1. Approach To The Patient With Cough

2. Case MKSAP 13 – Pulmonary Question #22
A 47 yo black male is evaluated because of a 2-month history of cough. Three months ago hypertension was diagnosed, for which he takes HTCZ and benazepril. He attributes his cough to the change of weather. He has a hx of GERD that is well controlled on PPI. No hx of asthma.
Which of the following would be the most appropriate next step?
CT scan of sinuses
pH probe
Methacholine challenge testing
Stop ACEI
Allergy testing

3. Cough By Duration Acute Cough < 3 weeks
Sub acute Cough from 3 – 8 weeks
Chronic Cough > 8 weeks
Irwin, R. S. et al. Chest 2006;129:1S-23S
Irwin R, Madison JM. The diagnosis and treatment of cough. N Engl J Med 2000; 343:1715–1721

4. Chronic cough algorithm for the management of patients >= 15 years
Irwin, R. S. et al. Chest 2006;129:1S-23S

5. Evaluation Of Nonsmokers Presenting With Chronic Cough
If on ACEI discontinue ACEI
Consider UACS, Asthma, GERD as most common diagnoses
Do not use the patient’s description of timing of onset or production of sputum to diagnose
The etiology of some cough syndromes is multifactorial
Pratter MR. Overview of common causes of chronic cough: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):59S–62S

6. Chronic Cough Syndrome Caused By Rhinosinus Disease
Formerly labeled post nasal drip syndrome
ACCP recommends calling this upper airway cough syndrome
Ddx: Allergic rhinitis, postinfectious rhinitis, bacterial sinusitis, rhinitis due to irritants, occupational, medicamentosa, anatomic abnormalities
Evaluation includes a combination of criteria, including symptoms, physical examination findings, radiographic findings, and, ultimately, the response to specific therapy
Pratter MR. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):63S–71S  

7. Chronic Cough Syndrome Caused By Rhinosinus Disease
Draining into throat, need to clear throat, tickle in throat, congestion, nasal discharge, hoarseness, wheeze
If obvious, treat with 1st generation A/D
If not responsive, image sinuses
Empiric therapy with 1st generation A/D
An empiric trial of therapy aids in diagnosis
An empiric trial of therapy should be given before considering exhaustive work-up
Pratter MR, Brightling CE, Boulet LP, et al. An empiric integrative approach to the management of cough: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):222S–231S  

8. Chronic Cough Syndrome Caused By Rhinosinus Disease
In the setting of the common cold;
Treat with A/D, consider Naprosyn
Nonsedating antihistamines do not work
Even if productive of sputum do not use antibiotics routinely

9. Cough And Asthma
May be a symptom of asthma or a distinct entity, cough variant asthma
Spirometry with bronchodilator, and methacholine challenge testing used to evaluate
Treat with inhaled bronchodilator and inhaled corticosteroids
Can only diagnose this as cause if syndrome is responsive to therapy

10. Cough And Asthma
Consider sputum eosinophil level for steroid responsiveness
If not responsive or noncompliant, consider leukotriene receptor antagonist
May consider oral steroids if severe
Dicpinigaitis PV. Chronic cough due to asthma: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):75S–79S  

11. Not exposed to environmental irritants nor a present smoker
Clinical Profile That Predicts That Chronic Cough Is Likely Due to GERD Chronic cough
Not exposed to environmental irritants nor a present smoker
Not taking an angiotensin-converting enzyme inhibitor
Chest radiograph is normal or shows nothing more than stable, inconsequential scarring
Symptomatic asthma has been ruled out: 
Cough has not improved with asthma therapy, or Methacholine inhalation challenge is negative
Upper airway cough syndrome due to rhinosinus diseases has been ruled out: First-generation H1 -antagonist has been used and cough failed to improve, and “Silent” sinusitis has been ruled out
Nonasthmatic eosinophilic bronchitis has been ruled out: Properly performed sputum studies are negative, or 
Cough has not improved with inhaled/systemic corticosteroids
Irwin, RS Chronic cough due to gastroesophageal reflux disease: ACCP evidence-based clinical practice guidelines. Chest 2006;129(suppl),80S-94S

12. Cough Associated With GERD
Suspected by clinical profile
Treat if suspected, even if they are otherwise asymptomatic
Cannot rule out on clinical profile
Cannot rule out GERD as cause of cough until it is fully treated/evaluated
Esophageal pH probe is the most sensitive and specific test for acid reflux

13. Cough Associated With GERD
Normal esophagoscopy does not rule out GERD
Barium esophography is the test of choice to evaluate for non-acid reflux cough complex
Esophageal manometry may be useful
Rudolph C, Mazur L, Liptak G, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 2001; 32(suppl):S1–S31  

14. Cough Associated With GERD
If initial treatment fails, escalate therapy (mixed modalities)
Evaluate for effective therapy
Lifestyle changes
Anti-reflux diet that includes no > 45 g of fat in 24 h and no coffee, tea, soda, chocolate, mints, citrus products, including tomatoes, or alcohol, no smoking, and limiting vigorous exercise that will increase intraabdominal pressure

15. Spectrum of Options for Treating Chronic Cough Due to GERD
Anti-reflux medical therapy
Diet
Lifestyle changes
Smoking
Exercising
Consuming alcohol
Medications
Acid suppression - PPI, PPI/BID, H2 blockers
Prokinetic
Address risk factors/Treat other causes of cough 
Treat comorbid conditions
Obesity
Obstructive sleep apnea
Consider changing medications for comorbid conditions
Anti-reflux surgery
Irwin, RS Chronic cough due to gastroesophageal reflux disease: ACCP evidence-based clinical practice guidelines. Chest 2006;129(suppl),80S-94S

