CHRONIC COUGH
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Transcript of CHRONIC COUGH
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CHRONIC COUGH
EVELYN VICTORIA E. RESIDE, MD., FPCP., FPCCP.Section of Pulmonary Medicine
The Medical City
ATENEO SCHOOL OF MEDICINEAND PUBLIC HEALTH
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SESSION OUTLINE
• Definition of terms• Etiologies• Burden of illness• Diagnostic algorithm• Summary
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DEFINITION OF TERMS
• ACUTE– < 3 weeks
• SUBACUTE– Between 3 and 8 weeks
• CHRONIC– > 8 weeks
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DEFINITION OF TERMS
• COUGH– A rapid expulsion
of air from the lungs, typically in order to clear the lungs
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ETIOLOGIES
• Bronchial Asthma, Cough Variant Asthma• GERD or LPR• Postnasal Drip Syndrome or Chronic Upper
Airway Cough Syndrome (UACS)• Pulmonary tuberculosis
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DISEASE BURDEN
• Among 284 cases seen:– Asthma 33.3% – UACS in 30.4%– PTB in 20.3%– GERD in 3.8%
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• May be due to – One condition 93% of the time– Two conditions 53% of the time– Three conditions 35% of the time– Four conditions 4% of the time
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• Clinical profile of patients with chronic cough due to asthma, UACS, GERD:– Patients complain of coughing– Patients are immunocompetent – Patients have a normal or near-normal chest Xray– Patients are nonsmokers and without significant
environmental exposures– Patients are not taking an ace inhibitor
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THE PHILIPPINE TASK FORCE ON CHRONIC COUGH
THE UNIFIED ALGORITHM:
Jennifer Mendoza-Wi, MD., FPCCP.Liza Llanes-Garcia, MD., FPCCP.
Camilo Roa, MD., FPCCP.Abundio Balgos, Jr., MD., FPCCP
Consuelo Obillo, MD., FPCCP.Rosauro Valenzuela, MD., FPCCP.
Evelyn Victoria Reside, MD., FPCCP.
With contributions from Dr. Richard Irwin(Immediate Past President, ACCP)
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THE PHILIPPINE TASK FORCE ON CHRONIC COUGH
CHRONIC UPPER AIRWAY COUGH SYNDROME:
Zenaides Wi, MD., FPSO-HNS.Cesar Villafuerte, MD., FPSO-HNS.Joselito Acuin, MD., FPSO-HNS.
WilliamLim, MD., FPSO-HNS.Madeleine Sumpaico, MD., FPSAII.
Eileen Alikpala-Cuajunco, MD., FPSAII.
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THE PHILIPPINE TASK FORCE ON CHRONIC COUGH
BRONCHIAL ASTHMA:
Liza Llanes-Garcia, MD., FPCCP.Dina Diaz, MD., FPCCP.
Camilo Roa, MD., FPCCP.
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THE PHILIPPINE TASK FORCE ON CHRONIC COUGH
GASTROESOPHAGEAL REFLUX (GERD):
Carla Sibulo, MD., FPSG.Gozaar Duque, MD., FPSG.Jaime Ignacio, MD., FPSG.
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THE UNIFIED DIAGNOSTIC ALGORITHM
Cough ≥ 2 weeks Normal CXR
History and PE
History of ACE-inhibitor intake, smoking & exposure
to occupational irritants
Stop ACE-inhibitor for 4 wks Smoking cessation
Avoid exposure
Cough gone
Ace-Induced Cough Smokers’ cough Or Irritant cough
YESNO
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Cough gone
NO
NO
Hx of TB exposure
PTB suspect
Initiate specific
treatment
3 sputum AFB smears
YES
Evaluate & treat for the Pathogenic Triad:
(1) Asthma, (2) UACS and/or (3)GERD
Response to treatment
UACS,Asthma
and/or GERD
YES
Cough gone
YESOptimize treatment
and consider overlapping etiologies
NO
NO
AFB smears (+)
Repeat Chest RadiographNO
Treat as TB
YES
Cough gone
YES
ON
PTB
Treatment Modification
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Repeat Chest Radiograph Normal CXR
Order according to likely clinical
possibility
Sputum cytology, HRCT scans, Modified BaE, Bronchoscopy,
Cardiac Studies
Treat Specific Conditions
Accordingly
Post-infectious Cough or Psychogenic Cough
YES
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LET’S PLAY A GAME!
WINNER: 10 POINTS2ND PLACE: 9 POINTS
3RD PLACE: 8.5 POINTS4TH PLACE: 8 POINTS
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DIAGNOSTIC ALGORITHM FOR CHRONIC COUGH & GERD
Chronic Cough
GERD Symptoms
Empiric treatment with acid suppressants
Improved?Continue treatment
Refer to Gastroenterologist
Y
Y
N
Y
Alarm Symptoms?
N Y
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FLOW IN THE DIAGNOSIS OF CHRONIC COUGH & CHRONIC UPPER AIRWAY COUGH SYNDROME
Allergic Rhinitis
Chronic Cough and Possible Chronic Upper
Airway Cough Syndrome
Non-Allergic Rhinitis
Rhinosinusitis Tonsillopharyngitis
Laryngopharyngeal Reflux
History Physical exam
Diagnostics: (+) Family history,
response to empiric treatment, allergy skin tests
Therapeutics: Environmental control,
antihistamines, nasal steroids, immunotherapy, surgery
Diagnostics: Sinus Xrays,
Sinus CT scan Therapeutics:
Antibiotics, decongestants,
mucolytics, surgery
Diagnostics: History and
Physical Exam Therapeutics: Antibiotics,
surgery
Diagnostics: Empiric therapy,
24-hr pH monitoring, Impedance
measurement Therapeutics: Proton pump
inhibitors
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DIAGNOSTIC ALGORITHM FOR CHRONIC COUGH AND ASTHMA
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SUMMARY
• History and PE !– ACE inhibitor treatment and cigarette smoking– When dealing with acute cough, rule out life-threatening
conditions, exacerbations of chronic illness or environmental/occupational exposure
• Non-infectious causes of subacute cough are managed in the same way as chronic cough
• Initial empiric treatment of chronic cough is a combination antihistamine + decongestant
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SUMMARY
• Stepwise approach towards the diagnosis – More than one etiology of cough can be present
• If cough is due to ACE inhibitor intake, the drug should be stopped and replaced
• If cough continues to persist, refer to a specialist!