CoughDiagnosis and Management

Dr Paul Plant

Consultant Chest Physician

I’m Coughing my lungs up Doc.

Areas To Cover

• Why do we Cough?

• Classification and Causes of Cough– Acute

– Subacute

– Chronic

• When and How to Investigate

• Management

• Case Study

What is Cough? ‘A Cough is a forced expulsive manoevere,

usually against a closed glottis and which is associated with a characteristic sound’

Classification of Cough

Three Categories of Cough

• Acute Cough = < 3 Weeks Duration

• Subacute Cough = 3 – 8 Weeks Duration

• Chronic Cough = > 8 Weeks Duration

Acute Cough

Acute Cough <3/52 Duration

Differential Diagnosis

• Upper Respiratory Tract infections:

Viral syndromes, sinusitis viral / bacterial

• URTI triggering exacerbations of Chronic Lung Disease eg Asthma/ COPD

• Pneumonia • Left Ventricular Heart Failure• Foreign Body Aspiration

Acute Cough Epidemiology

• Symptomatic URTI – 2-5 per adults per year– 7-10 per child per year

• 40-50% will have cough

• Self medication common -£24million per year

• 20% consult GP (2F:1M)

• Most resolve within 2 weeks

Duration of Cough in URTIPrimary Care SettingPrimary Care Setting

No antecedent or chronic lung diseaseNo antecedent or chronic lung disease

End of WeekEnd of Week % Coughing% Coughing

33 5858

44 3535

55 1717

66 8 8

*Jones FJ and Stewart MA, Aust Family *Jones FJ and Stewart MA, Aust Family Physician Vol. 31, No. 10, October 2002Physician Vol. 31, No. 10, October 2002

Sub-acute Cough

-Post viral cough

Managing Acute Cough

““Don’t just do something Don’t just do something stand there.”stand there.”

Alice in WonderlandAlice in Wonderland

Managing Acute CoughIdentify High Risk groups

Acute Cough Can be 1st Indicator of Serious

Disease

eg Lung ca, TB, Foreign Body, Allergy, Interstitial Lung disease

‘Chronic cough always preceded by acute

cough’.

Red Flags in Acute Cough

Symptoms• Haemoptysis• Breathlessness• Fever• Chest Pain• Weight Loss

Signs

Tachypnoea

Cyanosis

Dull chest

Bronchial Breathing

Crackles

THINK pneumonia, lung cancer, LVF

GET a CHEST X-Ray

Treatment of Simple Acute Cough

• Benign course -reassure

• Cough can distress

• Patients report OTC medication helpful

• Voluntary cough suppression -linctuses/ drinks

• Suppression of cough -dextromethorphan, menthol, sedating antihistamines & codeine

Which Anti-tussive?

Dextromorphaneg Benilyn non-drowsy

1 meta-analysis

high dose 60mg

beware combinations eg paracetomol

MentholSteam inhalation. Effect on

reflex short lived

Sedating Antihistaminesdanger sleepy - nocturnal cough

Codeine or PholcodeineNo better than dextromorphan

but more side-effects. Not recommended

Sub-Acute Cough

Sub-acute Cough 3-8 weeks

Likely Diagnoses• Postinfectious• Bacterial Sinusitis• Asthma• Start of Chronic Cough

• Don’t want to miss lung cancer

ACTIONS

•Examine Chest

•Chest X-Ray if signs or smoker

•Measure of airflow obstruction

ie peak flow -one off

peak flow -serial

spirometry

Post Infectious Cough

A cough that begins with an acute

respiratory tract infection and is not

complicated* by pneumonia

*Not complicated = Normal lung exam and normal chest X-ray

Post Infectious cough will resolve without treatment

Cause = Postnasal drip or Tracheobronchitis

Chronic Cough

Case Study -CP 2007• 60yr retd Nurse

• Chest infection 2002 in Spain -mild SOB since

• Chest infection 2006 -hospitalised for 4/7 antibiotics / steroids

• SOB and dry cough since

• No variation

• 4 lots of AB and steroids from GP plus tiotropium & oxis -no help for cough

• Wt climbing

• More SOB over 9/12

• Ex-smoker 30 pack yrs

• FEV1 0.97 43%

What else would you like to know?

