Recent update on management of chronic cough.pptx
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How to manage cough in the COVID era?
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Recent update on management of chronic cough.pptx
- 1. Evaluating cough in COVID crisis Dr. Aditya Jindal Interventional Pulmonologist & Intensivist Jindal Clinics SCO 21, Sec 20D, Chandigarh DM Pulmonary and Critical Care Medicine (PGI Chandigarh), FCCP
- 2. • Clear the upper airway of secretions: – Mucus, noxious substances, foreign particles, and infectious organisms • It is a complicated process: – Inspiratory phase – Forced expiratory effort against closed glottis – Opening of the glottis with rapid expiration(sound) Cough - pathophysiology Chung KJ and Pavord ID Lancet2008
- 3. • The cough reflex: – Transient receptor potential vanilloid-1 (TRPV-1) is a capsaicin receptor Cough - pathophysiology Chung KJ and Pavord ID Lancet2008
- 4. Morice AH, Millqvist E, Bieksiene K, et al. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J 2020; 55: 1901136 [https://doi.org/10.1183/ 13993003.01136-2019]. • Cough is a vital protective reflex preventing aspiration and enhancing airway clearance. However, pathologically excessive and protracted cough is a common and disabling complaint, affecting perhaps 5–10% of the adult population. • When severe, it causes a major decrement in the quality of life, with comorbidities such as incontinence, cough syncope and dysphonia leading to social isolation, depression and difficulties in relationships
- 5. Cough: classification • Cough is a sudden and repetitively occurring protective reflex, which helps clear the large breathing passages from fluids, irritants, foreign particles, and microbes. • Cough is classified into 3 categories on the basis of its duration in adults: – acute (<3 weeks) – subacute (3-8 weeks) and – chronic (>8 weeks) Indian Consensus on Diagnosis of Cough at Primary Care Setting. Journal of The Association of Physicians of India Vol. 67 January 2019
- 6. Approach to cough in primary care setting in India Indian Consensus on Diagnosis of Cough at Primary Care Setting. JAPI, January 2019
- 7. Acute Cough in Adults
- 8. Causes of acute cough • Upper respiratory tract infections (bacterial or viral) • Pneumonia • Asthma • Congestive heart failure • Pulmonary embolism • Foreign body aspiration Indian Consensus on Diagnosis of Cough at Primary Care Setting. Journal of The Association of Physicians of India Vol. 67 January 2019
- 9. Algorithm for the management of acute cough CHEST 2018; 153(1):196-209
- 10. Algorithm for the management of acute cough CHEST 2018; 153(1):196-209
- 11. Representative Punum ladders to assess (A) cough severity or (B) overall quality of life. CHEST 2018; 153(1):196-209
- 12. Subacute Cough in Adults
- 14. Algorithm for the management of Subacute cough CHEST 2018; 153(1):196-209
- 15. Algorithm for the management of Subacute cough CHEST 2018; 153(1):196-209
- 16. Chronic Cough in Adults
- 17. Causes of chronic cough
- 20. Morice AH, Millqvist E, Bieksiene K, et al. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J 2020; 55: 1901136 [https://doi.org/10.1183/ 13993003.01136-2019]. Cough assessment in adults
- 22. Algorithm for diagnosis of pulmonary tuberculosis Indian Consensus on Diagnosis of Cough at Primary Care Setting. Journal of The Association of Physicians of India Vol. 67 January 2019
- 23. • Chronic cough > 8 weeks, non smokers and no asthma • Baseline 24h pH study, methacholine challenge test, laryngoscopy • Esomeprazole 40 mg bid or placebo 12 weeks • Primary outcome cough-specific quality of life questionnaire (CQLQ) Chronic Cough – PPI Shaheen et al. Aliment Pharmacol Ther.2011
- 24. • 39 to 45% of patients had a positive pH study Chronic Cough – PPI Shaheen et al. Aliment Pharmacol Ther.2011
- 25. • No difference in cough questionnaire between the groups at 12 weeks Chronic Cough – PPI Shaheen et al. Aliment Pharmacol Ther.2011
- 26. Morice AH, Millqvist E, Bieksiene K, et al. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J 2020; 55: 1901136 [https://doi.org/10.1183/ 13993003.01136-2019]. Which cough neuromodulatory agents (pregabalin, gabapentin, tricyclics and opiates) should be used to treat patients with chronic cough? We recommend a trial of low-dose slow-release morphine (5–10 mg twice daily) in adult patients with chronic refractory cough (strong recommendation, moderate-quality evidence).
