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Presentation on theme: "DIAGNOSIS & MANAGEMENT APPROACH TO CHRONIC COUGH."— Presentation transcript:


2 COUGH One of the most common symptoms for which patients seek medical attention Defensive reflex that enhance the clearance of secretions and particles from the airway Protects the lower airways from the aspiration of foreign materials

3 Coughing may be initiated either voluntarily or reflexively. It has both afferent and efferent pathways. The cough starts with a deep inspiration followed by glottic closure, relaxation of the diaphragm, and muscle contraction against a closed glottis.

4 CLASSIFICATION Acute cough ~ maximum of 3 weeks Subacute cough ~ 3 to 8 weeks Chronic Cough ~ more than 8 weeks De Blasio et al. Cough 2011, 7:7

5 ETIOLOGY Acute cough ~ maximum of 3 weeks Upper Respiratory Infection (common cold, acute bacterial sinusitis, and pertussis) Pneumonia Pulmonary embolus Congestive cardiac failure Subacute cough ~ 3 to 8 weeks Post-infectious Postnasal drip following viral infection, Pertussis Tuberculosis Mycoplasma or Chlamydia infection Chronic Cough ~ more than 8 weeks Asthma COPD Tuberculosis Bronchogenic carcinoma Eosinophilic Bronchitis Esophageal Disease, Post Nasal Drip ACEI Smoking.

6 CHRONIC COUGH- ETIOLOGY In non-smoking adults with a normal CXR who are not taking ACE inhibitors, chronic cough is almost always due to which of the following 3 conditions? a)Congestive Heart Failure b)Upper Airway Cough Syndrome (UACS) c) Asthma d) Gastroesophageal reflux disease (GERD) e) Chronic Bronchitis


8 CHRONIC COUGH SOMETIMES CAN HAVE MORE THAN 1 CAUSE Smyrnios et al Arch Intern Med 1998 158:1222 3


10 GUIDELINE FOR EVALUATING CHRONIC COUGH A systematic, diagnostic approach has been validated in immunocompetent patients- 5 steps plan: Step 1: Review history and exam focusing on the most common causes of chronic cough

11 HISTORY TAKING HistoryReasons OnsetTo determine acute/subacute or chronic causes of cough Aggravating factor, relieving factorCough due to GERD affected by postural changes, post meal Cold induced or MDI relieved cough in asthma or COPD Sputum colourNormal sputum: clear to white colour, thin, odourless n tasteless Yellow-green: bacterial infection Rust-colored: pneumonia Sputum characterMucoid or mucopurulent: cigarette smokers as a result of chronic bronchitis Commonly purulent in bronchiestasis Sputum amountSignificant volumes: more than 1 cup per day

12 HistoryReasons FeverOngoing infection SOBRespiratory distress Noisy breathingWheezing suggest asthma/COPD Loss of appetite, loss of weight, hemoptysis Suggesting Tuberculosis, malignancy Allergy, nasal obstruction or congestion, rhinorrhoea, sneezing, facial pain, post- nasal drip or repetitive throat clearance Suggesting Rhinosinusitis Dyspepsia, heartburn, waterbrashGERD Medication usedACE-inhibitor OccupationExposure to asbestos, chemical or cigarette smoke Family historyAsthma, tuberculosis, lung cancer, cystic fibrosis Social historyContact with PTB suggesting PTB

13 PHYSICAL EXAMINATION Physical examinationReasons General condition such as altered conscious level, accessory muscles usage, cyanosis, grunting, nasal flaring, clubbing, nicotine stain To assess severity and to look for respiratory distress Vital signsFever – infection Tachycardia, tachypnoea – respiratory distress Pulsus paradoxus – asthma Nasal polypsAllergy rhinitis Pharynx: erythema, a cobblestone appearance of posterior pharyngeal mucosa or mucoid secretions dripping from the nasopharynx Post nasal drip Chest: Hyperinflated Recession Silent chest Crepitations, wheezing Suggest air trapping due to chronic disease Respiratory distress Severe asthma Pneumonia, asthma, heart failure

