TUBERCULOSIS HAS BEEN EXCLUDED BECAUSE IN INDIA TUBERCULOSIS IS THE MOST COMMON CAUSE OF CHRONIC COUGH AND REST OTHER CAUSES OF CHRONIC COUGHS ARE IGNORED

1. Approach to a patient with
Chronic Cough
Presented by-
Dr. Amit Kumar

2. MODERATORS
Dr C. Phukan
Dr. U. Islam
Dr P. N. Uzir
Dr. B. C. Das
Dr. U. Talukdar
Dr A. Sarma
Dr P. Das

3. INTRODUCTION
• Cough is an act of forceful expiration with the glottis closed
followed by sudden explosive release of the pent-up air along with
sputum or other irritant matter.
• Cough provides an essential protective function for human
airways and lungs.
• Without an effective cough reflex, we are at risk
for retained airway secretions and aspirated material,
predisposing to infection, atelectasis, and respiratory compromise.
• In many instances, cough is an expected and accepted
manifestation of disease, such as during an acute respiratory tract
infection.

4. COUGH MECHANISM
• Cough reflex is the basis of cough as a protective mechanism.
• Coughing may be initiated either voluntarily or reflexively.
• It has both sensory (afferent) and motor (efferent) components.
• Pulmonary irritant receptors (cough receptors) in the
epithelium of the respiratory tract are sensitive to both
mechanical and chemical stimuli.
• Stimulation of the cough receptors by foreign particles (dust,
mucus, etc.) produces a cough, which is necessary to remove
the foreign material from the respiratory tract before it reaches
the lungs

5. COUGH MECHANISM
Afferent Pathway
• Mechanical stimuli:
 Rapidly adapting receptors (RARs)
 Slowly adapting stretch receptors (SARs)
• Chemical stimuli:
 C-fibers

6. COUGH MECHANISM
Afferent Pathway
• Stimulation of the cough receptors by foreign particles (dust,
mucus, etc.) produces a cough, which is necessary to remove the
foreign material from the respiratory tract before it reaches
the lungs.
• Stimuli arise from:
Ear, Pharynx, Larynx, Lungs, Tracheobronchial tree, Heart,
Pericardium, Esophagus

7. COUGH MECHANISM
Efferent Pathway
• The efferent neural pathway brings relevant signals back
from the cerebral cortex and medulla via the vagus and
superior laryngeal nerves to the glottis, external
intercostals, diaphragm, and other major inspiratory and
expiratory muscles
Cough phases
Irritation Inspiration Compression Expulsion

9. TUBERCULOSIS (Very common in
india)

10. APPROACH TOWARDS COUGH

11. 1. Onset & Duration
• Acute (< 3 weeks)
• Subacute (3 – 8 weeks)
• Chronic (> 8 weeks)

12. 2. Quality
Dry Cough
(non-productive)
Wet Cough
(productive)
•Laryngitis
•Dry pleurisy
•Smoking cough
•Debut of diseases
•Acute viral diseases
•Bronchitis
•Pneumonia
•Tuberculosis
•Bronchiectatic disease

13. Sputum

14. Sputum
Green sputum Purulent sputum

15. Sputum
Foul smelling sputum:
• Bronchiectasis, lung
abcess, empyema
Solid matter present in viscid
secretions:
• In asthma, allergic
brochopulmonary
aspergillosis, necrotic
tumour, foreign body

16. Sputum
Hemoptysis

17. 3. Characteristic
• Barking: Laryngeal inflammation,
infection or tumour causes harsh, barking
or painful coughs and associated
hoarseness and the rasping or croaking
inspiratory sound of stridor.
• Whooping: Paroxysms of cough,
posttussive vomiting and inspiratory
whooping sound:-common in patients
with pertussis infection.
• Brassy: aortic aneurysm
• Moist: Secretions in the
upper and larger airways from bronchial
infection and bronchiectasis
• Bovine: A feeble non-explosive ‘bovine’
cough with hoarseness suggests lung
cancer invading the left recurrent
laryngeal nerve causing left vocal cord
paralysis, but may also occur with
respiratory muscle weakness due to
neuromuscular disorders.
• Wheezy: Asthma

18. 4. Timing
1. Diurnal variation
• Cough which gets worse in night and early morning :- Asthma.
• Persistent moist cough on waking up in smokers :- C/c bronchitis
2. Seasonal variation
• Winter cough: Asthma, C/c bronchitis
• Spring/Autumn – allergic cough, asthma
3. Postural variation
• Bronchiectasis, Lung abcess.
Short,dry irritating cough with pain behind jaw or neck:- Pharyngeal
Harsh,irritative and repetitive with stridor and cyanosis:- Laryngeal

19. 5. Aggravating & Relieving factors
 Cold air, smoke, dust, exertion, animal fur, pollens,:- asthma.
 Swallowing of liquids:- NM d/s of oropharynx.
 Otogenic cough:- impacted wax or foreign body in external auditory
meatus:subsides with removal of cause

