COUGH PRESENTED BY:MAHA
ALGHAMDI R4SUPERVISED BY:DR. ASMAA ALREFAEE
On a typical day, a family physician will see at
least one patient presenting with cough.
Cough is the most common presenting
symptom in PHCC (Ambulatory care visits to physician offices,
hospital outpatient departments, and emergency departments: United States,
2001-02.) Data from national health survey
Contents:
Cough reflex
Classifications of cough
Urgent consideration
DDX
Approach to patient with chronic cough
Non specific treatment of cough
Non pharmacological treatment
Complications
Objectives:
Approach to patient with chronic cough.
Treatment of the most common causes of
chronic cough.
Cough Reflex
Classification of Cough
(ACCP) classify cough According to duration:
Acute Cough
< 3 Weeks Duration
Sub acute Cough
3 – 8 Weeks Duration
Chronic Cough
> 8 Weeks Duration
DDx of acute cough
URTI:( the most common )
Common cold
Influanza
Pertussis
Pharyngitis
Sinusitis: viral or bacteria
Exacerbation of a preexisting condition (e.g.,
asthma, bronchiectasis, chronic obstructive
pulmonary disease or upper airway cough
syndrome)
Urgent consideration
Pulmonary embolism
Congestive heart failure
Foreign body
Pneumonia
TB
Group 1
33 Year old male presents for care complaining
of 4 weeks of nonproductive cough. The cough
was preceded by sinus congestion, muscle aches
and fatigue which he has been treated for. Now
sinus symptoms disappear but the patient is
bothered by the cough
Patient has no past medical history
Physical Exam
HR 87 BP 140/70 RR 14 T 37.6
ENT: clear
Sinuses: nontender with good
transillumination
Lungs: clear
Cardiac: regular without murmur
What is The most likely Diagnosis?
What is Your Treatment Plan?
Sub acute cough
The first step in diagnosing subacute cough is to
determine whether the cough has followed a
respiratory infection.
If the cough does not appear to be postinfectious,
it should be managed as if it were a chronic
cough.
Post infectious (The most common)
Mechanisms:
Secretions from a postnasal drip may
stimulate receptors in the upper respiratory
tract.
Enhanced sensitivity of airway nerves
Airway inflammation following acute viral
respiratory infections is associated with airway
hyperresponsiveness and the potential for
cough as well as airway constriction
HX and EX:
Cough of duration between 3 and 8 weeks
Following symptoms of acute respiratory
infection, nasal/sinus congestion, nonpurulent
nasal discharge, sore throat.
Can persist for more than eight weeks after
the acute infection
No specific signs
Diagnosis:
Clinical and one of exclusion.
Treatment:
Most cases will be self-limited.
Reassurance
Patients in whom postnasal drip (UACS)
seems to be contributing to the prolonged
cough following a viral upper respiratory tract
infection:
First generation antihistamines
Patients with postviral cough who have
transient bronchial hyperreactivity:
Treated as cough variant asthma
These patients often have positive methacoline challenge
test .
patients with postviral cough who have no
evidence of airway hyperreactivity:
Inhaled ipratropium bromide.
Chronic cough
The estimated prevalence of chronic cough
in the adult population is 12% to 17% with a
prevalence of approximately 30% in
smokers and 10% in nonsmokers.
(Barbee RA, Halonen M, Kaltenborn WT. A longitudinal study of respiratory symptoms in a community
population sample. Correlations with smoking, allergen skin-test reactivity, and serum IgE. Chest.
1991;99(1):20-26).
(Ford AC, Forman D, Moayyedi P. Cough in the community: a cross sectional survey and the relationship to
gastrointestinal symptoms. Thorax. 2006;61(11):975-979).
DDX
The most common:
Upper airway cough syndrome ( PND )
Asthma
Non asthmatic esinophilic bronchitis (NAEB)
Gastro esophegeal reflux disease (GERD)
Alone or in combination, are responsible for
approximately 90 percent of cases of chronic
cough
However, one study found that these disorders
were responsible for 99.4 percent of patients who
had the following characteristics :
Nonsmoker
No use of an ACE inhibitor
Normal or near normal and stable plain chest
radiograph
Approach to patient with chronic
cough
STEP1:
History and Examination
Urgent consideration
Lung carcinoma
Less than 2 % of the cases of chronic cough.
Cough is the most common symptom of lung
cancer.
