Based on the history and physical exam findings, this patient's chronic cough is most consistent with upper airway cough syndrome (UACS). Key factors include: - Duration of cough >8 weeks - Often dry cough, sometimes with white foamy sputum - Worse with exercise, cold air, and at night - Associated postnasal drip and throat clearing - History of sinus problems The physical exam is normal. Further workup and treatment based on the ACCP guidelines for UACS would be appropriate.

2. THE CURE
The owner of a drugstore walks in to find a guy leaning heavily against a wall
with an odd look on his face.
The owner asks the sell's man "What's with that guy over there by the
wall?“
The sell's man , "Well, he came in here at 7 A.M. to get something for his
cough. I couldn't find the cough syrup, so I gave him an entire bottle of
laxatives.“
The owner says, "You idiot! You can't treat a cough with laxatives!“
!!!! sell's man, "Oh yeah? Look at him—he's afraid to
cough !!!!

3. COUGH : DIAGNOSIS & MANAGEMENT
ACCP EVIDENCE BASED CLINICAL
PRACTICE GUIDELINES
Dr.Sajid Nomani
MD, MEM(USA)
Peerless Hospital

4. Cough: Public Health Concern

6. Importance !!!
• Cough is the most common presenting symptom
• The fourth most common symptom seen in PCP
• Acute cough accounted for 46 million GP‟s visits
• Leads to decreased patient quality of life and decreased school
and work productivity
• Chronic cough may account for up to 40% of visits to a
Pulmonologist

7. Areas To Cover !!!
• Why do we Cough?
• Classification and Causes of Cough.
• The ACCP guidelines for diagnosis &
Managment

8. What is a cough!!!
Coughing is the body's way
of removing foreign material or mucus
from the lungs & upper airway or of
reacting to an irritated airway

9. What is a cough!!!
• Cough is a 3-phase expulsive motor act
characterized by an inspiratory effort (inspiratory
phase), followed by a forced expiratory effort
against a closed glottis (compressive phase) followed
by opening of the glottis and rapid expiratory
airflow (expulsive phase)

10. Pressure in the lungs rises to 100-300mmHg. Markedly positive intrathoracic
pressure causes narrowing of the trachea.

11. Cough reflex!!!
• Voluntarily or Involuntarily.
• Each cough is elicited by stimulation of relex arc
• Afferent and Efferent pathways.
• cough receptors
• Mechano recp-touch/displacment
• Chemo recp.- heat/acid

12. Cough Reflex !!!
Impulses from the cough receptors
↓
via afferent limb vagus N.
↓
COUGH CENTER
↓
EFFERENT IMPLUSE GENERATED
↓ propagated
spinal motor : Expiratory muscles
Phrenic : Diaphragm
Vagus n. : Larynx,trachea,bronch
to the expiratory organs to produce
cough

13. What is the most common cause of cough???
1. Smoking
2. Infection
3. Asthma
4. Reflux
5. Occupation & Environmental Irritant.

14. Cough: What’s it good for ???
• Protect the airway from pathogens,
particulates, food, other foreign bodies
• Clear the airways of accumulated secretions,
particles
• Attract attention
• Signal displeasure

15. Complications of Cough!!!
• Result primarily from marked increase in
intrathoracic pressure (> 300 mmHg) during
cough
• Affect nearly every other organ system
• Disruption of surgical wounds
• Negative impact on quality of life, particularly
in chronic cough

16. Complications of Cough
Cardiovascular
Arterial hypotension
Loss of consciousness
Rupture of subconjunctival, nasal and anal veins
Dislodgement/malfunctioning of intravascular catheters
Bradyarrhythmias, tachyarrhythmias
Neurologic
Cough syncope
Headache
Cerebral air embolism
CSF rhinorrhea
Acute cervical radiculopathy
Malfunctioning ventriculoatrial shunts
Seizures
Stroke due to vertebral artery dissection
Gastrointestinal
Gastroesophageal reflux events
Hydrothorax in peritoneal dialysis
Malfunction of gastrostomy button
Splenic rupture
Inguinal hernia
Irwin,RS,Boulet,LP,Cloutier,MM,etal.Managingacough
asadefensemechanismandasasymptom.Aconsensus
panelreportoftheAmericanCollegeofChestPhysicians.
Chest1998;114(suppl2):133S.

