Cough

Core Clinical Core Clinical ProblemsProblems

CoughCough

A man presents to A man presents to you with coughingyou with coughingWhat would you like to know?What would you like to know?

CoughCough Onset?Onset? Duration?Duration? Character? Character? Nocturnal?Nocturnal? Precipitating factors?Precipitating factors? Relieving factors?Relieving factors? Sputum?Sputum? Haemoptysis?Haemoptysis? Association?Association?


Recent or long standing Recent or long standing (Chronic)(Chronic)


ChronicityChronicity PertussisPertussis TBTB Foreign bodyForeign body AsthmaAsthma DrugsDrugs BronchiectasisBronchiectasis ILDILD

CoughCough Onset?Onset? Duration?Duration? Character?Character? Nocturnal?Nocturnal? Precipitating factors?Precipitating factors? Relieving factors?Relieving factors? Sputum?Sputum? Haemoptysis?Haemoptysis? Association?Association?

Brassy?Brassy?

Pressure on the trachea?Pressure on the trachea?


Hollow/Bovine?Hollow/Bovine?

Laryngeal nerve palsy Laryngeal nerve palsy causing vocal cord causing vocal cord dysfunctiondysfunction


Barking?Barking?

Acute Epiglottitis Acute Epiglottitis


Dry?Dry? GORDGORD Drugs (e.g. ACEI)Drugs (e.g. ACEI)


Change in character of a Change in character of a chronic cough should chronic cough should make you consider other make you consider other pathology.pathology.


AsthmaAsthma

Also Early morningAlso Early morning


Usually in asthmaUsually in asthma EmotionEmotion WeatherWeather

Wind Wind RainRain ColdCold

DustDust AllergiesAllergies ExerciseExercise DrugsDrugs


Avoidance of Avoidance of precipitating factors!precipitating factors!


Presence?Presence? ColourColour VolumeVolume ConsistencyConsistency PatternPattern

Consider Consider InfectionsInfections COPDCOPD CFCF BronchiectatsisBronchiectatsis


Presence?Presence? ColourColour VolumeVolume ConsistencyConsistency PatternPattern

Will be covered Will be covered elsewhere!elsewhere!


BreathlessnessBreathlessness SputumSputum Chest painChest pain WheezeWheeze HoarsenessHoarseness Post nasal dripPost nasal drip

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Meet Mr Coughing

61 years old

PresentationPresentation Cough productive of white sputum most Cough productive of white sputum most

days over the past 2 yearsdays over the past 2 years Life long smoker (30 per day)Life long smoker (30 per day) Gets breathless going up the stairsGets breathless going up the stairs

Mr Coughing 61

What do you think he What do you think he has?has?

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1.1. AsthmaAsthma2.2. COPDCOPD3.3. Lung CancerLung Cancer4.4. SarcoidSarcoid5.5. RhinitisRhinitis

What test would you like What test would you like next?next?

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0% 0% 0%0%0%

1.1. SpirometrySpirometry2.2. Spirometry with Spirometry with

reversibilityreversibility3.3. Chest x-rayChest x-ray4.4. Peak flow diaryPeak flow diary5.5. Sputum cytologySputum cytology

What test would you like What test would you like next?next?

1.1. SpirometrySpirometry2.2. Spirometry with Spirometry with

reversibilityreversibility3.3. Chest x-rayChest x-ray4.4. Peak flow diaryPeak flow diary5.5. Sputum cytologySputum cytology

Confirm obstructive Confirm obstructive picturepicture

Assess severityAssess severity Lack of reversibility Lack of reversibility

more often found in more often found in COPD than asthmaCOPD than asthma

Mr Coughing 61

How would you like to How would you like to treat him?treat him?

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1.1. Smoking cessationSmoking cessation2.2. Smoking cessation plus Smoking cessation plus

CombiventR 2 puffs CombiventR 2 puffs QDSQDS

3.3. Beclomethasone 200 2 Beclomethasone 200 2 puffs BDpuffs BD

4.4. Pulmonary Pulmonary RehabilitationRehabilitation

5.5. Salbutamol 2 puffs PRNSalbutamol 2 puffs PRN

Unwell!Unwell! He becomes unwell with fevers, sweats, He becomes unwell with fevers, sweats,

increasing cough and sputum volume.increasing cough and sputum volume. Sputum is now greenSputum is now green He also complains of right sided pleuritic He also complains of right sided pleuritic

chest pain and had a few crackles at the chest pain and had a few crackles at the right base on chest auscultationright base on chest auscultation

Mr Coughing 61

What do you think has What do you think has happened?happened?

