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Cough Diagnosis and Management
Dr Paul Plant Consultant Chest Physician I’m Coughing my lungs up Doc.
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Areas To Cover Why do we Cough? Classification and Causes of Cough
Acute Subacute Chronic When and How to Investigate Management Case Study
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What is Cough? ‘A Cough is a forced expulsive manoevere, usually against a closed glottis and which is associated with a characteristic sound’
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Classification of Cough
Three Categories of Cough Acute Cough = < 3 Weeks Duration Subacute Cough = 3 – 8 Weeks Duration Chronic Cough = > 8 Weeks Duration
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Acute Cough
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Acute Cough <3/52 Duration Differential Diagnosis
Upper Respiratory Tract infections: Viral syndromes, sinusitis viral / bacterial URTI triggering exacerbations of Chronic Lung Disease eg Asthma/ COPD Pneumonia Left Ventricular Heart Failure Foreign Body Aspiration
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Acute Cough Epidemiology
Symptomatic URTI 2-5 per adults per year 7-10 per child per year 40-50% will have cough Self medication common -£24million per year 20% consult GP (2F:1M) Most resolve within 2 weeks
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Duration of Cough in URTI
Primary Care Setting No antecedent or chronic lung disease End of Week % Coughing *Jones FJ and Stewart MA, Aust Family Physician Vol. 31, No. 10, October 2002 Sub-acute Cough -Post viral cough
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“Don’t just do something stand there.”
Managing Acute Cough “Don’t just do something stand there.” Alice in Wonderland
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Managing Acute Cough Identify High Risk groups
Acute Cough Can be 1st Indicator of Serious Disease eg Lung ca, TB, Foreign Body, Allergy, Interstitial Lung disease ‘Chronic cough always preceded by acute cough’.
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Red Flags in Acute Cough
Signs Tachypnoea Cyanosis Dull chest Bronchial Breathing Crackles Symptoms Haemoptysis Breathlessness Fever Chest Pain Weight Loss THINK pneumonia, lung cancer, LVF GET a CHEST X-Ray
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Treatment of Simple Acute Cough
Benign course -reassure Cough can distress Patients report OTC medication helpful Voluntary cough suppression -linctuses/ drinks Suppression of cough -dextromethorphan, menthol, sedating antihistamines & codeine
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Which Anti-tussive? Dextromorphan Menthol Sedating Antihistamines
eg Benilyn non-drowsy 1 meta-analysis high dose 60mg beware combinations eg paracetomol Menthol Steam inhalation. Effect on reflex short lived Sedating Antihistamines danger sleepy - nocturnal cough Codeine or Pholcodeine No better than dextromorphan but more side-effects. Not recommended
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Sub-Acute Cough
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Sub-acute Cough 3-8 weeks
Likely Diagnoses Postinfectious Bacterial Sinusitis Asthma Start of Chronic Cough Don’t want to miss lung cancer ACTIONS Examine Chest Chest X-Ray if signs or smoker Measure of airflow obstruction ie peak flow -one off peak flow -serial spirometry
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Post Infectious Cough A cough that begins with an acute
respiratory tract infection and is not complicated* by pneumonia *Not complicated = Normal lung exam and normal chest X-ray Post Infectious cough will resolve without treatment Cause = Postnasal drip or Tracheobronchitis
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Chronic Cough
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Case Study -CP 2007 60yr retd Nurse
Chest infection 2002 in Spain -mild SOB since Chest infection hospitalised for 4/7 antibiotics / steroids SOB and dry cough since No variation 4 lots of AB and steroids from GP plus tiotropium & oxis -no help for cough Wt climbing More SOB over 9/12 Ex-smoker 30 pack yrs FEV % What else would you like to know? What causes can you think of?