17. Complications of Cough !!!
Genitourinary
Urinary incontinence
Inversion of bladder through urethra
Musculoskeletal
From asymptomatic elevations of serum creatine phosphokinase to rupture of rectus
abdominis muscles
Rib fractures
Respiratory
Pulmonary interstitial emphysema, with potential risk of pneumatosis intestinalis,
pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, pneumothorax,
subcutaneous emphysema
Laryngeal trauma
Tracheobronchial trauma (eg, bronchitis, bronchial rupture)
Exacerbation of asthma
Intercostal lung herniation
Miscellaneous
Petechiae and purpura
Disruption of surgical wounds
Constitutional symptoms
Lifestyle changes
Self-consciousness, hoarseness, dizziness
Fear of serious disease
Decrease in quality of life
*

18. TOOLS!!!!
• HISTORY / PHYSICAL EXAMINATION
• C-XRAY
• SPIROMETRY
• METHACHOLINE CHALLENGE TEST
• 24H.PH MONITORING
• BARIUM ESOPHAGOGRAPHY
• HRCT

19. ED……point of view!!!
• R/O life threatning causes
• ABC
• Treatment
• Paroxysm of caugh
• lidocaine - 4 cc of 1% or 2%
preservative-free nebulization

20. American College of
Physicians 2006 Cough
Guidelines
• Evidence-based
• Includes guidelines for
pediatric cough
• Should be used in
conjunction with “clinical
judgment

21. Grading of Recommendations !!!
ACCP GRADING SYSTEM
• Quality of evidence
• Net benefit of the recommendation of
diagnostic & therapeutic procedure
• Gr-A-Strong
• Gr-B-moderate
• Gr-C-weak
• Gr-E/A-strong expert openion
• Gr-E/B-moderate expert openion

22. Success Rate !!!
• Cause of cough can be determined in
88 to 100% of cases
• Success rates with specific therapies
range from
84 to 98%
Chest 1998;114(2):133s-181s
Thorax 1998;53:738-743

23. Categorization !!!
• Acute cough: < 3 weeks
• Subacute cough: 3-8 weeks
• Chronic cough: >8 weeks

24. ACUTE COUGH !!!
• Cough lasting less than 3 weeks
Key questions:
• 1. Is it life-threatening?
• 2. Are antibiotics needed?

25. Red flags: findings of particular concern
• Dyspnea….
• Hemoptysis….
• Resp. distress….
• Weight loss
• Risk factors for TB, HIV infection or
other immune suppressed states

26. Acute Cough
History,
Examination,
+/-
investigations
Life-threatening Dx Non-Life-threatening dx
Pneumonia, severe
exacerbation of asthma or
COPD, PE, Heart Failure,
other serious disease
Exacerbation
of pre-existing
condition
Environmental
or
Occupational
Infectious
1.URTI
2.LRTI
1.ASTHAMA
2.Bronchiectasis
3.UACS
4.COPD
Irwin R S et al. Chest 2006;129:1S-23S, American College of Chest Physicians

27. Causes and estimated frequencies of acute cough in the
adult !!!
• Common
• Common cold
• Acute bacterial
sinusitis
• Pertussis
• Exacerbations of
COPD
• Allergic rhinitis
• Environmental
irritant rhinitis
• Less common
• Asthma
• Congestive heart
failure
• Pneumonia
• Aspiration
syndromes
• Pulmonary
embolism
Irwin RS et
al. Chest 19
98,
114:133S-
181S

28. ACCP-GUIDELINES URTI
• Common cold
• 1st gen. Antihistamine / Decongestant –
BROMPHENARMINE+PSEUDOEPHEDRINE
(GR-A)
• In patients with cough and acute URTI,the
diagnosis of bacterial sinusitis should not be
made during the first week of symptoms. (gr-A)
• Clinical judgment is required to decide whether
to institute antibiotic Therapy(GR-D)

29. ACCP-GUIDELINES LRTI
• “Acute Bronchitis”
Most bronchitis in otherwise healthy adults is caused by
viruses (rhinovirus, adenovirus, RSV)
 NO ANTIBIOTICS (gr-A)
Bacterial causes to consider:
Mycoplasma pneumoniae, chlamydophila
pneumoniae
Bordetella pertussis (whooping cough)
• R/O PNEUMONIA:C-xray (gr-B)
 Heart rate > 100 beats/min;
 respiratory rate > 24breaths/min
 oral body temperature > 38 C;
 chest examination findings

30. ACCP-GUIDELINES LRTI
• B-2-agonist bronchodilators should not be
routinely used to alleviate cough. (GR-D)
• Acute bronchitis and wheezing + Cough
 BETA 2-agonist bronchodilators
 Antitussive agents (GR-C)

31. Are we missing Pertussis???
• 75 adults, cough for more than 14 days
• Pertussis diagnosis based on culture
• 26% of adults had evidence of B. pertussis infection
• JAMA 1995;273:1044-1046

32. When to suspect & Whom to treat?
Suspect and treat if a clear cut history of
Exposure
Suspect and treat –if suggestive symptom
Treat contact

