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MÜNEVVER ERDİNÇ Department of Chest Diseases Ege University Faculty of Medicine Differential Diagnosis And Treatment In Adults.

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Presentation on theme: "MÜNEVVER ERDİNÇ Department of Chest Diseases Ege University Faculty of Medicine Differential Diagnosis And Treatment In Adults."— Presentation transcript:

1 MÜNEVVER ERDİNÇ Department of Chest Diseases Ege University Faculty of Medicine Differential Diagnosis And Treatment In Adults

2 Acute Cough lasting less than 3 weeks Subacute Cough lasting 3 to 8 weeks Chronic Cough Lasting more than 8 weeks Morice AH.Eur Respir J 2004 :24: Fontana GA.Thorax 2003;58: Irwin RS.NEJM 343(23): ,2000 Irwin RS. Chest 1998; 114(suppl1) :133S-181S

3 Differantial Diagnosis of Chronic Cough in Adults PNDS – Allergic rhinitis – Chronic sinusitis GERD Cough variant asthma ACEI induced cough Pertusis Neurogenic – Traumatic – Postinfectious cough Phychogenic cough Chronic aspiration Zenker diverticulosis Foreign body Chronic bronchitis Bronchiectasis Lung cancer Subglottic stenosis Tracheomalasie Tracheoesophageal fistul Tuerculosis Sarcoidosis Congestive heart failure Simpson CB. Otolaryngology–Head Neck Surg 2006; 134:

4 In prospective studies in adults, chronic cough is most commonly due to 6 disorders : due to 6 disorders : Upper Airway Cough Syndrome (UACS) Asthma GERD Chronic Bronchitis Bronchiectasis Non-asthmatic Eosinophilic Bronchitis In prospective studies in adults, chronic cough is most commonly due to 6 disorders : due to 6 disorders : Upper Airway Cough Syndrome (UACS) Asthma GERD Chronic Bronchitis Bronchiectasis Non-asthmatic Eosinophilic Bronchitis Guidelines Writing Committee. Chest 2006; 129 (Suppl. 1): 1S-292S

5 New Considerations  Eosinophilic bronchitis  Atopic cough  Non acid(volume)/ weakly acid reflux  Idiopathic (unexplained) öksürük

6 Diagnosis and Management of Cough ACCP Evidence-Based CPG 2006 ACCP Evidence-Based CPG 2006 Guidelines Writing Committee. Chest 2006; 129 (Suppl. 1): 1S-292S Plevkova, et al. Respir Physiol Neurobiol 2004; 142: Postnasal drip syndrome (PNDS) renamed upper airway cough syndrome (UACS) Upper airway afferents may reflexly enhance coughing Nonasthmatic eosinophilic bronchitis recognized as a common cause of chronic cough Idiopathic cough renamed unexplained cough The term acid reflux disease, unless it can be definitively shown to apply, replaced by reflux disease Update of current diagnostic and therapeutic approaches Common diseases, Uncommon diseases New algorithms for the management of cough in adults and children An empiric integrative approach is recommended Postnasal drip syndrome (PNDS) renamed upper airway cough syndrome (UACS) Upper airway afferents may reflexly enhance coughing Nonasthmatic eosinophilic bronchitis recognized as a common cause of chronic cough Idiopathic cough renamed unexplained cough The term acid reflux disease, unless it can be definitively shown to apply, replaced by reflux disease Update of current diagnostic and therapeutic approaches Common diseases, Uncommon diseases New algorithms for the management of cough in adults and children An empiric integrative approach is recommended

7 ASTHMA PNDS GERD Chest 1999;116: Gastroesophageal reflux disease (21-41%) 2. Cough variant asthma (24-59%) 3. Postnasal drip syndrome (41-58%)

8 Chest 1999;116: Percentage of Cases Presenting 1,2,3, and 4 Causative Factors

9  İmmunocompetent patients  Not exposed to enviromental irritants  Chest radiograph is normal  Not taking an ACE inhibitor  Not a current smoker Asthma and/or GERD, PNDS responsible for 93.6% of the cases of chronic cough Harding SM.Chest 2003;123:

10 Changing Trends in Diagnosis Percentage of Diagnosis (%) GERD ASTHMARHINITIS

11 Impaired esophageal clearance Functional defect in LES syphincter Hiatal hernia Delayed gastric emptying İncreased intra-abdominal pressure GERD ? Decreased saliva Heartburn (pyrosis) and regurgitation At least weekly symptoms extraesophageal reflux symptoms and/or esophageal mucosal damage / Katzka & DiMarino 1995

