Presentation on theme: "The Otolaryngologist and Chronic Cough"— Presentation transcript:
1The Otolaryngologist and Chronic Cough Joshua Schindler, MDMedical DirectorNorthwest Clinic for Voice and SwallowingAssistant ProfessorDepartment of OtolaryngologyOregon Health & Science University
2Estimated 28 million outpatient visits annually (2002) Scope of the ProblemEstimated 28 million outpatient visits annually (2002)Most common condition for which patients seek medical treatmentCDC: National Ambulatory Medical Care Survey: 2002 Summary (2004)US Retail sales of OTC medications was $15.1 billion in 2004 (excluding Wal-Mart)$3.6 billion in cough and cold medicationConsumer Health Care Products Assn (2004)3% of all doctor visits are for cough.More than 20% of all OTC medications purchased were for cough and colds symptoms.
3Scope of the ProblemCDC: National Ambulatory Medical Care Survey: 2002 Summary (2004)
4Why We Cough Adaptive Maladaptive Defensive mechanism Protection from aspirationClearance of particulate debrisMaladaptiveUpper Airway Digestive Tract (UADT) irritationInflammationHyperreflexiaHabit?
10Vanilloid receptors in Chronic cough Laryngeal EpitheliumLaryngeal EpitheliumControlChronic CoughGroneberg, DA, et al.; Am J Respir Crit Care Med (2004); 170:
11Cough Freebies Smoking ACE (angiotensin converting enzyme) inhibitor therapy for hypertensionIncidence %Timing: hours - months after 1st doseResolution with cessation:Typical weeksRange to 3 months“In a patient with chronic cough, ACE inhibitors should be considered as wholly or partially causative, regardless of the temporal relation between initiation of ACE inhibitor therapy and the start of cough.”Dicpinigaitis, PV. Chest (1), 169S-173S
12These 3 causes are said to cause 90% of all chronic cough “The Trifecta”AsthmaUACS (PND)GERDThese 3 causes are said to cause 90% of all chronic cough
13Algorithm for Management of Chronic Cough Diagnosis and Management of Cough Executive Summary. Chest. 2006, 129(1) suppl.
14Distinguished by treatment Cough and AsthmaRoughly 30% of all coughSeveral variants:Classical asthmaCough-variantEosinophilic bronchitisAtopic coughDescribed by Glauser.Corrao confirmed improvement in cough with inhaled bronchodilator therapy.Up to 1/3 of all cough variant asthma patients go onto classical asthmaEosinophilic bronchitis and atopic cough may be same clinical entity.Distinguished by treatmentPavord, ID. Pulm Pharm Ther. 2004, 17,
15Cough and Asthma + + / - - Airway Hyper – Responsiveness Eosinophilic Airway InflammationBAL EosinophiliaResponse to BronchodilatorResponse to Inhaled SteroidsAtopyClassical Asthma++ / -Cough Variant AsthmaEosinophilic Bronchitis-Atopic CoughBoth cough variant asthma and eosinophilic bronchitis respond to leukotriene inhibitor therapy.Pavord, I.D. Pulm Pharm Ther. 2004, 17,
16Cough and Asthma Evaluation Management CXR Spirometry +/- bronchodilatorMethacholine challengeAllergy testingManagementBronchodilator / inhaled steroid/ leukotriene inhibitor therapyAntihistamine / desensitizationBoth cough variant asthma and eosinophilic bronchitis respond to leukotriene inhibitor therapy.
17UACS (PND) and Cough What is post nasal drip? Sensation something running down the back of the throatPoor definition of syndromeUsually no physical findings
18UACS (PND) and Cough What is post nasal drip? 2 liters secretions/day 500 cc nasal secretionsAbility to localize symptoms to OP/NP is poorThroat clearingGlobus sensationAssociation with cough is %
19Difference felt to be labeling /marketing UACS (PND) and CoughUACS is a US perceptionProctor & Gamble:US telephone interviews (892)50% in US suffer from “PND”UK telephone interviews (1000)< 25% in UK suffer from “PND”Difference felt to be labeling /marketing
20UACS (PND) and Cough“In patients with chronic cough, the diagnosis of upper airway cough syndrome should be determined by considering a combination of criteria, including symptoms, physical examination findings, radiographic findings, and, ultimately, the response to specific therapy. Because it is a syndrome, no pathognomonic findings exist.”Diagnosis and Management of Cough Executive Summary. Chest. 2006, 129, 1 suppl.