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1.1. Lung carcinomaLung carcinoma2.2. Lower respiratory Lower respiratory

tract infectiontract infection3.3. Upper respiratory Upper respiratory

tract infectiontract infection4.4. PneumothoraxPneumothorax5.5. Pulmonary Pulmonary

EmbolismEmbolism

This is his CXRThis is his CXR

Mr Coughing 61

www.meddean.luc.edu/.../pulmonar/cxr/segm.htm

How would you like to How would you like to treat him?treat him?

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1.1. OxygenOxygen2.2. NebulisersNebulisers3.3. AntibioticsAntibiotics4.4. PrednisolonePrednisolone5.5. All of theseAll of these

6 months later…6 months later… After making a good recovery, he presents 6 After making a good recovery, he presents 6

months later to his GP who asks you to see months later to his GP who asks you to see him at your out patient chest clinichim at your out patient chest clinic

You note that he has had at least 3 chest You note that he has had at least 3 chest infections since his discharge from hospital.infections since his discharge from hospital.

He still smokes!He still smokes! Examining him you note finger clubbing, Examining him you note finger clubbing,

bilateral inspiratory coarse crackles at the lung bilateral inspiratory coarse crackles at the lung bases on chest auscultationbases on chest auscultation

Mr Coughing 61

What investigation would What investigation would you like next?you like next?

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1.1. CT chestCT chest2.2. High Resolution High Resolution

CT chest (HRCT)CT chest (HRCT)3.3. Arterial Blood Arterial Blood

GasesGases4.4. Pulmonary Pulmonary

Function testsFunction tests5.5. BronchoscopyBronchoscopy

This is his HRCTThis is his HRCT

Mr Coughing 61

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What is the diagnosis?What is the diagnosis?

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1.1. Pulmonary fibrosisPulmonary fibrosis2.2. Hypersensitivity Hypersensitivity

PneumonitisPneumonitis3.3. Lung cancerLung cancer4.4. LymphangioleiomLymphangioleiom

yomatosisyomatosis5.5. BronchiectasisBronchiectasis

One year later…One year later… Mr coughing notices that his cough has Mr coughing notices that his cough has

changed character over the past couple changed character over the past couple of weeksof weeks

He has also noticed 5kg weight loss over He has also noticed 5kg weight loss over the past month and had one episode of the past month and had one episode of haemoptysis a week agohaemoptysis a week ago

Mr Coughing 61

This is his CXRThis is his CXR

Mr Coughing 61

What should you do next?What should you do next?

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1.1. Sputum cytologySputum cytology2.2. Sputum Sputum

microscopymicroscopy3.3. Bronchoscopy and Bronchoscopy and

CT chest stagingCT chest staging4.4. Lateral CXRLateral CXR5.5. Give him Give him

Tranexaemic acidTranexaemic acid

This is his BronchoscopyThis is his Bronchoscopy

Mr Coughing 61

Where is the tumour?Where is the tumour?

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1.1. Left Upper LobeLeft Upper Lobe2.2. Bronchus Bronchus

intermediusintermedius3.3. Right middle lobeRight middle lobe4.4. Right lower lobeRight lower lobe5.5. Left Lower lobeLeft Lower lobe

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Mrs Coughing 49

www.tbalert.org/resources/resources.php

HistoryHistory This 49-years-old lady has had a dry This 49-years-old lady has had a dry

cough for a few months.cough for a few months. Her BMI is 36Her BMI is 36 She doesn’t smokeShe doesn’t smoke She takes Gaviscon plus a tablet for her She takes Gaviscon plus a tablet for her

blood pressure which she can’t recallblood pressure which she can’t recall

Mrs Coughing 49

Which of the following blood Which of the following blood pressure tablets might be relevant pressure tablets might be relevant in her symptoms?in her symptoms?

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1.1. RamiprilRamipril2.2. BendrofluazideBendrofluazide3.3. NifedipineNifedipine4.4. AtenololAtenolol5.5. None of them!None of them!