12 FLR Signs Edema and hyperemia of larynxEdema and hyperemia of larynx Vocal cord erythema, polyps, granulomas, ulcersVocal cord erythema, polyps, granulomas, ulcers Hyperemia and lymphoid hyperplasiaHyperemia and lymphoid hyperplasia of posterior pharynx of posterior pharynx Interarytenoid changesInterarytenoid changes Subglottic stenosisSubglottic stenosis

13 GERD-related cough incidence % May be the sole presenting symptom(1/3) Thorax 2003:58; ) (Chest 1997; 111: ) Irwin RS. Chest 2006;129:80S-94S Association between cough and reflux is important  Esophageal-tracheal-bronchial reflex  Microaspiration ARRD 1981;123: Arch Intern Med 1996;156:997 Chest 1993;104: El Hennawi, 2004 OHNS Nonacidic factors? Esophageal dismotility?

14 . Mediator Release Release. Inflammation. Edema. Mucus. Smooth Muscle Muscle Microaspiration REFLUX EsophagealVagal Afferents Afferents Bronchial Hyperreactivity Airway Vagal Afferents CNS Stein MR.Am J Med 2003 Chest 1997;111: Airway Airway Vagal Efferents Esophagus Tracheobronchial Tree

15 Stomach Oesophagus

16 Pharyngeal pHmetry +- Not GERD Clinical GERD symptoms ? Nonacid, weakly acid reflux? Increase dose PPI + alginate İmproved Not improved Continue pHmetry under treatment Consider  Simultaneously dual probes 24 hours pHmonitoring and intraesophageal impedance Irwin RS.AJRCCM 165: ,2002 McGarvey LPA.Thorax 59: ,2004

17 3 cm 5 cm 7 cm 9 cm 15 cm 17 cm pH - 5 cm 6 impedance channels 1 pH electrode + Adult Standard Model ZAN-S61C01E Multichannel intraluminal impedance-pH catheter

18 Non acid reflux On going reflux of ‘non-acid’ material may be responsible for continuing symptoms while on acid-suppressing medications

19 Therapy in Esophageal-pulmonary reflux  Conservative and lifestyle measures  Ampirical therapy: Acid suppression Proton pump inhibitors Proton pump inhibitors  PPI x 2 / 3 months  PPI x 2 / 3 months  Therapy failure  24 hour intraesophageal pHmetry ( pharyngeal pHmetry ) ( pharyngeal pHmetry )  GERD (+)  GERD (+) High dose PPI High dose PPI + H 2 blocker agent + H 2 blocker agent Surgery(Fundoplication) Pulmonary and Crit Care Update 1994; Vol 9 Morice AH. ERJ 2004;24:

20 Weeks of antireflux therapy Patients responded No No (%) 2 16 (41) 4 38 (86) 6 42 (95) 8 43 (99) 12 weeks 44 (100) Poe RH.Chest 2003;123: Cumulative Response to GERD Therapy

21 Preop pH <4: %23.6 De Meester: 85 Postop pH <4: %2.4 De Meester: 9.9

22 1. Chronic cough for at least 2 months 2. Immunocompetent patients 3. Chest radiograph is normal 4. Not exposed to enviromental irritants nor a present smoker 5. Not taking an ACE inhibitor 6. Symptomatic asthma has been ruled out 7. Rhinosinus diseases has been ruled out: 8. ‘Silent sinusitis’ has been ruled out 9. Nonasthmatic eosinophilic bronchitis has been ruled out: BPT is negative Cough has not improved with asthma therapy First generation H 1 antagonists has been used Eo 3%  in induced sputum Cough has not improved with steroids Irwin RS. Chest 2006;129:80S-94S İrwin RS. AJRCCM Vol 165; , 2002 Clinical Profile That Chronic Cough İs Likely Due To ‘Silent GERD’

23 Postnasal Drip Syndrome (PNDS) Prevalence : 8 – 87% Pathogenesis : The sensation of drainage of secretions from the nose or paranasal sinuses into the pharynx Clinical Presentation: Dripping sensation Tickle in the throat Nasal congestion Mucus in oropharynx Cobblestone appearence of oropharynx ACCP consensus. CHEST 1998; 114: ERS Task Force. ERS Journal ; 24: Pathogenic Triad in Chronic Cough. CHEST 1999; 116: Evaluation of chronic cough. UPTODATE 2005

24 Chest 2006;129:63S-71S In patient with chronic cough that is related to upper airway abnormalities Upper Airway Cough Syndrome

25 UACS Treatment Antihistamines / decongestant combinations - “Older” sedating antihistamines more effective - Treatment effect should be observed in 1 week Additional / Alternative treatments : Ipratropium nasal spray : 2-7 days Nasal steroids (such as BDP, FP,BUD) : 2-3 days - 2 week 3 months prescribed