Bronchogenic cancer should be considered as a
possible etiology of cough in any current or former
smoker, and should be particularly suspected in those
with:
A new cough or a recent change in chronic
"smoker's cough"
A cough that persists more than one month
following smoking cessation
Hemoptysis that does not occur in the setting of an
airway infection
HX:
Tobacco smoking
Change in character of chronic cough
Hemoptysis, dyspnea, hoarseness, chest
pain.
Weight loss.
Superior vena cava syndrome (localized
edema of face and upper extremities, facial
plethora, distended neck and chest veins).
Symptoms related to distant metastases (e.g.
bone pain) are late symptoms
EX:
Cachexia.
Superior vena cava syndrome.
Central lung cancers may cause unilateral
localized wheezing(focal wheezing or
diminished breath sounds, indicative of focal
airway obstruction from tumor).
STEP 2:
ACEI OR SMOKING
In patients taking an ACE inhibitor or who
currently smoke, respective discontinuation
should be done before further investigation.
Cough due to an ACE inhibitor or smoking
typically resolves within 4 weeks after
cessation.
If the cough does not resolve after 4 weeks of
cessation of smoking, the patient should be
evaluated for chronic obstructive pulmonary
disease.
ACE (3 - 20 %)
pathogenesis of the cough is not known with
certainty.
hypothesized that accumulation of bradykinin,
which is normally degraded in part by ACE,
may stimulate afferent C-fibers in the airway
Group 2
Mention important characteristics of cough
caused by ACEI?
HX and EX:
Begins within 1week of therapy, but the onset can be delayed up
to 6 months.
Dry cough and a tickling, scratchy, or itchy sensation in the throat
.
Typically resolves within 1-4 days of discontinuing therapy, but
can take up to 4 weeks.
Recurs with rechallenge, either with the same or a different ACE
inhibitor.
More common in females than males, and is also more common
in those of Chinese ancestry .
It does not occur more frequently in asthmatics than in non-
asthmatics.
It is generally not accompanied by airflow obstruction.
No specific exam findings
Treatment
Discontinuing the ACE inhibitor and, if
necessary, switching the patient to losartan or
another angiotensin II receptor antagonist.
ARBs are alternatives to ACE inhibitors :
Do not affect kinin metabolism
Not appear to be associated with an
increased incidence of cough, even in patients
who had previously had an ACE inhibitor-
induced cough
Do not increase cough or bronchial
hyperresponsiveness in symptomatic
asthmatics
STEP 3:
CXR
In adult patients whose cough has
lasted more than eight weeks, a chest
radiograph is typically performed as
part of the initial evaluation, to rule out
a potential etiology that would require
additional evaluation or focused
treatment
STEP 4:
Treatment of the most
common causes
Group 3
55 year old school teacher c/o 3-month history
of dry cough and throat irritation. She reports
intermittent nasal congestion and the sensation
of something dripping into the back of her
throat, which necessitates frequent throat-
clearing. She also reports a persistent
discomfort arising from the presence of mucus
in her throat.
O/E:
Nasal voice, afebrile,
looks well
Pharynx: look at the picture
No facial tenderness
Normal heart and lungs
Normal spirometry
What is the sign shown in the picture?
What is the most likely dx?
What is your treatment plan?
Upper airway cough
syndrome 34%
Causes:
Allergic, perennial nonallergic, and vasomotor rhinitis.
Acute nasopharyngitis.
Sinusitis.
Postinfectious rhinitis.
Allergic fungal sinusitis.
Rhinitis due to anatomic abnormalities.
Nasal polyposis.
Rhinitis due to physical or chemical irritants.
Occupational rhinitis.
Rhinitis medicamentosa.
Rhinitis of pregnancy.
Once secretions are present in the upper airway, cough is probably induced
by stimulation of cough receptors within the laryngeal mucosa.
Hx and EX:
Cough: dry
Frequent throat clearing
Sensation of liquid dripping into the back of the
throat nasal discharge, nasal obstruction or
sneezing
Halitosis
Silent
Mucopurulent secretions seen in the nasopharynx
and oropharynx
Cobblestone appearance of posterior oropharynx
Diagnosis
No definitive criteria for dx.
UACS is a clinical syndrome and
diagnosis is based on the clinical
picture + response to therapy.
Radiographic evidence of mucosal thickening
is a relatively nonspecific finding.
Radiographic studies generally are not
indicated unless empiric treatment of chronic
rhinitis has failed.