What causes can you think of?

Chronic Cough Epidemiology

Epidemiology difficult -acute vs chronic

Cullinan 1992 Respir Med 86:143-9

n=9077

16% coughed on >50% days of year

13% coughed sputum on >50% days of year

54% were smokers

Chronic CoughEpidemiology

Associations with:

Smoking (dose related)

Pollutants (particulate PM10) -occupation

Environmental irritants (eg cat dander)

Asthma

Reflux

Obesity

Irritable bowel syndrome

Female

Making the DiagnosisCommon Differentials

Gastro-Oesophageal

Reflux

Post-nasal Drip-allergic rhinitis

-bacterial sinusitis

Lung Disease-normal CXR

-abnormal CXR

Non-structural

ACE-Inhibitors

Tobacco

Habit Cough

Chronic CoughInvestigating Chronic Cough

Purpose:

• To exclude structural disease

• To identify cause

How

History & Examination inc occupation

& Spirometry

ALWAYS GET A CHEST X-RAY

IN CHRONIC COUGH

Beware

Cough triggered by:

change in temperature

scent, sprays, aerosols and exercise

indicate

Increased cough reflex sensitivity

and Not just seen in Asthma.

Esp GORD, infection and ACEI

ACE-Inhibitors and Chronic Cough

Incidence: 5-20%

Onset: one week to six months

Mechanism

Bradykinin or Substance P increase

Usually metabolized by ACE)

PGE2 accumulates and vagal stimulation.

Treatment: switch to Angiotensin II Receptor Blockers (ARBs)

Gastro-oesophageal Reflux

GORD accounts alone or in combination for 10-40% of chronic cough

Two Mechanisms

a. Aspiration to larynx/ trachea

b. Acid in distal oesophagus stimulates vagus and cough reflex

Gastro-oesophageal Reflux Symptoms

GI Symptoms

If Aspiration main mechanism

Heart burn

Waterbrash/ Sour taste

Regurgitation

Morning Hoarseness

If Vagal - NO GI symptoms

Cough Features

Throat clearing

Worse at night / rising

On eating

Reflex hypersensitivity

CXR -normal or hiatus hernia

Spirometry normal

Gastro-oesophageal Reflux

Reflux may be due to Medications or Foods Reflux may be due to Medications or Foods

Drugs and foods that Drugs and foods that reducereduce lower esophageal lower esophagealsphincter (LES) pressure and can cause increasedsphincter (LES) pressure and can cause increasedreflux include:reflux include:

TheophyllineTheophylline Chocolate ChocolateOral Oral ββ adrenergic agonists adrenergic agonists Caffeine CaffeineNSAIDsNSAIDs Peppermint PeppermintAscorbic acidAscorbic acid Alcohol AlcoholCalcium Channel BlockersCalcium Channel Blockers Fat Fat

Gastro-oesophageal RefluxInvestigation

• Oesophageal pH monitoring for 24 hours (+diary) Oesophageal pH monitoring for 24 hours (+diary) – 95% sensitive and specific 95%95% sensitive and specific 95%

• Ba swallow not sensitive enoughBa swallow not sensitive enough

• Endoscopy - may confirm but false -ve rateEndoscopy - may confirm but false -ve rate

Endoscopy can show GORD, but cannot Endoscopy can show GORD, but cannot confirm GORD as the cause of cough.confirm GORD as the cause of cough.

GED

© Slice of Life and Suzanne S. Stensaas

GED

Gastro-oesophageal RefluxTreatment

Trial of Therapy• High dose twice daily PPI for min 8weeks• + prokinetic eg domperidone or metoclopramide• Eliminate contributing drugs.• Baclofen rarely

Improves in 75-100% of cases

Post-Nasal Drip

Symptoms:• ‘something dripping’• frequent throat

clearing• nasal congestion /

discharge• posture

Causes• Allergic rhinitis• Non-allergic rhinitis • Vasomotor rhinitis• Chronic bacterial

sinusiits

Post Nasal Drip Treatment

Options:

