Approach To The Patient With Cough

Case• MKSAP 13 – Pulmonary Question #22– A 47 yo black male is evaluated because of a 2-month

history of cough. Three months ago hypertension was diagnosed, for which he takes HTCZ and benazepril. He attributes his cough to the change of weather. He has a hx of GERD that is well controlled on PPI. No hx of asthma.

– Which of the following would be the most appropriate next step?• CT scan of sinuses• pH probe• Methacholine challenge testing• Stop ACEI• Allergy testing

Cough By Duration

• Acute Cough < 3 weeks • Sub acute Cough from 3 – 8 weeks • Chronic Cough > 8 weeks

Irwin, R. S. et al. Chest 2006;129:1S-23SIrwin R, Madison JM. The diagnosis and treatment of cough. N Engl J Med 2000; 343:1715–1721

Irwin, R. S. et al. Chest 2006;129:1S-23S

Chronic cough algorithm for the management of patients >= 15 years

Evaluation Of Nonsmokers Presenting With Chronic Cough

• If on ACEI discontinue ACEI• Consider UACS, Asthma, GERD as most

common diagnoses• Do not use the patient’s description of timing

of onset or production of sputum to diagnose• The etiology of some cough syndromes is

multifactorial

Pratter MR. Overview of common causes of chronic cough: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):59S–62S

Chronic Cough Syndrome Caused By Rhinosinus Disease

• Formerly labeled post nasal drip syndrome• ACCP recommends calling this upper airway cough syndrome• Ddx: Allergic rhinitis, postinfectious rhinitis, bacterial sinusitis,

rhinitis due to irritants, occupational, medicamentosa, anatomic abnormalities

• Evaluation includes a combination of criteria, including symptoms, physical examination findings, radiographic findings, and, ultimately, the response to specific therapy

Pratter MR. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):63S–71S  

Chronic Cough Syndrome Caused By Rhinosinus Disease

• Draining into throat, need to clear throat, tickle in throat, congestion, nasal discharge, hoarseness, wheeze

• If obvious, treat with 1st generation A/D• If not responsive, image sinuses• Empiric therapy with 1st generation A/D• An empiric trial of therapy aids in diagnosis• An empiric trial of therapy should be given before

considering exhaustive work-up

Pratter MR, Brightling CE, Boulet LP, et al. An empiric integrative approach to the management of cough: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):222S–231S  

Chronic Cough Syndrome Caused By Rhinosinus Disease

• In the setting of the common cold;– Treat with A/D, consider Naprosyn– Nonsedating antihistamines do not work– Even if productive of sputum do not use

antibiotics routinely

Cough And Asthma

• May be a symptom of asthma or a distinct entity, cough variant asthma

• Spirometry with bronchodilator, and methacholine challenge testing used to evaluate

• Treat with inhaled bronchodilator and inhaled corticosteroids

• Can only diagnose this as cause if syndrome is responsive to therapy

Cough And Asthma

• Consider sputum eosinophil level for steroid responsiveness

• If not responsive or noncompliant, consider leukotriene receptor antagonist

• May consider oral steroids if severe

Dicpinigaitis PV. Chronic cough due to asthma: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):75S–79S  

Clinical Profile That Predicts That Chronic Cough Is Likely Due to GERD Chronic cough

• Not exposed to environmental irritants nor a present smoker• Not taking an angiotensin-converting enzyme inhibitor• Chest radiograph is normal or shows nothing more than stable,

inconsequential scarring• Symptomatic asthma has been ruled out: • Cough has not improved with asthma therapy, or Methacholine

inhalation challenge is negative• Upper airway cough syndrome due to rhinosinus diseases has

been ruled out: First-generation H1 -antagonist has been used and cough failed to improve, and “Silent” sinusitis has been ruled out

• Nonasthmatic eosinophilic bronchitis has been ruled out: Properly performed sputum studies are negative, or 

• Cough has not improved with inhaled/systemic corticosteroids

Irwin, RS Chronic cough due to gastroesophageal reflux disease: ACCP evidence-based clinical practice guidelines. Chest 2006;129(suppl),80S-94S

Cough Associated With GERD

• Suspected by clinical profile• Treat if suspected, even if they are otherwise

asymptomatic• Cannot rule out on clinical profile• Cannot rule out GERD as cause of cough until it is

fully treated/evaluated• Esophageal pH probe is the most sensitive and

specific test for acid reflux

Cough Associated With GERD

• Normal esophagoscopy does not rule out GERD

• Barium esophography is the test of choice to evaluate for non-acid reflux cough complex

• Esophageal manometry may be useful

Rudolph C, Mazur L, Liptak G, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 2001; 32(suppl):S1–S31  

Cough Associated With GERD

• If initial treatment fails, escalate therapy (mixed modalities)

• Evaluate for effective therapy• Lifestyle changes– Anti-reflux diet that includes no > 45 g of fat in 24 h and no

coffee, tea, soda, chocolate, mints, citrus products, including tomatoes, or alcohol, no smoking, and limiting vigorous exercise that will increase intraabdominal pressure

Spectrum of Options for Treating Chronic Cough Due to GERD

• Anti-reflux medical therapy• Diet• Lifestyle changes• Smoking• Exercising• Consuming alcohol• Medications – Acid suppression - PPI, PPI/BID, H2 blockers– Prokinetic

• Address risk factors/Treat other causes of cough • Treat comorbid conditions– Obesity– Obstructive sleep apnea– Consider changing medications for comorbid conditions