26 Eosinophilic Eronchitis Airway obstruction Bronchial hyperreactivity NO YES YES NO Asthmatic Coughs Cough Variant Asthma Asthma

27 Cough Variant Asthma Prevalence : 24 – 59% Clinical Diagnosis Gold standard  History - Episodic symptoms, Family history Reversibility testing PEF monitoring Bronchoprovocation test Differential Diagnosis: Decreased of cough with classical asthma therapy ACCP consensus. CHEST 1998; 114: ERS Task Force. ERS Journal ; 24: The Journal of Respiratory Disease; 25; THORAX 59;

28 Middle age patients Smoking is unusual, occupational ? Prevalence of atopy similar population Good respond to inhaled steroids Gibson et al. Lancet 1989 Chest 2006;129:116S-121S Eosinophilic Bronchitis Isolated chronic cough,  productive of sputum Normal lung function without variable airflow limitation Airway hyperresponsiveness absent Eosinophilia in sputum and BAL Cough reflex to capsaicin increased Normal daily variability in peak expiratory flow (<20%)

29 10% Australia 30 patients, % Korea 92 patients, % USA 37patients % Turkey 36 patients, % UK 91patients, % China 86 patients )Kim et al AJRCCM 2003; 2) Brightling et al AJRCCM 1999;160:406-10, 3) Joo Korean JIM 2002;17:31-7, 4) Carney et al AJRCCM 1997; 156:211-6, 5) Ma et al Zhongua 2003;26:362-5, 6) Ayik, Erdinc et al Respir Med 2003;97: Eosinophilic Bronchitis A Worldwide Disease

30 Causes of chronic cough Primary cause of coughNo. of patients (%)* Eosinophilic bronchitis12 (33.3%) Postnasal drip syndrome8 (22.2%) Gastroesophageal reflux8 (22.2%) Idiopathic chronic cough8 (22.2%) Postinfectious cough2 (5.6%) Cough-variant asthma1 (2.8%) Ayık SÖ, Başoğlu ÖK, Erdinç M. Respir Med Vol. 97 (2003)

31 Causes of Isolated Chronic Cough Brightling CE et al. AJRCCM 1999

32 Positive Cough Variant Asthma İnhaled steroid β 2 -agonist Negative Induced sputum (3%  eosinophilia Eosinophilic Bronchitis İnhaled steroid Asthmatic Cough Airway obstruction Reversibility PEF değişkenliğiAsthma İnhaled steroid β 2 -agonist Yes Bronchial provocation test No Increased NO all of them PEF monitoring

33

34 Prevalence: 0-50% More agressive diagnosis and treatments UACS, GERD and postinfectious cough leads to lower incidence ‘unexplained’. Airway inflammation  Mast cell, histamin, cysteinil LTs, PD 2, PE 2 Irwin RS,et al. Chest 2006;130: Chronic Unexplained (Idiopathic) Cough

35  Important missed history (smoking,ACEI,enviromental,drugs,allergy)  Failure to do correct diagnostic tests  Failure to use ‘empiric’ treatment  Failure to use effective therapy  Unknown disease process Potential Reasons Chronic Unexplained (Idiopathic) Cough « Truly idiopathic cough is rare and misdiagnosis very common, especially if cough is provoked by sites outside the airways » Eur Respir J 24:

36 Idiopathic cough % ? Studies in the 1980’s % patients

37 Idiopathic cough % ? % patients

38 Idiopathic cough % ? % patients

39 Idiopathic cough % ? 2000  % patients

40 Haque et al Chest 2005;127: Chronic Idiopathic Cough

41  Predominantly female and associated with BAL lymphocytosis  Raising the possibility of a link between autoimmune diseases Surinder S. Et al. Respir Med 98: ;2004 Chronic Idiopathic Cough (n=22) Control (n=65) p Autoimmune disease13/22 (59%)8/65 (12%) p<0.001* Positive autoantibody 6/15 (40%)3/24 (13%) p<0.05 Chronic Idiopathic Cough *OR: 8.8

42 Inflammation Chronic Idiopathic Cough Birring et al AJRCM 2004

43 + BAL lymphocytosis Sarcoidosis Hypersensitivity pneumonitis Rheumatoid Arthritis Sjögren’s syndrome Lung tx Inflammatory bowel disease Hypothyroidism Autoimmune disorders (SLE, RA) Pernisious anemia DM Thorax 2003;58: Chronic Idiopathic Cough

44 Irwin RS,et al. Chest 2006;130: It is not correct to state that “a typical lymphocytic airways inflammation is seen in idiopathic cough” because lymphocytic or lymphoplasmacytic inflammation a non-specific finding related to trauma of coughing Chronic Idiopathic Cough

