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Chronic cough4 09

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Chronic cough4 09

  1. 1. Chronic Cough Barbara A. Cockrill, MD Massachusetts General Hospital Harvard Medical School
  2. 2. Cough • Vital protective mechanism • Four steps: – – – – inspiratory gasp Valsalva maneuver expiratory blast as cords abduct post-tussive prolonged inspiration
  3. 3. Chronic Cough • Common things are common • Patients who do not respond frequently have more than one cause • GERD causes cough. • Post-infectious cough is common
  4. 4. Causes of Cough ACCP Chest 2006 100 80 70 60 50 41 40 40 24 21 20 30 5 4 5 20 10 mi sc CB PI EB Br CB on ch iec t Mi sc As th m a GE RD UA CS ER D 0 0 UA C/ As /G 60 80 Irwin 1990
  5. 5. Number of causes of cough Patients % 100 75 73 50 20 25 7 0 1 2 Number of Causes of Cough Smyrnios et al Arch Intern Med 1998 158:1222 3
  6. 6. Chronic Cough: D.A. • • • • 55 yo school secretary C/O cough for 3 years Non-smoker Cough: – Often productive, wax/wane – Better c abx, but comes back – “no better” with asthma meds – worst in AM
  7. 7. Chronic Cough: D.A. • • • • • Nasal voice, afebrile, looks well Mild “cobblestoning” No facial tenderness normal heart and lungs normal spirometry
  8. 8. Chronic Sinusitis • • • Often paucity of symptoms Often improvement with antibiotics Dx: Clinical & Sinus CT scan
  9. 9. Chronic Sinusitis • Evaluation – Allergies – Immunological • Rx: • • • • • • Prolonged antibiotics (3-6 weeks) Immunotherapy Topical steroids antihistamine/decongestants Sinus irrigation Consider surgical evaluation
  10. 10. Chronic Cough: The Computer Programmer • 35 yo woman • Yearly cough – starts only after a “cold” in fall or winter,lasts until mid-summer – Severe coughing FITS – goes away by itself – has happened last 4 years. • Tried “everything”
  11. 11. Chronic Cough: The Computer Programmer • Denies: wheezes, PND sx, allergies heartburn, aspiration • No: pets, exposures, current meds • Family hx negative • PMH: negative • Physical exam and CXR normal • Normal spirometry, no bronchdilator effect • “I can’t take it any longer!”
  12. 12. Methacholine Challenge Testing
  13. 13. Cough Variant Asthma • • • • Cough is sole symptom Spirometry is normal Up to 25% of asthmatics Diagnosis: – Positive methacholine challenge – Response to therapy • Mechanism
  14. 14. Non-asthmatic Eosinophilic Bronchitis • Eosinophilic airway inflammation WITHOUT variable airflow obstruction • Responds to inhaled corticosteroids • Dx = – sputum or BAL eosinphilia – Lack of variable airflow obstuction – Response to corticosteroids
  15. 15. Asthma vs. NAEB: Different localization Mast cells Brightling et. Al. NEJM 2002;346:1699
  16. 16. Chronic Cough: The Computer Programmer • Aggressive asthma regimen x 4 weeks • “I am only one iota better.......” • NOW WHAT?!
  17. 17. Reflux Esophagitis
  18. 18. Esophageal-tracheobronchial cough reflex & GERD • 22 pts with reflux & cough, 12 controls • Instilled acid into distal esophagus • Looked at effects of – – – Esophageal lidocaine Esophageal ipratropium Inhaled ipratropium Ing et al 1994
  19. 19. ⇑ cough in patients (p<.0001) Ing 1994
  20. 20. Cough blocked by esophageal lidocaine, not by esophageal ipratroprium
  21. 21. Cough blocked by esophageal lidocaine, not by esophageal ipratroprium Instillation of lidocaine before instillation of HCl Ing 1994
  22. 22. Cough was blocked by INHALED ipratropium Ing 1994
  23. 23. Cough blocked by INHALED ipratropium Ing 1994
  24. 24. Cough and Reflux Cough GERD causes cough & lowers cough threshold ⇑ Reflux ⇑ abdominal pressure
  25. 25. Lifestyle Changes for GERD • Stop smoking • Avoid alcohol • Lose weight • Elevate HOB • Small meals • • • • Avoid fatty/acidic foods High protein/low fat diet Avoid caffeine Avoid – tight clothes – eating < 4 hrs pre-bed – Recumbency 3 hrs post
  26. 26. Medications that ⇓ LES tone • • • • • • Theophylline Progesterone Alpha-adrenergic antagonists Beta-adrenergic antagonists Calcium channel blockers Nitrates
  27. 27. Cough & GERD: treatment • Conservative measures • Antacid therapy: – Proton pump inhibitor (high dose) – H2 blockers less effective • Motility therapy: – Metoclopromide (Cisapride) • Surgery is last resort
  28. 28. Cough & GERD • May be silent (up to 75%) • May complicate other causes • Diagnosis can be difficult – pH probe vs. therapeutic trial • • • Treatment must be aggressive Bland reflux can still cause cough Surgery effective in some patients
  29. 29. Chronic cough: J.B. • • • • • • • 46 yo woman Secretary in College Infirmary 3 wks severe cough Followed mild “cold” Cannot talk, sleep Cough comes in “fits” Otherwise very healthy
  30. 30. “The art of medicine is amusing the patient until Nature cures the disease.” -Voltaire
  31. 31. The Boston Globe Friday, June 8, 2007 Cape hospital hunts for whooping cough exposure By Stephen Smith, Globe staff Cape Cod Hospital embarked on a massive hunt to track down about 1,000 patients, relatives, and staff members who might have been exposed to whooping cough by workers in a cancer clinic.
  32. 32. B. pertussis “The hundred Day Cough” • Bordatella pertussis, parapertussis • Immunity wanes 12 yrs after vaccine • Phases: – catarrhal, paroxysmal, convalescent • Abx ⇓ infectivity, no effect on cough • Prophylaxis
  33. 33. Trachea: effect of pertussis
  34. 34. Why diagnose pertussis? • Treatment: – does not ⇓ paroxysmal phase – does ⇓ infectivity • • • Prophylaxis To reassure patient Minimize further work-up
  35. 35. New CDC Guideline Dec. 2006 • All adults should receive Tdap x 1 •Tetanus •Diphtheria •Pertussis
  36. 36. Post-infectious cough: Vagal neuropathy?? Jeyakumar et. al. Laryngoscope 116: 2108, 2006
  37. 37. Chronic Cough: Conclusions • Common things are STILL common • Many patients have > 1 cause • Most patients respond to therapy
  38. 38. Thank you

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