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

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

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

4. 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

5. 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

6. 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

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

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

9. Chronic cough

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

11. 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

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

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

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

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

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

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

20. 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.

21. 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.

22. 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

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

24. 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

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

26. 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

27. Update on TB
East London

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

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

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

34. Baseline investigations
Sputum or pus for AFB
CXR

35. However….

40. 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

41. 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

42. In Summary If in doubt, refer. Max Caplin Clinic, Mile End Hospital
Fax:

44. Discussion…