14 Physical examinationReasons CVS: Displaced apex beat, raised JVP, loud P2, RV heave Cor pumonale Eczema, transverse nasal crease, injected conjunctiva Signs of atopic disease LymphadenopathyTo suggest infection Abnormal physical signs are rare in a chronic dry cough Wheeze may be audible on examination but is usually absent in cough variant asthma (CVA)

15 GUIDELINE FOR EVALUATING CHRONIC COUGH Step 2: Order a CXR in all patients Step 3: Do not order additional tests in present smokers or patients taking ACE inhibitors until the response to smoking cessation or drug discontinuation for at least 4 weeks can be assessed. - Cough due to smoking or ACE inhibitors should improve substantially or disappear during this time- frame of abstinence. Step 4: Order additional diagnostic tests or embark on empiric treatment

16 INVESTIGATIONS Spirometry : -demonstrate significant airway reversibility (asthma) -unavailable or normal and history suggestive: serial measurement of PEF (diurnal variability) Bronchoprovocation test : - negative: rules out asthma but does not rules out steroid- responsive cough Plain sinus radiography : low specificity but improves with history and findings Sputum eosinophilia




20 GUIDELINE FOR EVALUATING CHRONIC COUGH Step 5 : Determine the cause(s) of cough by observing which specific therapy eliminates cough If the evaluation suggests more than one possible cause, initiate treatment in the same sequence that the abnormalities were discovered Since cough can be simultaneously caused by more than one condition, do NOT stop therapy that appears to be partially successful; rather, sequentially add to it.

21 CASE SCENARIO 1 55 yo school teacher c/o cough for 3 years Non-smoker Cough: Often productive Better with abx, but comes back “no better” with asthma meds Worst in the morning Frequent clearing the throat, sensation of dripping into throat

22 Nasal voice, afebrile, looks well Pharynx: Mild “cobblestoning” No facial tenderness Normal heart and lungs Normal spirometry CASE SCENARIO 1

23 Chronic Sinusitis


25 UPPER AIRWAY COUGH SYNDROME Also called “Post-nasal drip syndrome” (PNDS) Common cause of chronic cough in all age groups – Second most common cause in children – Most common cause in adults and the elderly In addition to cough, UACS can also cause - Wheeze - Dyspnea

26 UPPER AIRWAY COUGH SYNDROME Clues to UACS – History of Need to frequently clear their throat Friend/relative notices that the patient frequently clears their throat Sensation of dripping into throat Nasal symptoms – Physical Exam demonstrating Secretions in nose or oropharynx Cobblestone appearance of mucosa

27 UPPER AIRWAY COUGH SYNDROME Diagnosis of UACS as a cause of cough is established when: a)frequent throat clearing is elicited from the history b) cobblestoning and phlegm are present on physical examination of the posterior pharynx c) cough responds favourably to specific therapy aimed at eliminating the drip

28 TREATMENT Antibiotics – sinusitis Oral antihistamine/decongestant x 3 weeks Intranasal decongestant for maximum of 5 days: e.g. oxymetazoline 2 sprays each nostril bid x 3 days only

29 TREATMENT Allergic Rhinitis Allergen avoidance Intranasal steroid Antihistamine Antihistamine/decongestant

30 CASE SCENARIO 2 The Computer Programmer, 35 y.o woman c/o Yearly cough lasted for > 8 weeks – starts only after a “cold weather” at end of the year – severe coughing – goes away by itself – has happened last year - nocturnal cough Tried “everything”

31 Denies: wheezes, PND sx, allergies, heartburn, aspiration No: pets, current meds Family hx: negative PMH: negative Physical exam and CXR normal Normal spirometry Any other Ix? Methacholine Challenge Testing CASE SCENARIO 2