45 Psychogenic Cough Cough is often triggered by a common cold Usually dissapears during sleep Like a dog barking The diagnosis of psychogenic cough is one of exclusion, after ruling out an organic or functional cause of cough. Specific or empiric treatment Antitussives are usually ineffective. Respirology 2006;Suppl 4 ;S160-S174 Irwin RS et al. Chest 1998, 114:2 suppl ERS Task Force: Eur Respir J 2004, 24:

46 Prevalence: % History: After a respiratory tract infection Diagnosis: Spasmodic cough Normal chest radiograph, with/without ronchii Respiratory viruses, m.pneumoniae, c.pneumoniae, B.pertussis Serum acute IgA antibody ELISA Rarely lymphocytosis Airway inflammation +/- Airway hyperresponsivenes Irwin RS et al. Chest 1998, 114:2 suppl ACCP consensus. CHEST 1998; 114: ERS Task Force. ERS Journal ; 24: Postinfectious Cough

47 –Oral and/or inhaled steroid (2-3 weeks) –Antibiyotic : Macrolides (Chlamydia, mycoplasma) TMP/SMX : Pertusis (3-6 weeks) –Ipatropium bromid decrease efferent limb of the cough reflex decrease stimulation of cough receptors –Antitussive therapy Irwin RS et al. Chest 1998,114:2 suppl Miyashita N. J Med Microbiol 2003, 52:3, Postinfectious Cough

48 ACEI Induced Chronic Cough Frequency: % Predominantly female Not dose related Appears within hours, weeks, months Pathogenesis: Neurokinin, Substance P, Prostoglandins, stimulates afferent C-fibers in the airway  increased cough reflex sensitivity Prefer Angiotensin II receptör antagonists

49 Treatment NONSPECIFICSPECIFIC AntitussiveProtussive Causative treatment Codein Dextromethorphan Difenhidramin Pseudoephedrine Dekstrobromfeniramin Ipatropium Bromide Naproksen Hypertonic saline Erdostein Amilorid N asetilsistein Terbutalin Physiotherapy Postural drainage Irwin RS et al. Chest 1998, 114:2

50 –Capsaicin type I Vanilloid receptor antagonists –Selective opioid receptor agonists –Opioid-like receptor agonists –Tachykinin receptor antagonists –Endogenous cannabinoids –5-HT receptor agonists –Large-conductance calcium-activated potassium channel openers Dicpinigaitis PV.Chest 2006 ;129:284S-286S Future Therapies

51 Chronic cough History,Examination, Chest X-Ray, PFT Normal Abnormal Sputum, bronchoscopy,CT, Cardiac tests Smoking, ACEI, Irritants ? Specific diagnosis - treatment Stop 4 weeks yes Chronic Cough Algoritm For the Management of Adults

52 Chronic cough History,Examination, Chest X-Ray, PFT Normal Abnormal Sputum, bronchoscopy,CT, Cardiac tests Smoking, ACEI, Irritants ? Specific diagnosis - Treatment Cough? Yes No UACS,GERD, Asthma, NAEB ? No Yes Stop 4 weeks İmproved? Chronic Cough Algoritm For the Management of Adults

53 Chronic cough Normal Abnormal Cough? Yes Yok No Yes Improved Cough? No Yes Empiric/ Specific Therapy History,Examination, Chest X-Ray, PFT Sputum, Bronchoscopy,CT, Cardiac tests Specific diagnosis - treatment Smoking, ACEI ?, Irritants? UACS,GERD, Asthma, NAEB Stop 4 weeks Chronic Cough Algoritm

54 Chronic cough History,Examination, Chest X-Ray, PFT Normal Abnormal Sputum, Bronchoscopy,CT, Cardiac tests Smoking, ACEI ?, Irritants? Cough? Yes No UACS,GERD, Asthma, NAEB No Yes Stop 4 weeks Improved Empiric Therapy ENT, Sinus CT BPT,PEF monit., NO Esophageal tests No response Specific diagnosis - treatment Specific Diagnosis - Treatment Chronic Cough Algoritm

55 UACS,GERD, Asthma, NAEB Empiric or Specific Diagnosis and Treatment Cough ? No Sputum, HRCT, Bronchoscopy Improved Yes Post infectious? Yes Consider uncommon causes Cough ? NoYes Physcogenic cough? Specific diagnosis - Treatment

56 UACS,GERD, Asthma, NAEB Empiric or Specific Diagnosis and Treatment Cough ? No Sputum, HRCT, Bronchoscopy Improved Yes Post infectious? Yes Consider uncommon causes Cough ? NoYes Physcogenic cough? Specific diagnosis - Treatment Improved Chronic idiopathic cough No

57 THANK YOU…


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