33. ACCP-GUIDELINES LRTI
• whooping cough:
 cough >2wks
 Paroxysms of coughing+ /- posttussive vomiting
 Inspiratory whooping sound
• Dx-
• Nasopharyngeal aspirate/swab culture
• PCR-Not Recommended
• T/T
 Macrolides * 5days
 Isolation * 5days (gr-A)

34. Exacerbation of pre-existing condition !!!
• COPD: always consider bacterial infection
• Asthma: try to identify the underlying cause
(exposure, viral URTI, viral LRTI, other)
• Bronchiectasis: always consider bacterial
infection (gram negative rods, staph.
aureus, organisms resistant to antibiotics)
• Upper airway cough syndrome (UACS)
• Environmental or occupational exposure:
allergens, irritants

35. Subacute Cough !!!
• Cough lasting 3-8 week
• Usually resolve in 2 wks
• Sign of chronic cough!!!!!
Key questions:
1. Is it post-infectious?
2. If post-infectious, are antibiotics needed

36. SUBACUTE COUGH
Post-infectious
Non-postinfectious
History and
Physical Exam
Pneumonia
and other
serious
diseases
New onset or exacerbation of pre-
existing condition
Workup same
as chronic
cough
Pertussis
Bronchitis
Asthma BronchitisUACS GERD
NAEB AECB
Irwin R S et al. Chest 2006;129:1S-23S
2006 by American College of Chest
Physicians

37. Post Infectious Cough !!!
Min 3 wks - < 8 wks
• A cough that begins with an acute respiratory tract
infection and is not complicated by pneumonia
• Post Infectious cough will resolve without treatment
CAUSE :
• UACS
• GERD
• ASTHMA
• Bronchial Hyperresponsivness
• Mucous hypersecration

38. Algorithmic approach to subacute cough.

39. ACCP-GUIDELINES
• Ipratropium inhalation
• Corticosteroid Inhalation
• For severe paroxysm of Cough
• Prednisone-40mg/day (gr-C)
if fails
• Codeine & Dextromethorphan
• R/O UACS /GERD /ASTHMA

40. Chronic Cough !!!
• Cough lasting longer than 8 weeks
• Causes
• GERD
• Asthma
• Post nasal drip
• COPD
• Bronchogenic carcinoma
• TB
• ILD
• ACE inhibitor

41. Lets Dx this lady…..
61 yo female c/o cough * 2 years, usually dry; sometime
Productive of white foamy material. Worse with exercise, cold
air, mildly hoarseness in voice.
What else would you like to know???
Relevant History…..
• Reports postnasal drip and throat clearing.
• Had sinus problems as child requiring drainage.
• Often awakened at night due to cough
• Worse with exercise, cold air

42. Physical Exam:
Vitals - Normal
• General: mod.overweight, NAD,
• HEENT: NAD
• CHEST: normal br.pattern, normal percussion,
inspection, palpation. Normal breath sounds
bilaterally. No wheezes, crackles, rhonchi,
• CV: Normal S1 S2, no murmurs, gallops, or rubs
• Abdomen: soft, nontender, no masses,/organomegaly
• Ext: no clubbing or edema.
• Neuro-normal

43. PMx:
• Several common cold in last 3-4 years.
• No other significant medical history.
• No medication
Sx :
• Non-smoker
• House maker
• No harmful environmental exposure
• Regular workout
1) WHAT IS THE CAUSE OF HER COUGH???
2) PLAN???

45. Most common causes of chronic cough in patients
investigated in specialist clinics
McGarvey et al. Pulm Pharmacol Ther 2004

46. Top 4 causes!!!
• Account for the etiologic cause of chronic cough in
92-100% of immunocompetent, nonsmoking
patients with normal CXR.
• Upper airway cough syndrome
• Asthma
• Gastroesophageal reflux disease
• Non-asthmatic eosinophilic bronchitis

47. Upper Airway Cough Syndrome!!!
Symptoms:
• „something dripping‟
• frequent throat clearing
• nasal congestion / discharge
• Hoarness
Causes
• Allergic rhinitis
• Non-allergic rhinitis
• Vasomotor rhinitis
• Chronic bacterial sinusiits
Mechanism: secretions from nose/sinuses stimulate upper
airway cough receptors; inflammation increases receptor
sensitivity

48. ACCP-GUIDELINES UACS
• Diagnostic/Therapeutic trial:
1st generation A/D combination(gr-B)
• 1st gen. Antihistamine / Decongestant –
BROMPHENARMINE+PSEUDOEPHEDRINE*2wks
(GR-A)
• Sinus Imaging

49. Back to the our patient!!!
• BROMPHENARMINE+PSEUDOEPHEDRINE * 2 WKs
FOLLOW-UP: No improvement !!!
NEXT—ASSESMENT /PLAN???
1) SPIROMETRY
2) START EMPERIC TREATMENT

