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Sankey

Follow The Female Patienton and The Female Patient | V 36 MAY 2011 25

OCSPOINT

A well-known but

oten overlooked

cause o chronic

cough is

angiotensin-

convertingenzyme inhibitors.

ACEi and is more common in women. It be-gins after approximately 3 weeks of treat-ment with ACEi and abates within days ofdiscontinuation.5 Other medications canhave a side eect of cough and need to beconsidered, including a common treatmentfor gastroesophageal reux disease (GERD),omeprazole.6

Unless there are obvious ndings on ex-amination, such as wheezing and retrac-tions in asthma, a chest x-ray is importantin ruling out neoplasm or pneumonia. If

the chest x-ray is negative, then there are 4diagnoses that account for up to 90% ofcases of chronic cough and should be con-sidered: asthma, nonasthmatic eosino-philic bronchitis, GERD, and upper airwaycough syndrome (formerly known as post-nasal drip).7

ASTHMAAsthma is a chronic inammatory disease,often worsened by certain stimuli, thatcauses airway obstruction and is reversiblewith treatment.8 Classic asthma presents

with symptoms of wheezing, shortness of

breath, chest tightness, cough with or with-out sputum, and breathlessness. e symp-toms are usually worse at night and early inthe morning. An acute episode is often inresponse to an environmental irritant suchas smoke, exercise, or an allergen.

However, asthma can present as a coughalone (cough-variant asthma) without othersymptoms. is cough occurs most com-monly at night, and studies on quality of lifein patients with asthma have found that thecough is often more troublesome for patients

than any other symptom.9

e physical nd-ings may be absent in between episodes, soit is important to consider asthma in the dif-ferential for a chronic cough with no obvioussource. e diagnosis is made through spi-rometry and documentation of the revers-ibility of the airway obstruction.1,10 First-linetreatment for asthma is with inhaled bron-chodilators and inhaled corticosteroids.11

NONASTHMATICEOSINOPHIIC BRONCHITISIn patients who have a chronic cough with-

out airow obstruction or hyperresponsive-

TABE 1. Questions to Ask in Evaluation o Chronic Cough

Cough Characteristics

What type of cough is it (productive vs dry)?

How often does it occur (frequency)? When is it worse?

Are there any associated symptoms (wheezing, shortness of breath)?

When did it start?

Does anything relieve the cough?

Are there any inciting factors (nighttime, cold exposure)?

Possible Related Symptoms

Do you have heartburn or reflux?

Have you gained or lost weight recently?

Have you had any fevers or night sweats?

Do you ever notice a postnasal drip or nasal congestion?

Aggravating Factors

Do you smoke?

Have you been exposed to any respiratory irritants at work or home?

Do you have any environmental allergies?

Do you know of any exposure to tuberculosis or pertussis?

Have there been any major changes in your environment, diet, or lifestyle?

What medications are you currently taking?

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26 The Female Patient | V 36 MAY 2011 All articles are available online at www.femalepatient.com.

Chronic Cough in Women

ness, the diagnosis of nonasthmatic eosino-philic bronchitis should be considered.ese patients will demonstrate elevatedlevels of eosinophils in the sputum. In thiscase, the rst step is to remove all environ-mental irritants. Inhaled bronchodilatorsare not eective with this disorder, but in-haled corticosteroids are associated withimproved symptoms.12

UPPER AIRWA COUGH SNDROMEPreviously known as postnasal drip syn-drome, upper airway cough syndrome(UACS) is now referred to when discussing

cough due to upper airway symptoms.

13

Pa-tients will frequently report congestion, adripping sensation at the back of thethroat, a hoarse voice, or a need to clear thethroat.

ere are a small number of patients whodo not report these kinds of symptoms butrespond to antihistamine therapy. ere isno pathognomonic nding on history orphysical exam, but if there are ndings thatlead to a specic cause for the UACS-induced cough, then targeted therapyshould be instituted.

Empiric therapy with a rst-generationantihistamine such as diphenhydramineand a decongestant can be tried when thereis either an unexplained cough or a coughwith signs and symptoms suggestive ofUACS. e rst-generation antihistaminesare preferable for the treatment of cough,because they have a centrally acting antitus-sive eect in addition to the eect on centraland peripheral histamine receptors.