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Chronic Cough Epidemiology
Epidemiology difficult -acute vs chronic Cullinan 1992 Respir Med 86:143-9 n=9077 16% coughed on >50% days of year 13% coughed sputum on >50% days of year 54% were smokers
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Chronic Cough Epidemiology
Associations with: Smoking (dose related) Pollutants (particulate PM10) -occupation Environmental irritants (eg cat dander) Asthma Reflux Obesity Irritable bowel syndrome Female
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Making the Diagnosis Common Differentials
Lung Disease -normal CXR -abnormal CXR Gastro -Oesophageal Reflux Post-nasal Drip -allergic rhinitis -bacterial sinusitis Non-structural ACE-Inhibitors Tobacco Habit Cough
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Chronic Cough Investigating Chronic Cough
Purpose: To exclude structural disease To identify cause How History & Examination inc occupation & Spirometry ALWAYS GET A CHEST X-RAY IN CHRONIC COUGH
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Beware Cough triggered by: change in temperature
scent, sprays, aerosols and exercise indicate Increased cough reflex sensitivity and Not just seen in Asthma. Esp GORD, infection and ACEI
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ACE-Inhibitors and Chronic Cough
Incidence: 5-20% Onset: one week to six months Mechanism Bradykinin or Substance P increase Usually metabolized by ACE) PGE2 accumulates and vagal stimulation. Treatment: switch to Angiotensin II Receptor Blockers (ARBs)
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Gastro-oesophageal Reflux
GORD accounts alone or in combination for 10-40% of chronic cough Two Mechanisms a. Aspiration to larynx/ trachea b. Acid in distal oesophagus stimulates vagus and cough reflex
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Gastro-oesophageal Reflux Symptoms
Cough Features Throat clearing Worse at night / rising On eating Reflex hypersensitivity CXR -normal or hiatus hernia Spirometry normal GI Symptoms If Aspiration main mechanism Heart burn Waterbrash/ Sour taste Regurgitation Morning Hoarseness If Vagal - NO GI symptoms
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Gastro-oesophageal Reflux
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Gastro-oesophageal Reflux Investigation
Oesophageal pH monitoring for 24 hours (+diary) 95% sensitive and specific 95% Ba swallow not sensitive enough Endoscopy - may confirm but false -ve rate
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GED Endoscopy can show GORD, but cannot
confirm GORD as the cause of cough. © Slice of Life and Suzanne S. Stensaas GED GED
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Gastro-oesophageal Reflux Treatment
Trial of Therapy High dose twice daily PPI for min 8weeks + prokinetic eg domperidone or metoclopramide Eliminate contributing drugs. Baclofen rarely Improves in % of cases
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Post-Nasal Drip Symptoms: ‘something dripping’
frequent throat clearing nasal congestion / discharge posture Causes Allergic rhinitis Non-allergic rhinitis Vasomotor rhinitis Chronic bacterial sinusiits
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Post Nasal Drip Treatment
Options: 1. Exclude /treat infection 2. Nasal steroid for 8/52 3. Sedating antihistamines 4. Antileukotrienes eg montelukast 5. Saline lavage 6. ENT opinion
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Lung Diseases inc Tobacco
Favouring Lung Disease Shortness of breath Wheeze Sputum production Haemoptysis Chest signs eg crackles
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Chest X-Ray and Differential of Cough
Normal CXR Gastro-oesophageal reflux Post-nasal Drip Smokers cough/ Chronic Bronchitis Asthma COPD Bronchiectasis Foreign body Abnormal CXR Left ventricular failure Lung cancer Infection/ TB Pulmonary fibrosis Pleural effusion
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Left Ventricular Failure
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Idiopathic Pulmonary Fibrosis
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TB
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Lung Cancer
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Chest X-Ray and Differential of Cough
Normal CXR Gastro-oesophageal reflux Post-nasal Drip Smokers cough/ Chronic Bronchitis Asthma COPD Bronchiectasis Foreign body
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Smoking and the Healthy Lung
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The Development of Chronic Bronchitis (Daily Cough)
Smoking Neutrophil Infiltration Goblet hyperplasia (mucous production) Release of Proteinases
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Normal Spirometry and Flow Volume Loops
Photo of MFM How to do peak flow meter
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Show booklet Normal Values Depend on Age/ Sex / Height / Race
Tables and slide rules available Asians decrease value by 7% Afro-Caribbean decrease by 13% Report results as Absolute and % predicted Normal is % Show booklet
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Obstructed Spirometry
FEV1 reduced FVC largely preserved FEV1/FVC low <70% FEV1 =1.0 Pinch straw trick Floops and explanation ‘FVC’ =2.0 FEV1/FVC=50% FVC = FEV1/FVC =33%
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Peak Flow Measurement Single or Repeated Measures
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Chronic obstructive pulmonary disease
Definition of COPD Chronic obstructive pulmonary disease is characterized by airflow limitation that is not fully reversible FEV1always <80% with airflow limitation that is usually progressive associated with an abnormal inflammatory response to noxious particles or gases.