1. Exclude /treat infection

2. Nasal steroid for 8/52

3. Sedating antihistamines

4. Antileukotrienes eg montelukast

5. Saline lavage

6. ENT opinion

Lung Diseases inc Tobacco

Favouring Lung Disease

Shortness of breath

Wheeze

Sputum production

Haemoptysis

Chest signs eg crackles

Chest X-Ray and Differential of Cough

Normal CXR• Gastro-oesophageal reflux

• Post-nasal Drip

• Smokers cough/ Chronic Bronchitis

• Asthma

• COPD

• Bronchiectasis

• Foreign body

Abnormal CXR• Left ventricular failure

• Lung cancer

• Infection/ TB

• Pulmonary fibrosis

• Pleural effusion

Left Ventricular Failure

Idiopathic Pulmonary Fibrosis

TB

Lung Cancer

Chest X-Ray and Differential of Cough

Normal CXR• Gastro-oesophageal reflux

• Post-nasal Drip

• Smokers cough/ Chronic Bronchitis

• Asthma

• COPD

• Bronchiectasis

• Foreign body

Smoking and the Healthy Lung

The Development of Chronic Bronchitis

(Daily Cough)Smoking

Neutrophil Infiltration

Goblet hyperplasia

(mucous production)

Release of Proteinases

Normal Spirometry and Flow Volume Loops

Normal Values

• Depend on Age/ Sex / Height / Race

• Tables and slide rules available

• Asians decrease value by 7%

• Afro-Caribbean decrease by 13%

• Report results as Absolute and % predicted

• Normal is 80-120%

Obstructed Spirometry

FEV1 reduced

FVC largely preserved

FEV1/FVC low <70%

FEV1 =1.0

‘FVC’ =2.0 FEV1/FVC=50%

FVC =3.0 FEV1/FVC =33%

Peak Flow MeasurementSingle or Repeated Measures

Definition of COPDDefinition of COPDChronic obstructive pulmonary disease

is characterized by

•airflow limitation that is not fully reversible. FEV1always <80% with

•airflow limitation that is usually progressive

•associated with an abnormal inflammatory response to noxious particles or gases.

Chronic obstructive pulmonary diseaseis characterized by

•airflow limitation that is not fully reversible. FEV1always <80% with

•airflow limitation that is usually progressive

•associated with an abnormal inflammatory response to noxious particles or gases.

Development of Emphysema

Proteinases diffuse out

Neutralised by Anti-proteinases

eg a1 Anti-trypsin

If balance incorrect alveolar walls

destroyed

Stopping smokingslows decline in lung function

FE

V1

(% o

f va

lue

at a

ge 2

5) 100

75

50

25

025 50 75

Never smoked or notsusceptible to smoke

Adapted from: Fletcher et al, Br Med J 1977.

Stopped at 65

Stopped at 45

Smoked regularlyand susceptible to

its effects

Death

Age (years)

SYMPTOMS

coughcoughsputumsputum

dyspneadyspnea

EXPOSURE TO RISKFACTORS

tobaccotobaccooccupationoccupation

indoor/outdoor pollutionindoor/outdoor pollution

SPIROMETRYSPIROMETRY

Step 1 Make Sure Patient Has COPDStep 1 Make Sure Patient Has COPD

REMEMBER:

•Only 1/3 smokers get COPD

•Need 15 pack years min

•Asthma/ Bronchiectasis

All COPD PATIENTS Stop Smoking -use Leeds Smoking Services Guidelines Short-acting bronchodilator prn (see note 1) Annual flu vaccination 5 yearly pneumonia vaccination (see note 2) Encourage regular exercise (5x 30mins walking at breathless pace per week) Maintain weight in healthy range

Is patient breathless walking on level ground at a normal pace?

Chronic Disease ManagementMain Algorithm

YES – LONG-ACTING BRONCHODILATOR

See Pulmonary Rehabilitation algorithm

Yes

Long-acting beta agonistsalmeterol 50mcg bd (MDI/ accuhaler)or formoterol 12 mcg bd (turbohaler)

(see note 3)Plus short acting bronchodilator prn

No

Longacting anticholinergicTiotropium 18mcg od

(see note 3)Plus short acting beta agonist prn(breathe actuated or dry powder)

No benefitStop longacting drug and try the

alternative

Partial ResponseAdd ipratropium bromide 40

mcg qds via MDI + spacer(see notes 3 & 4)

Partial ResponseAdd shortacting beta agomist 2puffs qds via breathe-actuated inhaler or

dry powder device(see note4)

CAN PATIENT USE AN MDI?