32 ASTHMA Second most common cause of cough in adults Clues that chronic cough is due to asthma: – Episodic wheezing, dyspnea, cold or exercise induced – Reversible airflow obstruction – Bronchial hyperresponsiveness Confirmed by resolution of cough with asthma treatment

33 COUGH VARIANT ASTHMA 30-60% of patients presenting with chronic cough that was due to asthma had cough as their ONLY symptom Clues: - nocturnal cough, exercise induced, after allergen exposure Bronchoprovocation test: positive Negative test exclude asthma but does not rule out steroid responsive cough

34 Treatment Inhaled corticosteroid ICS/LABA combination > 8 weeks Leukotrine receptor antagonist -Confirmed by resolution of cough with asthma treatment ASTHMA/COUGH VARIANT ASTHMA

35 NON-ASTHMATIC EOSINOPHILIC BRONCHITIS (NAEB) Eosinophilic airway inflammation WITHOUT variable airflow obstruction or airway hyperresponsiveness Diagnostic tests: - Spirometry: normal - Methacholine challenge: normal -Sputum or BAL eosinophilia: >3% eosinophils Diagnostic/Therapeutic trial : inhaled corticosteroid for ≥ 4 weeks Characteristically resistant to bronchodilator but reponds ICS Confirmed diagnosis if responded to ICS

36 The Computer Programmer… Aggressive asthma regimen x 8 weeks Not feeling better Now what?? CASE SCENARIO 2

37 GERD Suspect GERD when… – Symptoms of heartburn or sour taste in mouth – Reflux demonstrated by 24-hour pH-impedance monitoring Barium x-ray Cough is the only symptom of GERD in 40-75% of patients with chronic cough due to GERD

38 GERD Cough due to GERD occurs most commonly while patients are awake, stooping posture, meal related, and usually does not occur during the night Diagnosis of GERD as cause of chronic cough requires resolution of cough with GERD treatment

39 GERD Life-style changes Stop smoking Avoid alcohol Lose weight Elevate HOB Small meals Avoid fatty/acidic foods /low fat diet Avoid caffeine Avoid – tight clothes, eating < 4 hrs pre-bed, recumbency 3 hrs post meal

40 TREATMENT Conservative measures : Antacid therapy ≥ 2 months : – Proton pump inhibitor (high dose) – H2 blockers less effective Motility therapy: – Metoclopromide Surgery is last resort

41 ACE-INHIBITOR THERAPY Angiotensin converting enzyme (ACE) inhibitors (enalapril, captopril, lisinopril, ramipril, etc.) Dry cough in 3-30% patients Begins 1 week to 6 months after drug started Usually resolves 1-7 days after stopping therapy, but can take 4 weeks Diagnosis is confirmed when cough disappears after drug in discontinued



44 CASE SCENARIO 3 Hamid, a 45 year old gentleman who is a clerk presented to the outpatient clinic after coughing up 2 cups of bright red blood. For the past 2 months, he has chronic cough productive of whitish mucoid sputum Prior to this episode, he had, on two occasion a blood-streaking on his sputum. He has also noticed that over the last few weeks he tires easily and is short of breath whenever he exerts himself

45 Further history.. Constitutional symptoms (fever, LOA, LOW) Fhx or contact with PTB patient Smoking history Occupation and habits CASE SCENARIO 3 On direct questioning, he admit smoking 2 packs of cigarettes daily for the last 20 years but he has no known medical illness except for history of appendicectomy done 15 years ago. His appetite has been poor and he lost about 4 kg of his weight in 1 month, no contact with PTB paient.