• Anti-reflux surgery

Irwin, RS Chronic cough due to gastroesophageal reflux disease: ACCP evidence-based clinical practice guidelines. Chest 2006;129(suppl),80S-94S

Nonasthmatic Eosinophilic Bronchitis

• Common cause of cough 10-30% cases• Diagnosed by ruling out asthma and showing

induced sputum/bronchial wash eosinophilia, or response to ICS

• Evaluate for allergen or occupational cause• Avoidance is treatment of choice if cause found

Brightling CE. Chronic cough due to nonasthmatic eosinophilic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(

Nonasthmatic Eosinophilic Bronchitis

• Treat with inhaled corticosteroids• If firmly diagnosed and not responsive

consider burst of oral systemic steroids • Evaluate for reduction of eosinophilia • vs Asthma-mast cellsbiopsy

Brightling CE. Chronic cough due to nonasthmatic eosinophilic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(

Features Eosinophilic Bronchitis

Classic Asthma

Cough-Variant Asthma

Sx Cough and upper airway

Dyspnea, cough, wheeze

Isolated cough

Atopy No increase common Common

Airway hyperresponsiveness

Absent Present Present

Response BD Absent Good Good

Response ICS Good Good Good

Sputum eos Always Usually Usually

Bronchial bx eos Very common Common Common

Mast cells in airway smooth muscle

No Yes Yes

Irwin, R. S. et al. Chest 2006;129:1S-23S

Subacute cough algorithm for the management of patients >= 15 years

Post-infectious Cough

• <8 weeks• CXR normal• Resolves on its own• Postviral airway inflammation, bronchial

hyperresponsiveness, mucus hypersecretion, impaired mucociliary clearance

Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):95S–103S   Braman SS. Chronic cough due to chronic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):104S–115S Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):72S–74S

Post-infectious Cough

• No antibiotics unless sinusitis or Bordetella pertussis

• Consider trial of ipratropium to attenuate cough

• If this does not work consider trial of ICS• If severe paroxysms – prednisone 30-40mg

short finite period, only when GERD, asthma, UACS ruled out

Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):95S–103S   Braman SS. Chronic cough due to chronic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):104S–115S Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):72S–74S

Post-infectious Cough

• Codeine or Dextromethorphan when other measures fail

• Paroxysms of coughing posttussive vomit and inspiratory whoop

• Order nasopharyngeal aspirate or cx for B. pertussis

• IgG/IgA for presumptive diagnosis• Erythromycin, 5 day isolation

Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):95S–103S   Braman SS. Chronic cough due to chronic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):104S–115S Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):72S–74S

Irwin, R. S. et al. Chest 2006;129:1S-23S

Acute cough algorithm for the management of patients >= 15 years

Irwin, R. S. et al. Chest 2006;129:1S-23S

Chronic cough algorithm >15yrs

Irwin R, Boulet L-P, Cloutier MM, et al. Managing cough as a defense mechanism and as a symptom: a consensus panel report of the American College of Chest Physicians. Chest 1998; 114(suppl):133S–181S  

Cough stimulus

• Afferent limb of cough reflex • Sensory receptors stimulated• Mucus volume, production, consistency,

ciliary action• Neural brainstem elements • Spinal motoneurons innervate respiratory

muscles

Suppressant Therapy• Old term - non-specific therapy• Peripheral antitussive agents• Centrally acting antitussive agents• Inhibit efferent limb and paralytic agents• When cough is elevated over what is required

to defend airways• No evidence that therapy prevents cough

Suppressant Therapy

• Short-term basis • Symptomatic relief• Etiology of cough is unknown• Specific therapy requires time to become

effective• Specific therapy ineffective, ie inoperable lung

cancer

Drugs that alter mucocillary factors

• Conflicting study data on Guaifenesin, Ipratropium, Tiotropium, and Acetylcysteine

• Few drugs suppress cough consistently• In chronic bronchitis mucolytics are not

recommended• In URI or chornic bronchitis the only

anticholinergic recommended is ipratropium bromide

Peripheral antitussive agents

• Suppress excitability of sensory receptors• 2 drugs recommended by evidence based guidelines

in ACCP• Not available in US• Benzonatate - Tetracaine congener with antitussive

properties• Topical anesthetic action on the respiratory stretch

receptors

Centrally acting antitussive agents

• Work on brainstem CNS• Chronic bronchitis codeine and

dextromethorphan recommended for short-term relief

• Cough secondary to URI limited efficacy, not recommended

Inhibit efferent limb and paralytic agents

• In patients with chronic or acute cough requiring symptomatic relief, drugs that affect the efferent limb of the cough reflex are NOT RECOMMENDED– Baclofen - decreased cough secondary to ACE-inhibitor in

one study, not yet tested in DBPCT

• During intubation with GETA neuromuscluar blocking agents such as succinylcholine recommended to suppress coughing

Protussive effects – increase cough clearance

• Bronchitis – hypertonic saline solution recommended short term basis to increase cough clearance

Case• MKSAP 13 – Pulmonary Question #22– A 47 yo black male is evaluated because of a 2-month

history of cough. Three months ago hypertension was diagnosed, for which he takes HTCZ and benazepril. He attributes his cough to the change of weather. He has a hx of GERD that is well controlled on PPI. No hx of asthma.

– Which of the following would be the most appropriate next step?• CT scan of sinuses• pH probe• Methacholine challenge testing• Stop ACEI• Allergy testing

Referral To A Cough Specialist

• If no cause is found with previous algorithmic approach referral is appropriate

• Most involved evaluations involve specialists; GI, ENT, Pulmonary, Cardiology

• Consider pulmonary consult for assistance if needed

Questions