- 27. Morice AH, Millqvist E, Bieksiene K, et al. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J 2020; 55: 1901136 [https://doi.org/10.1183/ 13993003.01136-2019]. Should anti-asthmatic drugs (anti-inflammatory or bronchodilator drugs) be used to treat patients with chronic cough? We suggest a short-term ICS trial (2–4 weeks) in adult patients with chronic cough (conditional recommendation, low-quality evidence).
- 28. Morice AH, Millqvist E, Bieksiene K, et al. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J 2020; 55: 1901136 [https://doi.org/10.1183/ 13993003.01136-2019]. Should FeNO/blood eosinophils be used to predict treatment response to corticosteroids/ antileukotrienes in chronic cough? There is a need for convenient and practical tests for predicting anti- inflammatory treatment responses in patients with chronic cough. However, there is still a lack of quality evidence. Placebo-controlled trials are warranted to assess their utility and also consensus is required on threshold levels in patients with chronic cough.
- 29. Dina Visca, et al., European Journal of Internal Medicine. 2020
- 30. Efficacy and Safety of Levocloperastine in the Treatment of Dry Cough: A Prospective Observational Study • A total of 100 patients were enrolled in the study. • The mean scores of cough severity, cough frequency and sleep disruption due to night-time awakening were significantly reduced from baseline to Day 14 (p<0.0001) • Levocloperastine was found to be effective and safe in the management of dry cough. • A significant reduction in severity scores, frequency of cough and sleep disruption was reported, with an overall improvement in patient’s QoL Efficacy and Safety of Levocloperastine in the Treatment of Dry Cough: A Prospective Observational Study. Journal of The Association of Physicians of India ■ Vol. 66 ■ May 2018
- 31. • New medicines for cough – TRP receptor blockers – substance P antagonist orvepitant – P2X3 purinergic receptors gefapixant
- 32. Covid-19 Cough
- 33. CORONA VIRUS (COVID-19) What’s a Coronavirus? CORONA A family of viruses affecting Respiratory Tract Causing Disease from common cold to Pneumonia. Usually lives in bats & other wiled animals. Transmitted to humans directly, or via other animals. Can also transmit between humans via respiratory droplets,
- 34. CORONA VIRUS (COVID-19) Virus Structure Spike Glycopr otein Envelope Small Membrane Protein R N A Hemagglut inin Esterase Membr ane Protein • 2019-nCoV has enveloped virions that measure approximately 50–200 nm in diameter with a single positive-sense RNA genome. • Club-shaped glycoprotein spikes in the envelope give the virus a crown-like or coronal appearance.
- 35. CORONA VIRUS (COVID-19) Corona Virus Symptoms Shortness of breath High Fever Vomiting (In Some Case) Diarrhea (In Some Case) Coughing Pneumonia
- 37. Indian Consensus on Diagnosis of Cough at Primary Care Setting. JAPI, January 2019
- 38. • Cough is classified into acute, sub-acute and chronic cough • Cough may be treated empirically and may not require aggressive investigations unless it is characterized by “red flag signs” or persists for > 2 weeks. • Pulmonary tuberculosis should be excluded if the cough persists for > 2 weeks after the initial treatment with suggestive signs and symptoms. • Upper airway cough syndrome, gastroesophageal reflux disease, and cough variant asthma should be diagnosed based on medical history and nasal examination and treated empirically. • Spirometry and other specialized tests may be considered
Editor's Notes
- Acute cough algorithm for the management of patients ≥ 15 years of age with cough lasting < 3 weeks. Always screen for the presence of red flags as a clue to a potentially life-threatening condition. Always consider the presence of TB in endemic areas or high-risk populations even if chest radiographs are normal. Remember to routinely assess cough severity or quality of life before and after treatment and routinely follow patients 4- 6 weeks after initial visit. LRTI ¼ lower respiratory tract infection; PE ¼ pulmonary embolism; UACS ¼ upper airway cough syndrome; URI ¼ upper respiratory tract infection.
