Approach to Management of Cough...For educational purposes only Definitions Cough •Cough is a...

For educational purposes only

Approach to Management of Cough


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PP-NXM-IND-0261 30th Apr 2019


Outline

Definition and Classification of Cough

Assessment of Cough

Acute Cough

Subacute Cough

Chronic Cough

Take Home Messages


Definitions

Cough

•Cough is a forced expulsive maneuver, usually against a closed glottis and which is associated with a characteristic sound

•Cough frequently presents as a troublesome symptom to clinicians working in both primary and secondary care

Acute cough

•Acute cough is defined as one lasting less than 3 weeks

• It is most commonly associated with viral upper respiratory tract infection

• In the absence of significant co-morbidity, an acute cough is normally benign and self-limiting

Chronic Cough

•Chronic cough is defined as one lasting more than 8 weeks

•Most patients present with a dry or minimally productive cough

•The presence of significant sputum production usually indicates primary lung pathology

• In chronic cough a heightened cough reflex is the primary abnormality

Morice AH, McGarvey L, Pavord I. Recommendations for the management of cough in adults. Thorax. 2006 Sep 1;61(suppl 1):i1-24.


Classification of Cough: Duration and Pattern

Duration1

Acute<3 weeks

Subacute3–8-weeks

Chronic> 8 weeks

Pattern of CoughCommon Triggers2

Taking a deep breath

Talking over the telephone

Changes in temperature of inhaled air Eating crumbly food

Particular smells or perfumes

Lying in a supine posture

Laughing

1. Irwin RS, Madison JM. The diagnosis and treatment of cough. New England Journal of Medicine. 2000 Dec 7;343(23):1715-21..2. Chung KF, Widdicombe JG, Boushey HA, editors. Cough: causes, mechanisms and therapy. John Wiley & Sons; 2008 Apr 15.


Analysis of Cough Severity

Clinical historyCough symptom

scoreCough-specific quality of life

Ambulatory cough counts

Ambulatory cough intensity

Spectral analysis of cough sounds

Cough sensitivity (to capsaicin or

citric acid)

Estimating the duration of cough is the first step in narrowing the list of possible diagnoses 1

1. Irwin RS, Madison JM. The diagnosis and treatment of cough. New England Journal of Medicine. 2000 Dec 7;343(23):1715-21..2. Chung KF, Widdicombe JG, Boushey HA, editors. Cough: causes, mechanisms and therapy. John Wiley & Sons; 2008 Apr 15.


Potential Complications of Cough

Acute cervical radiculopathy, cerebral air embolism,

cerebral spinal fluid rhinorrhea

Neurological

Asthma exacerbation, herniation of the lung, laryngeal trauma

Respiratory system

Rib fractures, intercostal muscle rupture

Musculoskeletal system

Urinary incontinence

Genitourinary system

Arterial hypotension, bradyarrhythmia, tachyarrhythmia

Cardiovascular system

Gastroesophageal reflux events, inguinal hernia,

splenic rupture

Gastrointestinal system

Lifestyle changes, self-consciousness, fear of serious disease

Miscellaneous

Irwin RS. Complications of cough: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan 1;129(1):54S-8S.


Assessment of Cough


Clinical Assessment of an Adult with Cough

History (Including questions regarding the following)

• Duration, characteristics, associated symptoms and timing of cough

• Sputum production

• Smoking history- There is a threefold greater prevalence of cough among smokers compared to non smokers

• Occupational history

Physical examination: May demonstrate clinical signs of obstructive lung disease, lung cancer, pulmonary fibrosis, etc.

• Acute cough: Dullness on percussion, bronchial breathing and crackles on auscultation

• Chronic cough: An ear, nose and throat (ENT) examination may reveal evidence of nasal obstruction due to inflamed turbinates or the presence of polyps. The appearance of secretions draining in the posterior pharynx may be apparent

Chung KF, Widdicombe JG, Boushey HA, editors. Cough: causes, mechanisms and therapy. John Wiley & Sons; 2008 Apr 15.