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Development of Emphysema
Proteinases diffuse out Neutralised by Anti-proteinases eg a1 Anti-trypsin If balance incorrect alveolar walls destroyed
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How Emphysema causes Airway Narrowing
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Stopping smoking slows decline in lung function
Smoked regularly and susceptible to its effects Never smoked or not susceptible to smoke 100 75 50 25 FEV1 (% of value at age 25) Stopped at 45 This slide illustrates the risks of smoking on lung function: differences between the lines represent effects that smoking, and stopping smoking, can have on the FEV1 of a man who is liable to develop chronic obstructive pulmonary disease (COPD) if he smokes.1 FEV1 declines continuously and smoothly over an individual’s life but in most non-smokers and some smokers clinically significant airflow obstruction never develops.1 In susceptible people, however, smoking causes irreversible obstructive changes in the lungs.1 Although the damage caused to the lungs by years of smoking is permanent, quitting smoking prevents it from worsening.1 Consequently, the accelerated decline in lung function in smokers is halted when they stop, returning to the slower rates of decline that occur naturally with ageing.1 In smokers with established COPD, stopping smoking can improve lung function by about 5% within a few months.1 Smoking cessation in patients with COPD has also been found to reduce respiratory symptoms such as cough, phlegm, wheezing and dyspnoea.2 Stopped at 65 Death 25 50 75 Age (years) Adapted from: Fletcher et al, Br Med J 1977. 1. Fletcher C, Peto. R. Br Med J 1977; 1: 2. Kanner RE, Connett JE, Williams DE, Buist AS, for the Lung Health Study Research Group. Am J Med 1999; 106:
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indoor/outdoor pollution
Step 1 Make Sure Patient Has COPD EXPOSURE TO RISK FACTORS SYMPTOMS cough tobacco sputum occupation dyspnea indoor/outdoor pollution REMEMBER: Only 1/3 smokers get COPD Need 15 pack years min Asthma/ Bronchiectasis è SPIROMETRY
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Inhaled Steroids in COPD Steroid Reversibility
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YES – LONG-ACTING BRONCHODILATOR
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CAN PATIENT USE AN MDI? £30 £43 £34 £47
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Definition of asthma “A chronic inflammatory disorder of the airways … in susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.” Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92
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Asthma Variable airflow obstruction
Symptoms vary Measurements of airflow obstruction vary Associated with atopy (hayfever, eczema, urticaria) Occupational links eg bakers, isocyanates, wood-dust Dry cough, worse at night Episodic breathlessness Effects all ages
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Asthma Allergens Tree Grass Fungi House dust mite Pets Occupational
Triggers Exercise Fumes/ Smoke Cold air Oesophageal Reflux Occupational
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Looking for 20% variation
Proving Variability Looking for 20% variation in PEFR or 15% in FEV1 1. Opportunistic single low peak flow in surgery Give bronchodilator and repeat in 20 mins Give trial of therapy and repeat next visit 2. Opportunistic single normal peak flow in surgery Measure on subsequent visits -hope for variability naturally Home peak flow measurements Induce an asthma attack! -histamine challenge
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Peak Flow Measurement Single or Repeated Measures
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Stepwise management of asthma in adults
Step 5: Continuous or frequent use of oral steroids Step 4: Persistent poor control Step 3: Add-on therapy Step 2: Regular preventer therapy Step 1: Mild intermittent asthma Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
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Can Asthma become COPD? 30% Smoke Different location. 5-10% Asthma
Different cells Different cause Different prognosis Similar clinical pictures Similar treatments Can Co-exist 0.5-1% Chronic Asthma
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Case Study -CP 2007 Ex-smoker 30 pack yrs FEV1 0.97 43%
What else would you like to know? History positional /reflux What causes can you think of? COPD Obesity with Reflux 8/52 omeprazole 20mg bd + domperdone 10mg tds -asymptomatic 60yr retd Nurse Chest infection 2002 in Spain -mild SOB since Chest infection hospitalised for 4/7 antibiotics / steroids SOB and dry cough since No variation 4 lots of AB and steroids from GP plus tiotropium & oxis -no help for cough Wt climbing More SOB over 9/12
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Conclusions Acute Cough < 3/52 Usually URTI CXR if worried
Symptomatic therapy Subacute Cough 3-8/52 Usually post-viral CXR if smoker or worried Chronic Cough >3/12 CXR and Spirometry Consider GORD Post -Nasal Drip Lung - Abnormal CXR - Normal CXR (asthma/ COPD)
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