TABE 2. Diet and iestyleChanges or Chronic Cough

1. Stop smoking

2. Avoid or cut back on: Alcohol

Mints

Chocolate

Coffee

Caffeinated drinks

Citrus, including tomato

3. Minimize vigorous exercise thatincreases intra-abdominal pressure

Coding or Chronic Cough in Women Philip N. Eskew Jr, MD

he case describes a 45-year-old woman in the office for her

annual exam who complains of a dry cough.

he CP code for this encounter is:

99396 Periodic comprehensive preventive medicine reevalu-

ation and management of an individual including an

age and gender appropriate history, examination,

counseling/anticipatory guidance/risk factor reduction

interventions, and the ordering of laboratory/diagnos-

tic procedures, established patient; 40-64 years

Since the patient has a symptom that requires additional physi-

cian work, the physician should document the process involved

in the work-up of this condition. his should be in a separate

note detailing the additional history obtained, the additional

physical examination performed, and the ordering of any tests

to support the diagnosis. his additional physician work can be

coded as a 99213, in addition to the annual examination code.

Or, the physician can just code for the annual examination and

order a chest x-ray and have the patient return for a follow-up

office visit. his should depend on the patients insurance cover-

age, as some payors will not pay for additional services at the

time of an annual examination visit.

he ICD-9 code for symptoms mentioned in the article are:

786.2 Cough (also the code for chronic cough)

033.9 Whooping cough, unspecified organism (Pertussis)

491.0 Simple chronic bronchitis, Smokers cough

493.9 sthma, unspecified

518.3 Pulmonary eosinophilia, osinophilic asthma

530.81 sophageal reflux (GD)

784.91 Postnasal drip (now called pper irway

Cough Syndrome)

Philip N. Eskew Jr, MD, is past member, Current Procedural

Terminology (CPT)ditorial Panel; past member, CPTdvisory

Committee; past chair, COG Coding and Nomenclature Com-

mittee; and instructor, CPTcoding and documentation courses

and seminars.

(continued on page 29)

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Complaint: Chronic Cough

If no obvious findingschest x-ray

If on an ACEi, thenswitch to an alternative

antihypertensive therapy

If a smoker, then counselpatient to quit smoking

If findings treat If no findings, then evaluate or institute a trial oftherapy (consider the history and physical find-ings and the individual risk of each therapeutic

option for this patient) based on most likely

HISTORY AND PHYSICAL EXAM

Sankey

Follow The Female Patienton and The Female Patient | V 36 MAY 2011 29

GASTROESOPHAGEA REFUx DISEASEGERD is the third most common cause ofchronic cough.14 Symptoms associated withgastroesophageal reux may aect as manyas 20% of Americans daily.15 Commonly,women with GERD will notice heartburnthat is worse when lying down, after a fullmeal, and at night. Patients with these typi-cal GERD symptoms should have a trial of ahigh-dose proton pump inhibitor (PPI) for 1to 3 months.1,7 Endoscopy and ambulatory

pH monitoring are the traditional tests usedfor making the diagnosis and assessing thedamage from GERD, but they have not beenfound as helpful in patients with coughcaused by reux.7

In addition to medical treatment, patientsshould be educated about dietary and life-style changes (Table 2).16 If possible, theyshould stop intake of all foods that canworsen GERD or reux, for at least a periodduring which the impact on their cough canbe assessed. ese foods, along with smok-ing, all lower the pressure in the lower

esophageal sphincter and increase reux.

Many patients who have a chronic coughdue to reux disease will respond to treat-ment with a PPI. ere is a group who willnot respond to treatment despite adequateacid suppression. ese patients may bemore likely to have a cough during the dayand while upright. Recently it has been pos-tulated that nonacidic reux, known as la-ryngopharyngeal reux, may be the sourceof cough in these patients.17

Some patients who have undergone fun-

doplication after failed medical treatmentnoted successful resolution of their coughfollowing the surgery. Multichannel intralu-minal impedance testing has recently beensuggested as a way to identify patients withnonacidic reux who may be candidates foran alternate medical treatment such as pro-kinetic therapy (baclofen or metoclopra-mide) or surgery.15

SUMMARChronic cough can be aggravating for pa-tients and dicult to diagnose. A stepwise,

organized approach, such as listed in the

Abbreviations: ACEi, angiotensin-converting enzyme inhibitors; GERD, gastroesophageal reflux disease; PPI, proton pump inhibitor; UACS,upper airway cough syndrome.

