DR O ADEYO GPVTS ST2 16/04/13 COUGH – BTS guidelines

Cough Acute cough Chronic cough  History  Examination  Investigation Specific cough syndromes Cough clinic referral Questions/discussion

Acute cough < 3 weeks Mostly associated with viral URTI In absence of significant co-morbidity, usually self-limiting Little evidence for OTC preparations but patients report benefit Impact on UK economy £875 million to loss of productivity £104 million cost to the healthcare system and OTC medication

Acute cough Further investigate  Haemoptysis  Prominent systemic illness  Suspicion of inhaled FB  Suspicion of lung Ca

Chronic cough > 8 weeks 10-20% of adults Female and obese 10% of respiratory ref to 2◦ care Decrement in QOL comparable with severe COPD Most have dry or minimally productive cough Significant sputum - 1◦ lung pathology Heightened cough reflex is the 1◦ abnormality

History Age + sex Smoking Characteristic  Onset  Duration  Relation to infection  Sputum  Diurnal variation  Severe coughing spasms/paroxysms  Incontinence  Origin of sensation  Cough triggers + aggravants  Food  Cough on phonation

History Medication Occupation/hobbies/pets PMH FH  May be familial (inherited anatomical abnormality, neurological condition)

Physical examination Signs of respiratory disease or cardiac failure More often examination reveals less specific findings ENT exam If FH - neuro exam of legs to look for signs of familial neuropathy.

Baseline investigations in 1◦ care CXR  All chronic cough  Acute cough with atypical sx Assessment of pulmonary function  Spirometry – all chronic cough  Helpful in identifying cough caused by chronic airway obstruction  Normal does not exclude asthma  Avoid using single PEF or PEF to assess bronchodilator response in diagnosis of airflow obstruction as cause of cough

Specific cough syndromes

Cough variant asthma Eosinophilic bronchitis GORD Upper airway disease and cough Undiagnosed or idiopathic cough Cough due to other common respiratory disease

Cough variant asthma Chronic cough is the main (if not the sole) symptom present it is considered to be a variant type of asthma as well as a precursor to the development of classical asthma Clinical indicators include  Nocturnal, post-exercise, post-allergen exposure Progresses to typical asthma in 17–37% of patients Hyperresponsiveness is present

Cough variant asthma In these patients eosinophils in sputum, bronchoalveolar lavage (BAL) fluid, and in bronchial biopsy specimens is characteristic Measurement of airway hyperesponsiveness  Inhalation of methacoline  If negative excludes asthma but does not rule out steroid responsive cough. Management  Follow guidelines for asthma except no evidence for LABA  Evidence exists for use of Leukotriene receptor agonist  Responds to treatment with inhaled steroids

Eosinophilic bronchitis Patients have cough and eosinophils in sputum but spirometric tests and airway hyperresponsiveness is normal 50% of patients with CVA have associated EB Management  Responds to inhaled steroids  Use BTS asthma guidelines for guidance on dose, preparation and duration

GORD Pt’s have increased cough reflex sensitivity which improves with antireflux therapy  Microaspiration of gastric content into larynx and tracheobronchial tree  Vagally mediated oesophageal reflex stimulated by acid or non-acid volume reflux  Oesophageal motor dysfunction and reduced oesophageal clearance

GORD Management  PPI – omeprazole BD before meals – at least 8 weeks  Prokinetic agents – metoclopramide 10mg TDS may be required in some  Consider stopping medication that can potentially worsen GORD ( biphosphonates, nitrates, ca channel blockers, theophylline, progesterones)  Antireflux surgery in carefully selected cases

Upper airway disease and cough Cough commonly accompanied by  Nasal stuffiness  Sinusitis  Post-nasal drip In presence of prominent upper airway sx  1 month trial of topical steroid recommended  Can be a diagnostic approach

Undiagnosed or idiopathic cough Chronic cough should only be considered idiopathic following thorough assessment at a specialist cough clinic Clinical hx of reflux is usually present A typical lymphocytic airways inflammation is seem Middle aged women  Present with chronic dry cough which starts at time of menopause  Often appears to follow a viral respiratory tract infection

Undiagnosed or idiopathic cough Organ specific autoimmune disease is present in up to 30% - autoimmune hypothyroidism is particularly common Treatment is disappointing and is largely limited to non- specific antitussive therapy such as dextromethorphan and drugs with weak evidence of benefit such as baclofen and nebulised local anaesthetics (lidocaine, mepivicaine) Low dose morphine recently shown to be helpful

Cough due to other common respiratory diseases Cough suppression undesirable in certain conditions LRTI (acute tracheobronchitis + pneumonia) COPD  Control of sx and reduction of exacebations  No studies on effectiveness of any particular treatment on the cough itself Lung Ca  Radiotherapy  Opiod and non-opiod antitussives recommended Diffuse parenchymal lung disease  Mostly breathlessness though frequently reported  Limited information on treatment

Referral to cough clinic Lack of availability of relevant diagnostic testing in 1◦ or 2◦ care Failed trial of empirical treatment directed at asthma, GORD or rhinosinusitis History suggestive of serious cough complication such as syncope or chest wall trauma Patient preference Recruitment and participation in clinical trials of antitussive therapy

References BTS Guideline. Recommendations for the management of cough in adults. A H Morice, L McGarvey, I Pavord, on behalf of the British Thoracic Society Cough Guideline Group Gp Practice Notebook – a UK medical reference

Cough Thanks for listening Any questions?