Management of acute and chronic cough Dr Veronica White MD FRCP Clinical Lead, TB service Barts Health NHS Trust

Definition “Cough is a forced expulsive manoeuvre against a closed glottis and which is associated with a characteristic sound”

Acute and chronic cough Acute cough: lasts < 3 weeks Chronic cough: lasts > 8 weeks ?3-8 weeks – difficult to define

Acute cough Commonest new presentation to primary care Most commonly associated with viral URTI Normally benign and self-limiting Commonest symptom associated with acute exacerbations and hospitalisations with asthma and COPD

Acute cough – statistics (2006) Approx £100 spend per annum on non-prescription cough medicines 12 million consultations with GPs per annum Cost to economy £979 million

Management In general – advice only Little evidence of pharmacological benefit from over the counter preparations “Honey and lemon” best home remedy(!) Voluntary suppression of cough may be sufficient to reduce symptoms Opiate antitussives not recommended

Management Worrying history/symptoms: Haemoptysis Breathlessness Fever Chest pain Weight loss Evidence of vocal cord palsy History of foreign body inhalation

Common serious conditions associated with isolated cough Neoplasms Infection e.g. TB Foreign body inhalation Acute allergy – anaphylaxis Interstitial lung disease

Chronic cough

Taking a history Age and sex – more common in middle aged women Smoking Occupation/hobbies/pets Family history

Taking a history Characteristics: Onset and duration; ?diurnal variation; ?coughing on phonation Relation to infection Sputum Severe coughing spasms/paroxysms Incontinence Chemical triggers; posture; food

Taking a history Past medical history Asthma, eosinophilic bronchitis COPD Bronchiectasis Lung cancer Pertussis infection; atopic disease Cardiovascular disease Autoimmune disease

Baseline investigations Primary care Chest X-ray Spirometry Secondary care Bronchoscopy High resolution CT

What I tell patients…. Five commonest cause of chronic cough with normal CXR Asthma Hayfever/post nasal drip GORD Recent URTI Smoking

Management Asthma – treat as per BTS guidelines GORD – 8 weeks of high dose PPI Upper airways disease – antihistamine, nasal spray

Management Also: Smoking – STOP! Post viral cough - ?low dose steroid inhaler Treat these empirically first

Other diagnosis COPD Infection – bacterial, TB Interstitial lung disease including sarcoidosis Bronchiectasis Drugs – (ACE) inhibitors Foreign body

Intractable cough Can lead to musculoskeletal chest pain, cough rib fracture, urinary incontinence. Cough syncope has also been described where an individual collapses after a severe fit of coughing.

Intractable cough Aggressive treatment: inhaled steroid high dose oral steroids codeine linctus – not in simple coughs Patients with cough associated with an underlying malignancy - diamorphine and morphine - help both the pain and distress Side effects: drowsiness, and constipation.

Specialist cough clinics Selective diagnostics and empirical trials of treatment – cost effective Refer to specialist clinic when empirical treatment has failed Systemic, cost effective approach Management algorithms improve outcome

Specialist investigations Bronchial provocation testing Oesophageal testing Sinus imaging Fibreoptic laryngoscopy Cough provocation test

Summary Most acute cough is benign, but look for additional, worrying symptoms Chronic cough: take a good history; baseline investigations Treat presumed/probable underlying cause Refer to specialist clinic if necessary

Red flags Haemoptysis Breathlessness Fever Chest pain Weight loss Evidence of vocal cord palsy History of foreign body inhalation

If CXR abnormal Refer urgently to relevant service: 2 WW lung cancer ILD clinic – Dr Gavin Thomas TB clinic – Dr Veronica White, Max Caplin clinic, Mile End Oncology

Update on TB East London

Epidemiology UK cases in 2013 – 7892; 38% in London Barts Health – largest TB service in UK - 600 cases per annum; tertiary referrals Tower Hamlets – 100 cases Newham – 335 cases

Making a diagnosis Cough +/- haemoptysis Fever Night sweats Weight loss

Making a diagnosis Blood tests – not specific X-rays Samples – sputum, pus, biopsy Scans such as CT and MRI

Baseline investigations Sputum or pus for AFB CXR

However….

Coming soon…. Screening of new entrants for latent TB in primary care Funding and commissioning will come via CCG Chemoprophylaxis will be given in TB clinics

Summary Symptoms can be insidious Ask about systemic symptoms – often forgotten (by patient and medics) Multi- organ disease; TB can occur at any site Samples/biopsies are crucial – send for AFB

In Summary If in doubt, refer. Max Caplin Clinic, Mile End Hospital Fax: 0208 1214185 TBenquires@bartshealth.nhs.uk

Discussion…