- Acute cough algorithm for the management of patients ≥ 15 years of age with cough lasting < 3 weeks. Always screen for the presence of red flags as a clue to a potentially life-threatening condition. Always consider the presence of TB in endemic areas or high-risk populations even if chest radiographs are normal. Remember to routinely assess cough severity or quality of life before and after treatment and routinely follow patients 4- 6 weeks after initial visit. LRTI ¼ lower respiratory tract infection; PE ¼ pulmonary embolism; UACS ¼ upper airway cough syndrome; URI ¼ upper respiratory tract infection.
- Always screen for the presence of red flags as a clue to a potentially life-threatening condition as well as historical clues for environmental and occupational factors that might be contributing to the cough. Always consider the presence of TB in endemic areas or high-risk populations even if chest radiographs are normal. Remember to routinely assess cough severity or quality of life before and after treatment and routinely follow patients 4 to 6 weeks after initial visit. AECB ¼ acute exacerbation of chronic bronchitis; GERD ¼ gastroesophageal reflux disease; NAEB ¼ nonasthmatic eosinophilic bronchitis. See Figure 1 and 3 legends for expansion of other abbreviations.
- Chronic cough algorithm for the management of patients $ 15 years of age with cough lasting > 8 weeks. Always screen for red flags as a clue to a potentially life-threatening condition, as well as historical clues for environmental and occupational factors that might be contributing to the cough. Always evaluate whether sitagliptin as well as angiotensin-converting enzyme inhibitors are contributing to the patient’s cough. Always consider the presence of TB in endemic areas or high-risk populations even if chest radiographs are normal. Be aware that treatment of cough due to GERD should not be limited to acid suppression. Remember to routinely assess cough severity or quality of life before and after treatment and routinely follow patients 4 to 6 weeks after the initial visit. Consider referral to a recognized cough clinic for patients with refractory unexplained chronic cough. ACEI ¼ angiotensin-converting enzyme inhibitor; A/D ¼ antihistamine/decongestant; BD ¼ bronchodilator; HRCT ¼ high-resolution CT; ICS ¼ inhaled corticosteroid; LTRA ¼ leukotriene antagonist; PPI ¼ proton pump inhibitor. See Figure 3 and 4 legends for expansion of other abbreviations.
- VAS: visual analogue scale; HARQ: Hull Airway Reflux Questionnaire; ACE: angiotensin-converting enzyme; FeNO: exhaled nitric oxide fraction; LTRA: leukotriene receptor antagonist; PPI: proton-pump inhibitor; AAFB: alcohol and acid-fast bacilli; CT: computed tomography.
- Chronic cough algorithm for the management of patients $ 15 years of age with cough lasting > 8 weeks. Always screen for red flags as a clue to a potentially life-threatening condition, as well as historical clues for environmental and occupational factors that might be contributing to the cough. Always evaluate whether sitagliptin as well as angiotensin-converting enzyme inhibitors are contributing to the patient’s cough. Always consider the presence of TB in endemic areas or high-risk populations even if chest radiographs are normal. Be aware that treatment of cough due to GERD should not be limited to acid suppression. Remember to routinely assess cough severity or quality of life before and after treatment and routinely follow patients 4 to 6 weeks after the initial visit. Consider referral to a recognized cough clinic for patients with refractory unexplained chronic cough. ACEI ¼ angiotensin-converting enzyme inhibitor; A/D ¼ antihistamine/decongestant; BD ¼ bronchodilator; HRCT ¼ high-resolution CT; ICS ¼ inhaled corticosteroid; LTRA ¼ leukotriene antagonist; PPI ¼ proton pump inhibitor. See Figure 3 and 4 legends for expansion of other abbreviations.