(1) Asthma suspectedspirometry

(2) UACS Empirictreatment with first-generation antihistamineand decongestant

(3) GERD Empirictreatment with high-dose PPI; dietarychanges

(4) Nonasthmatic eosino-philic bronchitisenvironmental changes;inhaled corticosteroids

FIGURE. Algorithm for work-up of chronic cough.

(continued from page 26)

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30 The Female Patient | V 36 MAY 2011 All articles are available online at www.femalepatient.com.

Chronic Cough in Women

Figure, will result in successful resolution ofthe cough for most women.

Te author reports no actual or potential

conict of interest in relation to this article.

REFERENCES1. Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis

and management of cough, executive summary:ACCP evidence-based clinical practice guidelines.Chest. 2006;129(1 Suppl):S1-S23.

2. Irwin RS, Madison JM. The diagnosis and treatmentof cough. N Engl J Med. 2000;343(23):1715-1721.

3. Chung KF, Pavord ID. Prevalence, pathogenesis, andcauses of chronic cough. Lancet. 2008;371(9621):1364-1374.

4. Kretsi nger K, Broder KR, Cortese MM, et al; CDC.

Preventing tetanus, diphtheria, and pertussis amongadults: use of tetanus toxoid, reduced diphtheria tox-

oid and acellular pertussis vaccine recommenda-tions of the Advisory Committee on ImmunizationPractices (ACIP) and recommendation of ACIP, sup-

ported by the Healthcare Infect ion Control PracticesAdvisory Committee (HICPAC), for use of Tdapamong health-care personnel. MMWR Recomm Rep.2006;55(RR-17):1-37.

5. Vegter S, de Jong-van den Berg LT. Misdiagnosis and

mistreatment of a common side-effectangiotensin-converting enzyme inhibitorinduced cough. Br JClin Pharmacol. 2010;69(2):200-203.

6. Reiche I, Trger U, Martens-Lobenhoffer J, et al.Omeprazole-induced cough in a patient with gastro-esophageal reflux disease. Eur J Gastroenterol Hepa-tol. 2010;22(7):880-882.

7. Frye JW, Vaezi MF. Extraesophageal GERD. Gastroen-terol Clin North Am. 2008;34(4):845-858.

8. Dombrowski MP, Schatz M. Asthma in pregnancy.Clin Obstet Gynecol. 2010;53(2):301-310.

9. Smith JA. Interrupting the cough reflex in asthma.Curr Opin Allergy Clin Immunol. 2010;10(1):77-81.

10. Kaplan AG, Balter MS, Bell AD, Kim H, McIvor RA.Diagnosis of asthma in adults. CMAJ. 2009;181(10):E210-E220.

11. Fanta CH. Drug therapy: asthma. N Engl J Med.2009;360(10):1002-1014.

12. Desai D, Brightling C. Cough due to asthma, cough-variant asthma and non-asthmatic eosinophilic bron-chitis. Otolaryngol Clin North Am. 2010;43(1):123-130.

13. Pratter MR. Chronic upper airway cough syndromesecondary to rhinosinus diseases (previously referredto as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1

Suppl):63S-71S.14. Hersh MJ, Sayuk GS, Gyawali CP. Long-term thera-

peutic outcome of patients undergoing ambulatorypH monitoring for chronic unexplained cough.J ClinGastroenterol.2010;44(4):254-260.

15. Merati AL. Reflux and cough. Otolaryngol Clin NorthAm. 2010;43(1):97-110.

16. Kahrilas PJ. Clinical practice. Gastroesophagealreflux disease. N Engl J Med. 2008;359(16):1700-1707.

17. McGarvey LP, Elder J. Future directions in treatingcough. Otolaryngol Clin North Am. 2010;43(1):199-211.

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