46 Physical examination discloses a slightly apprehensive looking man who is not in acute distress. T: 38.5. PR:100 bpm,regular, BP:130/80 mmHg and RR:17 per minute Slight pallor but no cyanosis, no significant lymphadenopathy or finger clubbing Auscultation of the chest: generalized coarse crepitations but more over the right upper lobe CVS is normal with no signs of cardiac failure There is no calf tenderness CASE SCENARIO 3

47 Investigations: Full blood count ESR Blood C & S Mantoux test Sputum AFB & cytology Chest X-ray ECG CASE SCENARIO 3

48 Mantoux test is 12mm Sputum: negative for AFB Bronchoscopic washings :positive for acid fast bacilli Smear positive Pulmonary Tuberculosis

49 STANDARD TREATMENT REGIME: Intensive phase Goal is to quickly kill the rapidly dividing organism to control disease and render patient non-infectious and prevent emergence of drug resistance Continuation phase Sterilize the lungs by killing dormant and semi- dormant organisms to prevent relapse DOT allows for intermittent therapy

50 TREATMENT OF TUBERCULOSIS 2 months of daily EHRZ (2EHRZ) 4 months of daily HR (4 HR) Dosage of 1 st line anti-TB drugs

51 TUBERCULOSIS Frequency New patient with PTB: daily intensive regimen f/by daily maintenance regimen Thrice weekly maintenance regimen can be considered under direct observation Optimal Duration All extrapulmonary: minimum 6 months except- - Bone and joint TB: 6 – 9 months - TB Meningitis: 9 –12 months No retrievable evidence on optimal duration of treatment for disseminated TB and miliaryTB -- should be low threshold to suspect TB meningitis

52 TUBERCULOSIS Follow-Up During & After Treatment

53 CASE SCENARIO 4 Tony is a bus conductor aged 45 years c/o recent exacerbation of his chronic cough with productive of yellow-green sputum Heavy smoker for 25 years. He has a long standing smoker’s cough frequently productive in recent years. Last year he suffered many exacerbation of his bronchitis, two of which were severe enough for him to be admitted to hospital. Although he had returned to work, progressive dyspnoea had made his job increasingly difficult

54 Examination: drowsy, plethoric and cyanosed, flapping tremor was elicited. RR was 25/min, T: 38.2, PR: 124/min, regular rhythm, BP 120/80mmHg JVP raised 8cm, gallop rhythm was heard, sacral oedema present. Both lung fields had scattered crepitations and diminished air entry. The liver was felt 3 cm below the costal margin. No focal neurological deficit. CASE SCENARIO 4

55 CHRONIC OBSTRUCTIVE AIRWAY DISEASE EXPOSURE TO RISK FACTORS Tobacco Occupation Indoor/outdoor pollution EXPOSURE TO RISK FACTORS Tobacco Occupation Indoor/outdoor pollution SYMPTOMS Shortness of breath Chronic cough Sputum SYMPTOMS Shortness of breath Chronic cough Sputum SPIROMETRY: Required to establish diagnosis

56 An exacerbation of COPD is: “an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication.” CHRONIC OBSTRUCTIVE AIRWAY DISEASE

57 The goal of treatment is to minimize the impact of the current exacerbation and to prevent the development of subsequent exacerbations Arterial blood gas measurements (in hospital) : PaO 2 6.7 kPa in room air indicates respiratory failure. Chest X-Ray : useful to exclude alternative diagnoses. ECG : may aid in the diagnosis of coexisting cardiac problems. Full blood count: identify polycythemia, anemia, infection Purulent sputum during an exacerbation: indication to begin empirical antibiotic treatment. Biochemical tests: detect electrolyte disturbances, diabetes, and poor nutrition. Spirometric tests : not recommended during an exacerbation.

58 Oxygen : titrate to improve the patient’s hypoxemia with a target saturation of 88-92%. Bronchodilators : Short-acting inhaled beta 2 -agonists with or without short-acting anticholinergics are preferred. Systemic Corticosteroids: - Shorten recovery time, improve lung function (FEV 1 ) and arterial hypoxemia (PaO 2 ) - reduce the risk of early relapse, treatment failure, and length of hospital stay. - 30-40 mg prednisolone per day for 10-14 days is recommended Noninvasive ventilation (NIV): - Improves respiratory acidosis, decreases respiratory rate, severity of dyspnea, complications and length of hospital stay

