watchful waiting & review Continue trial of therapy American college of chest physician algorythm Ix and Rx according to the diagnosis
- 96. Case 4: • 4 year old otherwise healthy boy presents with cough • Cough is intermittent, dry and sporadic • Started with cold 1 month ago • Now doesn’t have nasal drainage/congestion
- 97. What do you do? • NOTHING • R/V 1-2/52 • Cough still present
- 98. Look for cough pointers,CXR changes,Abnormal spirometry, Neurodev issues, Feeding issues, Malnutrition, Recurrent Lower RTI, Chest wall deformities, clubbing, Abnormal auscultation, Classic cough characteristics, Fail to respond to treatment . No features above Specific cough,Features of other specific diagnosis(BA), CSLD WET COUGH DRY COUGH Features of protracted Bacterial Bronchitis Non specific cough, No features of specific diagnosis Antibiotics Watchful waiting & review Continue trial of therapy American college of chest physician algorythm Ix and Rx according to the diagnosis
- 99. What do you do? • Get CXR -Negative • Discuss options with parents • Continue watch, wait and review • Trial of therapy. Inhaled steroids (Budesonide 400micg/daily) • Recheck in 2-3/52
- 100. • If cough persists/ cough pointers develops • Treat with Antibiotics if wet cough • Inhaled steroids if dry cough
- 101. Role of AB in wet cough? • Role of AB (Marchant et al 2011) • AB reduced proportion not cured • Progression of illness lower • Adverse events not increased
- 102. Role of AB in wet cough?.... •Without specific cough pointers •Treat with AB for 2 weeks •If resolves with 2 week Rx…Protracted Bacterial Bronchitis
- 103. Role of AB in wet cough?.... • If cough persists after 2 weeks of AB…Additional 2 weeks AB • If cough persists after 4 weeks…Further Ix warranted • Skin prick test • Mantoux • Bronchoscopy • Ct Chest
- 104. •If CXR, PFT normal and no characteristic cough • Watchful waiting…do NOTHING • If persists/develop cough pointers • Dry…Inhaled steroids • Wet….AB •ACC doesn’t recommend OTC/codeine/Dextromethorphan
- 105. Case 5: • 4 year old child presented with sudden onset of cough while playing with toys • O/E • Not dyspnoeic • Lungs- Air entry low on L/side • CXR • Hyper inflated chest • Rigid Bronchoscopy under GA • Foreign body in L/Bronchus
- 106. Foreign body inhalation… • Near total obstruction of Larynx/trachea causes sudden asphyxia/death • Partial obstruction • Ball-valve effect • Distal to the obstruction, air trapping • local emphysema& atelectasis • post-obstructive pneumonia or bronchiectasis
- 109. Habit cough (Psychogenic cough) • No detectable physiologic etiology • Diagnosis of exclusion • Identify psychogenic stressors • Psychotherapy, Family therapy
- 110. Take away pearls Chronic cough lasting>4/52 Signs of severe illness, Cough characteristic of illness, Not respond to treatment Pulmonary Consultation Dry cough Inhaled steroids If no resolution, Pulmonary consult Wet cough 2-6 weeks Antibiotics If no resolution, Pulmonary consult No signs of severe illness, No characteristic of illness, Watchful waiting, Evaluation of environmental exposure, Address parental concerns
- 111. Take away pearls • Only effective Rx are • Antibiotics for wet cough • Inhaled steroid for dry cough • Only honey effective for symptomatic relief • No OTC medications recommended • Rx with anti-reflux, anti-cholinergics, anti-histamines, LT receptor antagonist or B2-agonists…no benefit
- 112. Take away pearls…. • If chronic cough fail to resolve…early pulmonary consult is recommended • If child >6yeras..CXR and spirometry should be obtained • Use cough pointers for cough characteristic Hx • Emperic Rx for acid reflux/ Rhinosinusitis/BA should be made only those suggested conditions present.
- 113. CONCLUSIONS • Chronic cough is defined as lasting >4 weeks • Differential diagnosis are large • Refractory…Culture, CXR, Endoscopy • Evaluation and Rx is individualized • According to History and clinical findings
- 114. Acknowledgement • American Academy of Otolaryngology-Head and Neck Surgery Annual academic sessions(2018)
- 115. Visit Adam’s peak THANK YOU…
- 116. THANK YOU AGAIN.. Visit Horton plains in 2021! It is located at an elevation of 6,900–7,500 ft and encompasses montane grassland and cloud forest.
- 117. QUESTIONS???