Clinical Assessment of an Adult with Cough

Chest radiograph

• A chest radiograph is mandatory at an early stage as a significant abnormality will alter the diagnostic algorithm and avoid unnecessary investigation

Spirometry and peak expiratory flow measurements

• When available, spirometry both before and after an inhaled bronchodilator should be performed at an early stage in the routine testing of all patients with cough

Sinus imaging

• A plain radiograph of the sinuses may reveal evidence of opacity, mucosal thickening and air–fluid levels in individuals with sinusitis but is rather less helpful when rhinitis is the prominent element

Fiber-optic bronchoscopy

• Fibreoptic bronchoscopy together with a chest radiograph are the first tests to consider in evaluating a smoker with cough. However, the diagnostic yield from bronchoscopy in the routine evaluation of chronic cough is low


Clinical assessment involves an evaluation of the severity of cough in terms of its frequency and intensity and any impact on psychological well-being


Evaluations for Chronic Cough

Investigation Comment

Chest radiograph Essential investigation in all patients

Spirometry and reversibility testing A baseline investigation; not readily available in primary care

Peak flow recording May reliably demonstrate diurnal variability

Bronchial challenge A negative study effectively rules out asthma but not steroid responsive cough

24-h ambulatory pH monitoring If available; helpful in patients with no reflux symptoms to assess duration and frequency of reflux episodes and any temporal association with cough

Paranasal sinus radiograph (or CT scan)

May reveal sinus opacity, mucosal thickening and air–fluid levels

Non-invasive assessment of airway inflammation

Induced sputum useful in identifying an eosinophilic bronchitis; best reserved for patients with negative broncho-provocation test



Acute Cough


Acute Cough

Irwin RS, Madison JM. The diagnosis and treatment of cough. New England Journal of Medicine. 2000 Dec 7;343(23):1715-21..

Acute cough can be the presenting manifestation of pneumonia, left ventricular failure, asthma, or conditions that predispose patients to the aspiration of foreign matter

In the absence of any treatment, the prevalence of cough due to the common cold ranges from 83% within the first 48

hours of the cold to 26% on day 14

Viral infections of the upper respiratory tract are the most common causes of acute cough

Cough appears to arise from the stimulation of the cough reflex in the upper respiratory tract by postnasal drip or clearing of the throat


Acute Cough

In the absence of chronic obstructive pulmonary disease, the failure to diagnose bronchitis when present will not adversely affect the patient, because most acute respiratory infections are viral

The common cold is diagnosed when patients with an acute respiratory illness are characterized by symptoms and signs related primarily to the nasal passages(e.g., rhinorrhea, sneezing, nasal obstruction, and postnasal drip), with or without fever, lacrimation, and irritation of the throat, and when a chest examination is normal



LRTI: lower respiratory tract infection; PE: pulmonary embolism; UACS: upper airway cough syndrome; URI: upper respiratory tract infection;COPD: Chronic obstructive pulmonary disorder

Acute cough

History and physical examination, environmental and occupational factors,

travel exposures + investigations

Non-life-threatening

diagnosis

Life-threatening

diagnosis

InfectiousExacerbation of pre-

existing condition

Asthma

Bronchiectasis

UACS COPD

Other

LRTI URTI

PertussisAcute bronchitis

Consider TB in endemic areas

or high risk

Pneumonia, severe exacerbation of asthma or

COPD, PE, heart failure, other serious disease

Evaluate and treat

first

Red flags

Irwin RS, French CL, Chang AB, Altman KW, Adams TM, Azoulay E, Barker AF, Birring SS, Blackhall F, Bolser DC, Boulet LP. Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report. Chest. 2018 Jan 1;153(1):196-209.