Treatment
ACCP:
Avoidance
Treatment to block or reduce inflammation
and secretions
Treatment of infection
Correction of structural abnormalities
Oral first generation antihistamine
or a combined antihistamine-
decongestant for 1 to 2 weeks
(ACCP)
Patients who are not candidates for use of an oral
first generation antihistamine (eg, due to excess
somnolence):
Intranasal administration of :
Azelastine (may cause somnolence even with intranasal
use )
Glucocorticoid
Ipratropium bromide (significantly reduces the rhinorrhea
associated with perennial nonallergic rhinitis and has few
side effects)
With coexisting allergic rhinitis :
Intranasal glucocorticoids are the
most effective therapy
Excess sputum production or lack of
improvement in cough after one to two weeks
of empiric therapy for UACS:
Sinus CT
Response to treatment
Improvement of cough after one to two weeks
of antihistamine/decongestant therapy:
Upper airway cough syndrome was the
cause .
Therapy should be continued.
Partial or no improvement of cough+ No
sinusitis:
Evaluation for asthma should be done.
Group 4
A 23 year old female present for care C/O > 9
weeks of Cough .
Not productive of sputum. The cough is worse
when she exercises or is exposed to cold air. The
cough is associated with shortness of breath
The patient has no past medical problems
She does not smoke
Physical Exam:
HR 70 BP 140/60 RR 12 T 37.6
Sinuses: non tender, no rhinorrhea
Lungs: diffuse musical wheezes with a
prolonged expiratory phase
Cardiac: regular without murmur
• What is The most likely dx?
• What test Do You Need for diagnosis?
• What is Your Treatment Plan?
ASTHMA 25%
Asthma is the second leading cause of
persistent cough in adults, and the most
common cause in children
HX and EX:
Wheezing, chest tightness, dyspnea,
symptom variability, strong FHx of
asthma/atopic disease, cough paroxysms,
exacerbation by irritants or seasonal
exposures; cough may sometimes be the sole
symptom (cough-variant asthma)
Wheezing and prolonged expiratory phase on
pulmonary exam
Cough variant asthma can progress to include
wheezing and dyspnea
The best way to confirm asthma as a cause
of cough is to demonstrate improvement in
the cough with appropriate therapy for asthma
(eg, two to four weeks of inhaled
glucocorticoids ).
Asthma-related cough may be seasonal, may
follow an upper respiratory tract infection, or
may worsen upon exposure to cold, dry air,
dust, mold, or to certain fumes or fragrances.
A cough accompanied by wheezing or
dyspnea, or one that occurs following initiation
of beta-blocker therapy also suggests asthma.
Treatment
Chronic cough due to asthma should be treated
initially with :
ICS and bronchodilators per asthma
management guidelines.
Patients should be advised that it can take up to 8
weeks for cough to resolve after treatment is
initiated
In patients who do not respond or cannot take
inhaled medication:
Oral corticosteroids for five to 10
days is an option
Because oral leukotriene inhibitors
may be effective, consideration should be
given to adding a leukotriene inhibitor before
an oral corticosteroid.
Cough variant asthma :
Suspected based on the presence of
reversible airflow obstruction or a positive test
for bronchial hyperresponsiveness (eg,
methacholine or histamine challenge test).
Confirmation that cough is due to asthma
requires a beneficial response to therapy for
asthma .
Therapy for cough variant asthma follows the same
general principles as standard therapy for asthma
Similar to therapy for moderate or severe asthma,
the mainstays of therapy for cough variant asthma:
Regular use of inhaled glucocorticoids
(GC) and as-needed use of inhaled
bronchodilators
LTRA have also been shown to improve cough in
patients with cough variant asthma
For patients who are disabled by their cough:
A short (1 to 2week) course of
oral prednisone
Once the patient has improved, prednisone is
discontinued and maintenance therapy with
inhaled GCs is continued.
Response to treatment
If treatment for upper airway cough syndrome
and asthma have both failed, nonasthmatic
eosinophilic bronchitis should be considered
next.
Nonasthmatic eosinophilic bronchitis
13%
It is an increasingly recognized cause of chronic
nonproductive cough.
considered in atopic patients with an idiopathic
chronic cough and sputum eosinophilia in the
absence of airway hyperreactivity.
BA – Cough variant
NAEB
asthma NAEB
Atopic tendencies Atopic tendencies
Elevated sputum Elevated sputum
eosinophils eosinophils
Active airway Active airway
inflammation inflammation
Mast cell infiltration No mast cell infiltration
Airway Absent airway
hyperresponsiveness hyperresponsiveness
+ve bronchial -ve bronchial
hyperresponsiveness hyperresponsiveness
test test
Diagnosis
Induced-sputum test should be performed to
determine if the patient has an increased
number of eosinophils
Although bronchial mucosal biopsies are
required to definitively diagnose eosinophilic
bronchitis, a trial of therapy is usually performed
without biopsy, since most patients respond well
to inhaled glucocorticoids
Treatment
Patients with suspected NAEB :
Should undergo testing for sputum
eosinophilia or a trial of treatment
with ICS.