50. ASTHMA!!!
• Mechanism: inflammatory mediators, mucus,
bronchoconstriction stimulate cough receptors
• CH.cough always consider as a potential couse (gr-B)
• Classic symptoms: intermittent wheeze
• Signs (often absent): expiratory wheezing on chest exam

51. ACCP-GUIDELINES ASTHMA
• Diagnostic tests:
Spirometry :before and after Bonchodilator
Methacholine inhalation challenge:

52. ACCP-GUIDELINES ASTHMA
• Diagn./Therapeutic trial: Antiasmatic rg.
• ICS+ Inh. bronchodilator (gr-A)
↓
• Refractory cough→Airway inflamation assessment
↓
• Leukotriene Recep.antagonist
↓ (gr-B)
• Systemic corticosteroid *2wks
↓
• ICS

53. Question???
Can asthma be a possibility if a pre and
post-bronchodilator spirometry is completely
normal?
• (A)Yes
• (B) No

54. • COUGH MAY BE THE ONLY SYMPTOM IN
57% PATIENTS (DEPENDS ON STUDY)--
“COUGH-VARIANT ASTHMA”
• Chest 1999;116(2):279-84

55. Back to the our patient!!!
Follow-up -8wks : Marked improvment!!!!
But still coughing specially at night and @
exsercise ??
NEXT—ASSESMENT /PLAN???
CONSIDER MULTIPLE Dx
ANTIREFLUX DIET
PROTON PUMP INHIBITOR
PROKINETIC THERAPY
LIMITED VIGOROUS EXERCISE

56. Gastroesophageal Reflux Disease!!!

57. ACCP-GUIDELINES
• ACID REF. VS NON ACID REF.
• Classic symptoms: heartburn,
sour taste in mouth
• Cough may be only symptom
in 75%
• Diagnostic tests:
• 24-hour esophageal pH
probe (best)
• Barium Esophagography

58. ACCP-GUIDELINES GERD
• ANTIREFLUX DIET
No > 45 g of fat in 24 h/ no coffee, tea, soda,
chocolate, mints, citrus products, including
tomatoes,or alcohol, no smoking
• limiting vigorous exercise that will increase
intraabdominal pressure
• Acid suppression -proton pump inhibitor
-prokinetic therapy
IF FAIL----ANTIREFLUX SURGERY
24h.ph--+ve
GERD sugs.symp
3mo.therapy
↓ quality of life

59. 8 WEEKS LATER……..
• COUGH GONE COMPLETELY
Dx :
• COUGH VARIENT ASTHAMA
.NON REFLUX GERD

60. Non-Asthmatic Eosinophilic Bronchitis
(NAEB)
• Eosinophilic airway inflammation WITHOUT variable airflow
obstruction or airway hyperresponsiveness
• Consider Occupation related cause
• Diagnostic tests:
- Cxray : normal
- Spirometry: normal
- Methacholine challenge: normal
- Induced sputum / bronchial wash fluid : >3% eosinophils
• Diagn/Therap. Trial: inhaled corticosteroid ≥ 4 wks
• : avoidance of occup.sensitizer

61. Other causes!!!
• ACE-inhibitor—Dsicontinue(gr-A)
• Effects in 1-4wks
• Swictched to other agents.
• Restart ACE
• inhaled sodium cromoglycate,
theophylline,Baclofen (gr-B)
Peter V. DicpinigaitisCHEST. january 2006;129(1_suppl):169S-173S.
• Smoking—cesasation
• Occupational & enviromental cause-avoidance

62. Stopping smoking
slows decline in lung functionFEV1(%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)
stopping smoking can improve lung function by about 5% within a
few months.

63. Last Question ????
A 67 y/o man,heavy smoker , complains of 12 weeks of
non-productive cough. He’s had a couple of “colds”
this winter. He has no current nasal or sinus
symptoms, rarely has heartburn, and never wheezes.
He’s on no meds. Vitals and physical exam are normal.
Your next step would be:
A) Prescribe a 1st generation antihistamine/decongestant
B) Prescribe an inhaled corticosteroid for asthma
C) Counseling for smoking
D) Order a chest x-ray
E) All of the above

65. I am sure you don’t want to miss this!!!
• All that coughs is
not UACS,
asthma, GERD,
or NAEB

66. Therapeutic trials: When to expect a response?
• Smoking cessation: up to 4 weeks
• ACE-inhibitor discontinuation: up to 4 weeks
• Upper airway cough syndrome: up to 2-3 weeks
• Asthma: up to 6-8 weeks
• GERD: up to 8-12 weeks
• Eosinophilic bronchitis: up to 3-4 weeks
Chest1998;114(2):133s-181s

67. I am open forDiscussion
/ Questions