Important Reminders and Red Flags

• Check for red flags

• Routinely assess cough quality of life or cough severity with validated tool

• Routinely follow up with patient in 4-6 weeks

Reminders

• Hemoptysis• Smoker > 45 years of age with a new cough, change in cough, or

coexisting voice disturbance• Adults aged 55-80 years who have a 30 pack-year smoking history

and currently smoke or who have quit within the past 15 years• Prominent dyspnea, especially at rest or at night• Hoarseness • Systemic symptoms :

• Fever• Weight loss • Peripheral Edema with weight gain

• Trouble swallowing when eating or drinking• Vomiting• Recurrent pneumonia• Abnormal respiratory exam and/or abnormal chest radiograph

coinciding with duration of cough

Red flags



COPD: Chronic obstructive pulmonary disease

Indications for further investigations1,2

• Inadequate response to optimal treatment

• Hemoptysis• Systemic illness• Suspicion of inhaled

foreign body• Suspicion of lung cancer

Chest radiography and spirometry remain baseline investigations in the diagnosis of cough1

Bronchoscopy Methacholinechallenge test

Sinus imaging24-h esophageal pH

monitoring

Indications for Further Investigations in Cough

1. McGarvey LP. Cough• 6: Which investigations are most useful in the diagnosis of chronic cough?. Thorax. 2004 Apr 1;59(4):342-6.2. Irwin RS, Madison JM. The diagnosis and treatment of cough. New England Journal of Medicine. 2000 Dec 7;343(23):1715-21..


British Thoracic Society Guidelines– Acute Cough


Acute viral cough is almost invariably benign and prescribed treatment can be regarded as unnecessary

Acute viral cough can be distressing and cause significant morbidity

Patients report benefit from various over-the-counter preparations but there is little evidence of a specific pharmacological effect

The simplest and cheapest advice may be to provide a ‘‘home remedy’’ such as honey and lemon

Central modulation of the cough reflex is common; simple voluntary suppression of cough may be sufficient to reduce cough frequency

Opiate antitussives have a significant adverse side effect profile and are not recommended


British Thoracic Society Guidelines – Acute Cough Pharmacotherapy


• Non-sedating opiate which is a component of many over-the-counter cough remedies

• The general recommended dosage is probably sub-therapeutic

• There is a dose response, and maximum cough reflex suppression occurs at 60 mg and can be prolonged

Dextromethorphan

• Menthol by inhalation suppresses the cough reflex and may be prescribed as menthol crystals BPC or in the form of proprietary capsules

• Cough suppression is acute and short lived

Menthol

• First generation antihistamines with sedative properties suppress cough but also cause drowsiness. They may be a suitable treatment for nocturnal cough

Sedative antihistamines

• These opiate antitussives have no greater efficacy than dextromethorphan but have a much greater adverse side effect profile and are not recommended

Codeine


Subacute Cough


Subacute Cough

• When cough is subacute and not associated with an obvious respiratory infection, evaluate patients in the same way as those with chronic cough

• For a cough that began with an upper respiratory tract infection and has lasted for 3 to 8 weeks, the most common conditions to consider are post-infectious cough, bacterial sinusitis, and asthma

• When a patient presents with wheezes, rhonchi, or crackles on physical examination, a chest radiograph should be obtained

Post-infectious cough: Cough that begins with an acute respiratory tract infection that is not complicated by pneumonia (i.e., the chest radiograph is normal) and that ultimately resolves without treatment. It may result from postnasal drip or clearing of the throat due to rhinitis,

tracheobronchitis, or both, with or without transient bronchial hyper-responsiveness



UACS: upper airway cough syndrome; AECB: acute exacerbation of chronic bronchitis; GERD: gastroesophageal reflux disease; NAEB: non-asthmatic eosinophilic bronchitis; COPD: Chronic obstructive pulmonary disorder