Treatment Response
Response to treatment should be seen within
2 to 4 weeks of treatment initiation.
Any patient who responds only partially or not
at all to the above therapies should be
empirically treated for GERD
Group 5
48 years old obese man presented with cough for 4
months increasing when he laid down associated with
burning abdominal pain and acidic taste in his mouth
Past medical hx: DM on OHA
Patient is not smoker
On EX:
v/s: stable
Abdomen: soft , lax and no tenderness
What is the most likely dx?
What you will advise the patient to decrease
his symptoms?
Investigations vs empirical treatment?
What is the medication will you prescribe for
the patient and for how long?
GERD 20%
Mechanism
Stimulation of receptors in the upper respiratory tract
(eg, in the larynx).
Aspiration of gastric contents, leading to stimulation of
receptors in the lower respiratory tract.
An esophageal-tracheobronchial cough reflex induced
by reflux of acid into the distal esophagus
GERD can trigger adult onset asthma
HX and EX:
Heartburn, dysphagia, sour taste in the
mouth,acid regurgitation
Association of cough with supine position,
phonation, rising from bed, or eating suggest
reflux disease
May be silent
No differentiating features on exam
Treatment
Lifestyle modifications
The evidence in favor of lifestyle modifications
to reduce or prevent GERD and thereby treat
cough is limited.
Suggested interventions :
Weight loss for patients who are overweight
Elevation of the head of the bed three to four inches
Cessation of smoking
Avoidance of reflux-inducing foods (eg, fatty foods,
chocolate, excess alcohol)
Avoidance of very acidic beverages (eg, colas, red wine,
orange juice)
Avoidance of meals for two to three hours before lying
down (except for medications)
Medical treatment:
regimens proven effective in the management
of GERD may not necessarily be the optimum
regimen for cough due to GERD.
Empiric trial of a PPI at a moderate dose
(omeprazole 40 mg once daily in the
morning). This is based on the evidence that
therapy with a PPI is more effective than
H2 antagonist treatment .
Other therapies
The addition of prokinetic therapy such as
metoclopromide may be beneficial in patients
with nonacidic reflux or may add to the
effectiveness of acid suppression therapy in
cough due to acidic reflux.
Supportive data are weak and patients placed
on metoclopramide should be followed for the
possible development of extrapyramidal side
effects (eg, rigidity, bradykinesia, tremor, and
restlessness).
Treatment Response
Failure of response to appropriate therapeutic trial of 8-12
weeks should promote confirmatory testing:
Dx is suggested by an abnormal barium swallow
( this study is negative in the majority of patients )
Prolonged (24 hour) esophageal pH monitoring:
Ideally performed with event markers to allow correlation
of cough with esophageal pH
Optimal diagnostic study
Sensitivity exceeding 90 percent
laparoscopic or open Nissen fundoplication is
reserve for the small number of patients with:
Chronic cough +
Objectively documented gastroesophageal or
laryngopharyngeal reflux disease +
Refractory to medical measures
Laryngopharyngeal reflux
LPR is the retrograde movement of gastric
contents (acid and enzymes such as pepsin)
into the laryngopharynx leading to symptoms
referable to the larynx/hypopharynx.
Most patients are relatively unaware of LPR
with only 35 % reporting heartburn.
Typical symptoms:
Dysphonia/hoarseness, chronic cough, mild
dysphagia and nonproductive throat clearing.
Group 6
What are the main differences
between GERD and LPR?
GERD LPR
LES UES
Heartburn Only 40% heartburn
Upright position during
Recumbent periods of physical
position. exertion (eg, bending
Majority esophigitis over, Valsalva,
exercise)
Higher incidence of Only 25% esophigitis
esophageal lower incidence of
dysmotility esophageal dysmotility
Direct laryngoscopic evaluation can assist in
the diagnosis of cough from reflux.
Arytenoid erythema and edema and pharyngeal
inflammation often suggest laryngeal and
pharyngeal reflux, and when seen, suggest that
a course of treatment for reflux is indicated with
monitoring of the cough on such therapy.