20. 6. Associated symptoms
Fever:- TB, RTI; lung abscess;
Chest pain:-Bronchitis, bronchogenic carcinoma
Pleuritic chest pain:-Pleurisy, pleural effusion, bronchiectasis
Dyspnea:- COPD, Asthma, ILD, Pneumonia, Bronchogenic carcinoma,
Sarcoidosis, CHF ( orthopnea & PND)
Wheeze:- asthma “cough variant asthma”
Nasal discharge, tickling sensation in throat:- Postnasal drip
Loss of weight:- bronchogenic carcinoma, TB
Stridor:-FB, Laryngeal nerve involvement
Hoarseness of voice:- Laryngeal nerve involvement
Heart burn, regurgitation:- GERD
Erythema nodosum:-Sarcoidosis

21. HISTORY OF PAST ILLNESS
• COPD,
• Asthma,
• Postnasal drip,
• GERD
• R/c or complicated Pneumonia,
• Tuberculosis.
• Whooping cough
• Bronchiectasis
• Immunosuppression
• Surgery

22. PERSONAL HISTORY
• Loss of appetite, sleep
• Low grade fever
• Weight loss
• Smoking
• Occupational exposure
• Allergy or atopy

23. FAMILY HISTORY
• Chronic bronchitis with emphysema,
• Respiratory allergy,
• Asthma,
• Cystic fibrosis
• TB

24. TREATMENT HISTORY
• Angiotensin Converting Enzyme Inhibitors
• Past treatment of d/s like
allergies,asthma,pneumonia,TB,Bronchitis
• Immunosuppressants

25. General Examination
Pallor
Icterus
Clubbing
Edema
Cyanosis
JVP
Lymphadenopathy

26. Systemic Examination

28. Common causes
• Postnasal drip (UACS)
• Asthma
• GERD
• ACEI use
• COPD
• More than one cause

29. 1.Post-nasal drip (PND)
• PND of any etiology can cause cough as a
response to stimulation of sensory receptors of
the cough-reflex pathway in the hypopharynx or
aspiration of draining secretions into the trachea.
 Clues
• frequent throat clearing
• sneezing and rhinorrhea
 speculum examination
• excess mucoid or purulent secretions
• inflamed and edematous nasal mucosa,
and/or nasal polyps.
• cobblestoned appearance

30. 1. Upper airway cough syndrome
• Previously termed as Post Nasal Drip syndrome
• Most common cause of chronic cough due to variety of rhino- sinus
conditions, like Infection, Allergy, or Vasomotor rhinitis.
• Described as ‘dripping of secretions into throat’ nasal discharge,
tickling sensation of throat or frequent throat clearing.
• PNDS includes cough– combination of criteria- symptoms, physical
examination, radiographic findings and ultimately the response to
specific Therapy.

31. Treatment of UACS
• Specific cause apparent- therapy directed at the condition.
• Patients with chronic cough if no specific cause apparent-
empiric therapy for UCAS in the form of a first generation A/D
prescribed before beginning extensive diagnostic w/u
• Resolution of cough in response to specific treatment is
important factor in confirming the diagnosis of UCAS.
• No response to empirical A/D & topical therapy consider sinus
imaging

32. 2. Asthma
Asthma is a common chronic inflammatory disease of
the airways characterized by variable and recurring
symptoms, reversible airflow obstruction and
bronchospasm.
• Asthma accounts for 24 to 29% of cases of chronic
cough in adult non-smokers with normal CXR.
• Cough variant asthma(CVA) - Subset of
asthmatics
who present with chronic cough without history of
SOB or wheezing.
• Reason- significantly more sensitive cough reflex,
blunted Broncho constrictor response(less rapid
rise of resistance in CVA in MIC).

33. 2. Asthma

34. Treatment of cough variant Asthma
• Treatment similar to standard
treatment for asthma.
Inhaled bronchodilator and
corticosteroid mainstay of the
therapy.
• Partial response in1 week and
complete response
in 8 weeks.
• Poor response-
1.Evaluate for sputum for
eosonophilia.
2.Increase dose of ICS
3. Oral LTRA (zafirlukast)
4.Oral corticosteroid

35. 3.Gastro Esophageal Reflux
Disease (GERD)
ABchronic condition in which the
LES allows gastric acids to
reflux into the esophagus,
causing heartburn, indigestion,
and possible injury to the
esophageal lining.
• It is a Common cause of
chronic cough after
UACS, CVA.
Clues to GERD: Retrosternal
burning after meals or on
recumbency, frequent eructation,
hoarseness, and throat pain.
Mechanisms of cough:
 Micro or macro-aspiration of
esophageal contents into the
tracheo-bronchial tree.
 Acid in the distal esophagus
stimulating
a vagally mediated
esophageal-tracheobronchial
cough reflex.

36. 4. Use of ACE inhibitors

37. 4. Use of ACE inhibitors
• Angiotensin-converting-enzyme inhibitors (ACE inhibitors) are a
group of medicaments used primarily for the treatment of arterial
hypertension and congestive heart failure.
• Frequently prescribed ACE inhibitors include perindopril,
captopril, enalapril, lisinopril, and ramipril.
• ACE inhibitors cause a nonproductive cough in 5 to 20% of patients.
• The cough is usually dry and hacking.
• This effect is not dose related, and the cough may begin
1 week to 6 months after therapy is initiated.

41. Summary
Don’t try to cure the chronic cough. Try to find and
cure the reason of the cough!!!