Sub-Acute cough

History and physical examination, environmental and occupational factors,

travel exposures + ask about red flags

Not post infectious

New onset or exacerbation of pre-existing condition

Consider TB in endemic areas or

high risk

Pneumonia, severe exacerbation of

asthma or COPD, PE, heart failure, other

serious disease

Evaluate and treat

first

Workup same as chronic

cough

Post infectious or life

threatening diagnosis

Asthma

Bronchiectasis

UACS

Other

Bronchitis

GERD

NAEBAECB/COPDPertussis

TB Post-infection

COPD



Important Reminders and Red Flags

• Check for red flags

• Routinely assess cough quality of life or cough severity with validated tool


Reminders







Red flags



Chronic Cough


Chronic Cough

Chronic cough can result simultaneously from more than one condition (as is the case in 18 to 93% of instances),

therefore therapy that is partially successful should not be stopped but should instead be sequentially supplemented

Recommendation for evaluation of chronic cough: A systematic evaluation that initially assesses the most common causes by means of trials of empirical therapy and trials involving the avoidance of irritants and drugs, along with focused laboratory testing (e.g., chest radiography or methacholine challenge), and if required, additional testing and consultation with a specialist

The definitive diagnosis of the cause of chronic cough is established on the basis of an observation of which specific therapy eliminates the cough



Clinical Evaluation of Chronic Cough

Review the patient’s history and do a physical examination and

focus on the most common causes of chronic cough (i.e.,

postnasal-drip syndromes, asthma, and gastroesophageal

reflux disease)

Obtain a chest radiograph. Determine whether the symptoms

conform to the clinical profile that is usually associated with a diagnosis

of postnasal-drip syndrome, asthma, gastroesophageal reflux disease or eosinophilic bronchitis, alone or in

combination

If the cough is productive of blood, evaluate according to

published guidelines for hemoptysis

If the patient has a history of smoking or of exposure to other

environmental irritants or is currently being treated with an angiotensin-converting–enzyme inhibitor, eliminate the irritant or discontinue the drug for 4 weeks

In the absence of exposure to irritants, a diagnosis of chronic bronchitis is untenable even if

the cough is productive

A definitive diagnosis can be made only when cough responds

to specific therapy



Common Causes of Chronic Cough

Postnasal drip syndrome is the most

common cause of chronic cough

The outcome of specific therapy will depend on

the determination of the correct cause and the choice of the correct

specific therapy

The differential diagnosis of postnasal-drip syndrome includes sinusitis and the following types of rhinitis,

alone or in combination: non-allergic, allergic, post-

infectious, vasomotor, drug-induced, and environmental-

irritant–induced



UACS: upper airway cough syndrome; AECB: acute exacerbation of chronic bronchitis; NAEB: non-asthmatic eosinophilic bronchitis; COPD: Chronic obstructive pulmonary disorder; ACEI: angiotensin-converting enzyme inhibitor; A/D: antihistamine/decongestant; BD: bronchodilator; HRCT: high-resolution CT; ICS: inhaled corticosteroid; LTRA: leukotriene antagonist; PPI: proton pump inhibitor

Chronic cough

History to include red flags, environmental and occupational factors, travel exposuresPhysical exam and chest radiograph

Smoking, ACEI,

Sitagliptin

Investigate and treat

Discontinue for at least 4

weeks

A cause of cough is suggested or concern for life threatening condition

4 most common causes to consider:1. Upper Airway Cough Syndrome (UACS) secondary to rhinosinus diseasesConsider: • Sinus imaging• Naso-pharyngoscopy• Allergy evaluation or empiric treatment2. AsthmaIdeally evaluate:• Spirometry• Bronchodilator reversibility• Broncho-provocation challenge• Allergy evaluation or empiric treatment

3. Non-asthmatic Eosinophilic Bronchitis (NAEB)Ideally evaluate:• Sputum eosinophilia• Fraction exhaled nitric oxide (FENO)• Allergy evaluation or empiric treatment4. Gastroesophageal Reflux Disease (GERD)Physiologic testing for refractory patients Initial treatment to include:• More than acid suppression

