2. COUGH!

3. QUESTIONS Worst complication of cough T or F: can usually find 1 etiology T or F: GERD almost always symptomatic(heartburn) BONUS

4. PERSISTENT COUGH Defined as lasting at least 3 weeks Some term cough subacute between 3 and 8 weeks >30 million physician visits annually first or fifth most common reason to see a doctor costs estimated at $30billion annually in U.S.

5. MECHANICS Intrathoracic pressure increases up to 300mmHg Expiratory velocity reaches 500mph. Helps to clear mucous BUT can cause complications

6. COMPLICATIONS headache dizziness musculoskeletal pain syncope urinary incontinence Rib fracture …….drives patient and everyone else crazy.

7. COUGH REFLEX Afferent arm lower respiratory tract upper respiratory tract— Includes pharynx, larynx, ear canal pericardium –esophagus –diaphragm –stomach

8. RECEPTORS Chemoreceptors respond to –acid –heat –capascin-like compounds Mechanical receptors respond to touch

10. COMMON CAUSES Post-nasal drip –Post infection –Allergic and vasomotor rhinitis GERD Asthma Chronic bronchitis Eosinophillic bronchitis 25-50% ------multiple causes

11. POST-NASAL DRIP Probably most common cause allergic vs. vasomotor rhinitis sinusitis Symptoms: clearing throat sensation of mucous in back of throat nasal congestion dry mouth may be asymptomatic Exam nasal congestion, polyps, secretions throat: erythema, mucous, cobblestoning

12. POST-INFECTIOUS Many lump this with post-nasal drip as this symptom common for weeks post viral respiratory tract infection Can affect upper and/or lower respiratory tracts postulated enhance sensitivity of airways due to epithelial cell necrosis airway hyperresposiveness(RADS)

13. TREATMENT UPPER TRACT Intra-nasal corticosteroids antihistamines---systemic and intra-nasal Decongestants Anti-cholinergic nasal sprays LOWER TRACT Anti-cholinergics BOTH ? Anti-leukotriene rx

15. ASTHMA Considered second most common cause(disagree) “cough-variant” asthma may not wheeze or complain of dyspnea spirometry, even methacholine challenge may be negative ? Trial of therapy---- e.g. beta2 agonist inhaled corticosteroids anti-leukotrienes oral steroids

16. GERD May be silent ENT exam frequently positive 24hr. pH monitor with even markers for cough barium swallow frequently negative ?trial of treatment –PPI –elevate head of bed –?propulsive agent

17. DRUGS ACE inhibitors up to 15% of patients cough thought secondary to accumulation of bradykinin that normally degraded by ACE usually begins within 1 week of starting treatment resolves after 4 days to 4 weeks off therapy Beta blockers cough rare as isolated symptom

18. CHRONIC BRONCHITIS Defined as productive cough, “most days,” at least 3 months in 2 consecutive years

19. EOSINOPHILLIC BRONCHITIS Atopy increased sputum eosinophils active airway inflammation WITHOUT airway hyper-responsiveness small series(20) chronic isolated cough without bronchodilator response: bronchial biopsy: eosinophil infiltration in 16 most patients respond clinically to ICS 1 year after onset of symptoms(1 series) 55% symptomatic with normal spirometry 32% asymptomatic 13% asthma

20. ODDMENTS Lung Ca laryngopharyngeal reflux anything that compresses airway, e.g.retrosternal mass irritation of ear canal pertussis tracheobronchiomalacia foreign body

22. WORK UP HISTORY Time course prior episodes initial symptom e.g. URI, recent respiratory infection or exposure smoking history asthma or other atopic history productive? Color of sputum time of day, e.g. nocturnal GERD anything aggravating or relieving symptoms recent medication changes recent exposure to new potential allergens prior pneumonia(possible bronchiectasis) rhinitis history AM dry mouth and/or nasal congestion

23. EXAM Ears--fluid, cerumen nose--polyps, erythema, secretions, blue or boggy turbinates throat--erythema, frothy secretions, cobblestoning neck--masses, stridor, adenopathy chest(of course) wheezes, rhonchi

24. TESTS All debatable chest radiograph spirometry sinus films pH monitor

26. IF DX NOT APPARENT……. Recommend treat for post nasal drip initially add anti-reflux measures if cough disabling cough suppressants anticholinergics oral corticosteroids ENT or allergy workup TIME