Which of the following Which of the following Blood pressure tablets Blood pressure tablets might be relevant in her might be relevant in her symptoms?symptoms?


Mrs Coughing 49

Which of the following Which of the following Blood pressure tablets Blood pressure tablets might be relevant in her might be relevant in her symptoms?symptoms?1.1. RamiprilRamipril

2.2. BendrofluazideBendrofluazide3.3. NifedipineNifedipine4.4. AtenololAtenolol5.5. None of them!None of them!

ACE inhibitors are ACE inhibitors are known to cause known to cause cough by inhibiting cough by inhibiting the breakdown of the breakdown of BradykininBradykinin

Mrs Coughing 49

Which of the following Which of the following Blood pressure tablets Blood pressure tablets might be relevant in her might be relevant in her symptoms?symptoms?


Beta Blockers can Beta Blockers can worsen or precipitate worsen or precipitate underlying asthmaunderlying asthma

Mrs Coughing 49

More historyMore history She tells you that her cough is quite bad She tells you that her cough is quite bad

first thing in the morning and sometimes first thing in the morning and sometimes wakes her up during the nightwakes her up during the night

She also wheezes whenever she tries to She also wheezes whenever she tries to catch the buscatch the bus

Mrs Coughing 49

This is her SpirometryThis is her Spirometry FEV1 FEV1 1.6L (76%)1.6L (76%) FVCFVC 2.4L (83%)2.4L (83%) FEV1/FVC FEV1/FVC 67%67%

Mrs Coughing 49

How would you treat her?How would you treat her?

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1.1. Salbutamol 2 puffs Salbutamol 2 puffs PRNPRN

2.2. Salbutamol 2 puffs Salbutamol 2 puffs PRN + Becotide 200 2 PRN + Becotide 200 2 puffs B.D.puffs B.D.

3.3. Nebulised SalbutamolNebulised Salbutamol4.4. Theophylline Theophylline 5.5. TiotropiumTiotropium

How would you treat her?How would you treat her?1.1. Salbutamol 2 puffs Salbutamol 2 puffs

PRNPRN2.2. Salbutamol 2 puffs Salbutamol 2 puffs

PRN + Becotide 200 2 PRN + Becotide 200 2 puffs B.D.puffs B.D.

3.3. Nebulised SalbutamolNebulised Salbutamol4.4. Theophylline Theophylline 5.5. TiotropiumTiotropium

You need to give her You need to give her PEF meter and ask her PEF meter and ask her to keep a diaryto keep a diary

Review her in a weekReview her in a week Advise her to return Advise her to return

promptly if her promptly if her symptoms worsensymptoms worsen

Mrs Coughing 49

3 months later…3 months later… Your treatment has been helpful Your treatment has been helpful She has no cough during the night but She has no cough during the night but

still has a dry cough during the day still has a dry cough during the day occasionallyoccasionally

She also complains of quite bad She also complains of quite bad heartburn and indigestionheartburn and indigestion

Mrs Coughing 49

What would you advise?What would you advise?

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1.1. Life style measuresLife style measures2.2. Anti reflux treatmentAnti reflux treatment3.3. Dietary modificationDietary modification4.4. ExerciseExercise5.5. All of the aboveAll of the above

Miss Coughing 23

Their daughter!Their daughter! Usually keeps wellUsually keeps well Eczema as a childEczema as a child Presents with dry cough, lethargy and Presents with dry cough, lethargy and

generalised aches and painsgeneralised aches and pains She has also developed a painful red She has also developed a painful red

lesion on her left shin lesion on her left shin

Miss Coughing 23

Miss Coughing 23

www.patient.co.uk/showdoc/40001001/

What is your next step?What is your next step?

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1.1. Dermatology Dermatology referralreferral

2.2. Arrange skin Arrange skin biopsybiopsy

3.3. SpirometrySpirometry4.4. CXRCXR5.5. Peak Flow diaryPeak Flow diary

This is her CXRThis is her CXR

Miss Coughing 23

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What is the likely What is the likely diagnosis?diagnosis?

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1.1. TuberculosisTuberculosis2.2. Non Tuberculous Non Tuberculous

mycobacteriummycobacterium3.3. Breast cancerBreast cancer4.4. LymphomaLymphoma5.5. SarcoidosisSarcoidosis

This is their dogThis is their dog

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Just Kidding!Just Kidding!

Cough

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