No response at 4-6 week

follow up

Initial treatments:• UACS: A/D• Asthma – ICS, BD, LTRA, trigger avoidance• NAEB – ICS, Trigger avoidance• GERD – PPI, diet/lifestyle changes (Treatment of GERD should not be limited to acid suppression

Inadequate response to optimal treatment, follow up 4-6 weeks

Inadequate response to optimal treatment, follow up 4-6 weeks

Further investigations (next slide)



Reminders and Further Investigations

• Check for red flags and address them

• Optimize therapy for each diagnosis

• Check compliance during regularly scheduled and frequent follow ups (assess for patient barriers to enactment or receipt of instructions)

• Due to the possibility of multiple causes, maintain all partialIy effective treatment

• Routinely assess for environmental and occupational factors

• Routinely assess cough severity & quality of life with validated tools


• Consider a referral to a Cough Clinic for refractory cough

Reminders

• UACS: A/D• Asthma – ICS, BD, LTRA, trigger avoidance• NAEB – ICS, Trigger avoidance• GERD – PPI, diet/lifestyle changes (Treatment of GERD should not be limited to acid suppression

Further investigations



Red flags for Chronic Cough







Red flags



British Thoracic Society Guidelines – Chronic Cough


One of the commonest causes of persistent cough is smoking, which appears to be dose related. Patients often state that their cough changes in character with smoking cessation

A chest radiograph should be undertaken in all patients with chronic cough and those with acute cough demonstrating atypical symptoms

Note all medications, particularly ACE inhibitors, and consider which might be causing or potentiating the cough. The cough may take some months to settle following withdrawal of ACE inhibitors

Chronic cough is a common association of respiratory diseases and a thorough respiratory history should be sought

Interpretation of the diagnostic characteristics of the cough should be done with caution

Chronic cough is more likely to occur in middle aged women


Pitfalls in Managing Chronic Cough

Asthma

• Failure to recognize it as a syndrome ofcough and phlegm

• Failure to recognize that inhaled medicationsmay exacerbate cough

• Assuming a positive result of methacholinechallenge alone is diagnostic of asthma

Post nasal drip

• Failure to recognize it as a syndrome of cough and phlegm

• Assuming all H1 antagonists are the same• Failure to consider sinusitis (being not obvious)• Failure to consider allergic rhinitis and

recommend avoidance of allergens (as symptoms are perennial)

GERD

• Failure to recognize it as a syndrome of cough and phlegm

• Assuming that cough cannot be due to GERD because it remains unchanged when GI symptoms improve

• Failure to recognize effects of co-existing diseases or their treatment

• Failure to adequately treat co-existing causes of cough that perpetuate the cycle of cough



Take Home Messages

• Cough is a symptom with many facets: a protective mechanism for the lungs, a warning sign of disease, and a detrimental symptom when persistent

• It is one of the most common symptoms for which patients seek medical attention from primary care physicians and pulmonologists

• Viral infections of the upper respiratory tract are the most common causes of acute cough

• Nearly all conditions affecting the respiratory system may cause cough, but to the physician it is most important to exclude the most serious conditions that need prompt treatment

• With a systematic approach based on guidelines, it should be possible to diagnose and treat cough successfully in the majority of cases

• Chronic cough is a common association of respiratory diseases and a thorough respiratory history should be sought

Irwin RS, Madison JM. The diagnosis and treatment of cough. New England Journal of Medicine. 2000 Dec 7;343(23):1715-21..Chung KF, Widdicombe JG, Boushey HA, editors. Cough: causes, mechanisms and therapy. John Wiley & Sons; 2008 Apr 15.Morice AH, McGarvey L, Pavord I. Recommendations for the management of cough in adults. Thorax. 2006 Sep 1;61(suppl 1):i1-24.McGarvey LP. Cough• 6: Which investigations are most useful in the diagnosis of chronic cough?. Thorax. 2004 Apr 1;59(4):342-6.

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