STEP 5:
Evaluate for less common causes
and Further dx tests
If none of the most common causes seem likely
after thorough assessment, other tests to
consider include:
Sputum test
Hrct
Esophegeal ph probe moinitring
Esophegeoscopy
Flexible bronchoscopy
Cardiac studies
Other causes
Chronic bronchitis
Broncheactesis
Nonacid reflux disease
Bordetella pertussis infection
Interstitial lung disease
Giant cell arteritis
Occult pulmonary infection
Occult heart failure
Occult aspiration
Tracheobronchial foreign body or mass (other than bronchogenic
carcinoma)
Occupational asthma
Nasal polyps
Disorders of the external auditory canals, pharynx, larynx, diaphragm, pleura
pericardium, esophagus, stomach, or thyroid
Psychogenic cough
Somatic cough syndrome, tic cough or habit cough
Rarely be the cause of a chronic cough that
remains troublesome despite a thorough
evaluation, including ruling out tic disorders.
No particular clinical manifestations or associated
conditions have been confirmed
Patients should be evaluated for common problems
such as anxiety, depression, and domestic violence.
The diagnostic features are the lack of a diagnosis
following a complete evaluation and improvement
with behavior modification or psychiatric therapy.
Idiopathic cough
Also, known as “unexplained chronic cough”,
“chronic idiopathic cough”, or “cough
hypersensitivity syndrome”.
If a complete work-up fails to find a cause for the
cough, the remaining diagnosis is unexplained
cough.
exaggerated cough reflex sensitivity has been
suggested
It is rare and is a diagnosis of exclusion
At this point, referral to a cough specialist is
appropriate.
All groups
Summarize steps for approach to patient with
chronic cough
NONSPECIFIC TREATMENT
Reserved for those patients who do not
respond to the previous treatment.
For idiopathic cough
Centrally acting antitussive agents
By an action on the central cough center.
The data are limited regarding efficacy despite
widespread use.
usually start with dextromethorphan, due to its better
side effect profile. If that is ineffective, then
codeine or long-acting morphine are tried,
recognizing the risk of addiction and other
narcotic-related adverse effects.
Use of gabapentin for cough is “off-label”, but may
be tried for cough refractory to other
measures
Peripherally acting
antitussive agents
Benzonatate
Few good controlled studies of its use.
One report showed: a combination of 200 mg of benzonatate
and 600 mg of guaifenesin significantly suppressed capsaicin-
induced cough compared to guaifenesin alone.
Case reports : effective in the palliative treatment of cough in
advanced cancer
Accidental ingestion of benzonatate and fatal overdoses have
been reported in children <10 years of age .
Signs and symptoms of overdose (restlessness, tremors,
convulsion, coma, cardiac arrest) may occur within 15 to 20
minutes after ingestion.
Thalidomide
Has been evaluated as an antitussive agent for patients with
cough due to idiopathic pulmonary fibrosis (IPF).
Additional study of thalidomide is needed before widespread
implementation for chronic cough, because of its serious
adverse effect profile, including teratogenicity.
Nebulized lidocaine
May be helpful in a minority of patients with refractory chronic
cough. In an observational study, nebulized lidocaine (3 mL of
4 percent lidocaine [120 mg]) was prescribed two or three
times daily to patients with chronic cough with the option to
increase to 5 mL (200 mg) if numbness of the throat lasted
less than 20 minutes
Adverse events, such as unpleasant taste, throat irritation,
and choking on water or food, were reported by 43 percent.
Inhaled glucocorticoids
The observation that chronic cough is associated with
airway inflammation even in nonasthmatic patients, has
prompted use of inhaled glucocorticoids (GCs) for
nonspecific management of chronic cough.
Studies of inhaled glucocorticoids for the treatment of cough
in the absence of asthma have yielded conflicting results.
Ipratropium bromide
Mechanism:
Blocking the efferent limb of the cough reflex
Decreasing stimulation of cough receptors by
alteration of mucociliary factors
Dose:
2 inhalations by metered dose inhaler, four times a
day.
Macrolide antibiotics
No benefit
Non-pharmacologic
Modalities such as speech therapy, breathing exercises,
cough suppression techniques, and patient counseling
have been tried in the management of chronic cough
A systematic review reported that studies of such
interventions showed improved cough severity and
frequency, but few of them used validated cough
measurement tools. Thus, the robustness of these
studies’ findings is limited.
COMPLICATIONS
Exhaustion, decrease in quality of life
Rupture subconjunctival, nasal and anal veins
Inguinal hernia
Insomnia
Headache
Dizziness
Musculoskeletal pain
Hoarseness
Excessive perspiration
Urinary incontinence
Concern that "something is wrong"
Cough-induced rib fractures : often involve multiple ribs, particularly ribs five
through seven. Women with decreased bone density are at the greatest risk of
this complication; however, fractures can occur in patients with normal bone
density as well
References