59 Indications for Hospital Admission Marked increase in intensity of symptoms Severe underlying COPD Failure of an exacerbation to respond to initial medical management Presence of serious comorbidities Frequent exacerbations Older age Insufficient home support CHRONIC OBSTRUCTIVE AIRWAY DISEASE

60 MANAGEMENT OF STABLE COPD KEY POINTS Identification and reduction of exposure to risk factors are important steps in prevention and treatment Individualized assessment of symptoms, airflow limitation, and future risk of exacerbations should be incorporated into the management strategy All COPD patients benefit from rehabilitation and maintenance of physical activity. Pharmacologic therapy is used to reduce symptoms, reduce frequency and severity of exacerbations, and improve health status and exercise tolerance. Long-acting formulations of beta 2 -agonists and anticholinergics are preferred over short-acting formulations Long-term treatment with inhaled corticosteroids added to long-acting bronchodilators is recommended for patients with high risk of exacerbations Long-term monotherapy with oral or inhaled corticosteroids is not recommended in COPD The phospodiesterase-4 inhibitor roflumilast may be useful to reduce exacerbations for patients with FEV 1 < 50% of predicted, chronic bronchitis, and frequent exacerbations

61 GLOBAL STRATEGY FOR DIAGNOSIS, MANAGEMENT AND PREVENTION OF COPD Assessment of COPD Assess symptoms : CAT, mMRC Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities

62 GLOBAL STRATEGY FOR DIAGNOSIS, MANAGEMENT AND PREVENTION OF COPD COMBINED ASSESSMENT OF COPD Risk (GOLD Classification of Airflow Limitation) Risk (Exacerbation history) > 2 1 0 (C) (D) (A) (B) mMRC 0-1 CAT < 10 4 3 2 1 mMRC > 2 CAT > 10 Symptoms (mMRC or CAT score)) © 2013 Global Initiative for Chronic Obstructive Lung Disease

63 GLOBAL STRATEGY FOR DIAGNOSIS, MANAGEMENT AND PREVENTION OF COPD COMBINED ASSESSMENT OF COPD Risk (GOLD Classification of Airflow Limitation) Risk (Exacerbation history) > 2 1 0 (C)(D) (A)(B) mMRC 0-1 CAT < 10 4 3 2 1 mMRC > 2 CAT > 10 Symptoms (mMRC or CAT score)) Patient is now in one of four categories: A: Less symptoms, low risk B: More symptoms, low risk C: Less symptoms, high risk D: More symptoms, high risk Use combined assessment © 2013 Global Initiative for Chronic Obstructive Lung Disease

64 PHARMACOLOGIC THERAPY RECOMMENDED FIRST CHOICE Exacerbations per year > 2 1 0 GOLD 4 GOLD 3 GOLD 2 GOLD 1 SAMA prn or SABA prn LABA or LAMA ICS + LABA or LAMA AB DC ICS + LABA and/or LAMA mMRC 0-1 CAT < 10 mMRC > 2 CAT > 10

65 Rehabilitation Exercise training programs : improves exercise tolerance and symptoms of dyspnea and fatigue Pulmonary rehabilitation program : the longer the program continues, the more effective the results Oxygen Therapy: The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival in patients with severe, resting hypoxemia Ventilatory Support: Combination of noninvasive ventilation (NIV) with long-term oxygen therapy may be of some use in a selected subset of patients Lung volume reduction surgery (LVRS) : more efficacious than medical therapy among patients with upper-lobe predominant emphysema and low exercise capacity Lung Transplantation : In appropriately selected patients with very severe COPD, improve quality of life and functional capacity

66 TAKE HOME MESSAGE In patients with chronic cough and a normal CXR finding who are nonsmokers and are not receiving therapy with an ACE inhibitor, the diagnostic approach should focus on the detection and treatment of UACS (formerly called PNDS ), asthma, NAEB, or GERD, alone or in combination. This approach is most likely to result in a high rate of success in achieving cough resolution. ACCP Evidence-Based Clinical Practice Guidelines



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