21GERD and Cough GERD Prevalence as cause of cough 5 - 41% Trend toward increasing associationCommon GI symptomsHeartburnRegurgitationDysphagiaWide spectrum of clinical manifestations? Distal acid exposure can cause coughIng, A. Am J Respir Crit Care Med. 1994, 149,
22Koufman 1991 – “reflux laryngitis” and “laryngopharyngeal reflux” GERD vs. LPRKoufman 1991 – “reflux laryngitis” and “laryngopharyngeal reflux”Belafsky, PC, et al. Laryngoscope, 2001, 111,
23Profile of GERD / LPR American College of Chest Physicians CPG Chronic coughNot exposed to chemical irritantsNo ACE-I useNormal chest radiographFailure of asthma therapy / Normal methacholineFailure of antihistamineNormal / stable sinus imagingNo eosinophilia of induced sputum / failure to respond toinhaled corticosteroidsIrwin, R.S. Chest. 2006, 129(1), 80S-94S.
24LPR Evaluation and Management Empiric treatment before testingOmeprazole (Prilosec) 40 mg BID or equivalentTreatment should continue for 3-6 monthsNo benefit expected for 3 monthsRevisit diagnosis if no improvement at 6 months
25LPR Evaluation and Management Empiric treatment before testingOmeprazole 40 mg BID or equivalentTreatment should continue for 3-6 monthsNo benefit expected for 3 monthsRevisit diagnosis if no improvement at 6 monthsEsophagoscopy can be normal24-hour pH probe is “gold standard”Conventional indices (DeMeester score)Reflux induced coughsBarium esophagography or impedance testing for non-acid reflux determinationOropharyngeal acid studies
26Problems with LPR / GERD Diagnosis Definitions are unclearSymptoms are poorly definedPhysical findings are vaguePoor “gold standard”Poor correlation with histologic findingsHigh treatment failure rateRemarkably poor studies
29Sensory Neuropahy Lee & Woo (2005) 28 patients “cryptogenic” cough Average duration of cough = 7 mo (range 2 wk – 20 yr)2/3 had “previous work-up”20/28 felt to have RLN/SLN neuropathyLee, B.; Woo, P. Ann Otol Rhinol Laryngol. 2005, 114,
30Sensory Neuropahy “Cryptogenic Cough” Lee & Woo (2005) Treated with gabapentin (Neurontin)Started 100 mg/qd– increased to ~900 mg/qdDose titrated to effect/side effectsResults:68% overall improvement80% of those with L-EMG neuropathyLee, B.; Woo, P. Ann Otol Rhinol Laryngol. 2005, 114,
31Behavior Modification Cortical control is evidentVoluntary coughPlacebo-mediated cough suppressionEccles R; Pulm Pharmacol Ther. 2002, 15, 303 – 8.
32Behavior Modification Cortical control is evidentVoluntary coughPlacebo-mediated cough suppressionCough depressed / absent in:ComaLeft cortical strokeSleep / anesthesiaCough SuppressionCapsaicin-induced cough can be suppressed in humansHutchings, et al. Respir Med. 1993, 87,
34Retrospective chart review 132 patients (2005-2010) OHSU and Chronic CoughRetrospective chart review132 patients ( )Cough greater than 10 weeksEvaluate work up and interventionsResponse to therapyNonePartial response (therapy continued)Complete response (>85% improved by report)
47Take Home PointsThe causes of cough are as myriad as the nerves that meditate themAsthma and atopic/eosinophilic bronchitis probably account for the majority of chronic coughPost-nasal drip / UACS is probably “Voodoo”GERD / LPR is difficult to diagnose and expensive to treatAn otolaryngologist may be helpful in evaluating and managing chronic cough
48KNOWLEDGE Pearls Chronic cough is almost always multifactorial Listen to patient’s symptomsOptimize therapy and testing for each suspected diagnosis– use high yield definitive studiesEliminate OTC medications / cough dropsPatience is criticalBehavioral cough suppression can be tremendously useful