£30 £43

£34 £47

Acute Management

Increase short acting beta agonist

for duration of exacerbation eg 2-8 puffs upto 4 hourly

1st Line Antibiotic

amoxycillin 250-500mg tds or doxycycline 100mg bd for

1 week(see note 6)

Steroids

Prednisolone 30mg od for 1

week

No Improvement

at 1 week

2nd line antibiotic if sputum still

purulent

ciprofloxacin 750mg bd

(Half maintenance theophylline dose)

(see note 7)

Continue prednisolone 30mg

od upto 2 weeks maximum

Prevention of Future Exacerbations

Is the FEV1 <50% predicted

and has the patient had >2 exacerbations in the last 12

months requiring oral steroids or antibiotics?

NoNo additional

therapy

YesAdd budesonide 400mcg bd or fluticasone

500mcg bd.If on a longacting beta agonist -prescribe as symbicort 200/6 2 clicks bd or seretide 500

1 click bd (cheaper than separates) (see note 8)

>2 exacerbations in next 12 months after starting the above

add carbocisteine 750mg bd (see note 9)

Definition of asthmaDefinition of asthma

Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92

“A chronic inflammatory disorder of the airways …

in susceptible individuals, inflammatory symptoms

are usually associated with widespread but variable

airflow obstruction and an increase in airway

response to a variety of stimuli. Obstruction is often

reversible, either spontaneously or with treatment.”

Asthma

• Variable airflow obstruction– Symptoms vary

– Measurements of airflow obstruction vary

• Associated with atopy (hayfever, eczema, urticaria)• Occupational links eg bakers, isocyanates, wood-dust• Dry cough, worse at night• Episodic breathlessness• Effects all ages

Asthma

Triggers• Exercise• Fumes/ Smoke• Cold air• Oesophageal Reflux• Occupational

Allergens• Tree• Grass• Fungi• House dust mite • Pets• Occupational

Proving Variability

Looking for 20% variation

in PEFR or 15% in FEV1

1. Opportunistic single low peak flow in surgeryGive bronchodilator and repeat in 20 mins

Give trial of therapy and repeat next visit

2. Opportunistic single normal peak flow in surgery

Measure on subsequent visits -hope for variability naturally

Home peak flow measurements

Induce an asthma attack! -histamine challenge

Peak Flow MeasurementSingle or Repeated Measures

Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

Stepwise management ofStepwise management ofasthma in adultsasthma in adults

Step 1: Mild intermittent asthmaStep 1: Mild intermittent asthma

Step 5: Continuous or frequent Step 5: Continuous or frequent use of oral steroidsuse of oral steroids

Step 4: Persistent poor controlStep 4: Persistent poor control

Step 3: Add-on therapyStep 3: Add-on therapy

Step 2: Regular preventer therapyStep 2: Regular preventer therapy

Case Study -CP 2007• 60yr retd Nurse

• Chest infection 2002 in Spain -mild SOB since

• Chest infection 2006 -hospitalised for 4/7 antibiotics / steroids

• SOB and dry cough since

• No variation

• 4 lots of AB and steroids from GP plus tiotropium & oxis -no help for cough

• Wt climbing

• More SOB over 9/12

• Ex-smoker 30 pack yrs• FEV1 0.97 43%

What else would you like to know?

History positional /reflux

What causes can you think of?

COPD

Obesity with Reflux

8/52 omeprazole 20mg bd + domperdone 10mg tds -

asymptomatic

Conclusions

Acute Cough < 3/52

Usually URTI

CXR if worried

Symptomatic therapy

Subacute Cough 3-8/52

Usually post-viral

CXR if smoker or worried

Chronic Cough >3/12

CXR and Spirometry

Consider

GORD

Post -Nasal Drip

Lung - Abnormal CXR

- Normal CXR (asthma/ COPD)