16. Nonasthmatic Eosinophilic Bronchitis
Common cause of cough 10-30% cases
Diagnosed by ruling out asthma and showing induced sputum/bronchial wash eosinophilia, or response to ICS
Evaluate for allergen or occupational cause
Avoidance is treatment of choice if cause found
Brightling CE. Chronic cough due to nonasthmatic eosinophilic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(

17. Nonasthmatic Eosinophilic Bronchitis
Treat with inhaled corticosteroids
If firmly diagnosed and not responsive consider burst of oral systemic steroids
Evaluate for reduction of eosinophilia
vs Asthma-
mast cells
biopsy
Brightling CE. Chronic cough due to nonasthmatic eosinophilic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(

18. Eosinophilic Bronchitis Classic Asthma Cough-Variant Asthma
Features
Eosinophilic Bronchitis
Classic Asthma
Cough-Variant Asthma Sx
Cough and upper airway
Dyspnea, cough, wheeze
Isolated cough
Atopy
No increase
common
Common
Airway hyperresponsiveness
Absent
Present
Response BD
Good
Response ICS
Sputum eos
Always
Usually
Bronchial bx eos
Very common
Mast cells in airway smooth muscle No
Yes

19. Subacute cough algorithm for the management of patients >= 15 years
Irwin, R. S. et al. Chest 2006;129:1S-23S

20. Post-infectious Cough
<8 weeks
CXR normal
Resolves on its own
Postviral airway inflammation, bronchial hyperresponsiveness, mucus hypersecretion, impaired mucociliary clearance
Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):95S–103S   Braman SS. Chronic cough due to chronic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):104S–115S
Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):72S–74S

21. Post-infectious Cough
No antibiotics unless sinusitis or Bordetella pertussis
Consider trial of ipratropium to attenuate cough
If this does not work consider trial of ICS
If severe paroxysms – prednisone 30-40mg short finite period, only when GERD, asthma, UACS ruled out
Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):95S–103S   Braman SS. Chronic cough due to chronic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):104S–115S
Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):72S–74S

22. Post-infectious Cough
Codeine or Dextromethorphan when other measures fail
Paroxysms of coughing posttussive vomit and inspiratory whoop
Order nasopharyngeal aspirate or cx for B. pertussis
IgG/IgA for presumptive diagnosis
Erythromycin, 5 day isolation
Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):95S–103S   Braman SS. Chronic cough due to chronic bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):104S–115S
Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl):72S–74S

23. Acute cough algorithm for the management of patients >= 15 years
Irwin, R. S. et al. Chest 2006;129:1S-23S

24. Chronic cough algorithm >15yrs
Irwin, R. S. et al. Chest 2006;129:1S-23S

25. Irwin R, Boulet L-P, Cloutier MM, et al
Irwin R, Boulet L-P, Cloutier MM, et al. Managing cough as a defense mechanism and as a symptom: a consensus panel report of the American College of Chest Physicians. Chest 1998; 114(suppl):133S–181S  

26. Cough stimulus Afferent limb of cough reflex
Sensory receptors stimulated
Mucus volume, production, consistency, ciliary action
Neural brainstem elements
Spinal motoneurons innervate respiratory muscles

28. Suppressant Therapy Old term - non-specific therapy
Peripheral antitussive agents
Centrally acting antitussive agents
Inhibit efferent limb and paralytic agents
When cough is elevated over what is required to defend airways
No evidence that therapy prevents cough

29. Suppressant Therapy Short-term basis Symptomatic relief
Etiology of cough is unknown
Specific therapy requires time to become effective
Specific therapy ineffective, ie inoperable lung cancer

30. Drugs that alter mucocillary factors
Conflicting study data on Guaifenesin, Ipratropium, Tiotropium, and Acetylcysteine
Few drugs suppress cough consistently
In chronic bronchitis mucolytics are not recommended
In URI or chornic bronchitis the only anticholinergic recommended is ipratropium bromide

31. Peripheral antitussive agents
Suppress excitability of sensory receptors
2 drugs recommended by evidence based guidelines in ACCP
Not available in US
Benzonatate - Tetracaine congener with antitussive properties
Topical anesthetic action on the respiratory stretch receptors

32. Centrally acting antitussive agents
Work on brainstem CNS
Chronic bronchitis codeine and dextromethorphan recommended for short-term relief
Cough secondary to URI limited efficacy, not recommended

33. Inhibit efferent limb and paralytic agents
In patients with chronic or acute cough requiring symptomatic relief, drugs that affect the efferent limb of the cough reflex are NOT RECOMMENDED
Baclofen - decreased cough secondary to ACE-inhibitor in one study, not yet tested in DBPCT
During intubation with GETA neuromuscluar blocking agents such as succinylcholine recommended to suppress coughing

34. Protussive effects – increase cough clearance
Bronchitis – hypertonic saline solution recommended short term basis to increase cough clearance

35. Case MKSAP 13 – Pulmonary Question #22
A 47 yo black male is evaluated because of a 2-month history of cough. Three months ago hypertension was diagnosed, for which he takes HTCZ and benazepril. He attributes his cough to the change of weather. He has a hx of GERD that is well controlled on PPI. No hx of asthma.
Which of the following would be the most appropriate next step?
CT scan of sinuses
pH probe
Methacholine challenge testing
Stop ACEI
Allergy testing

36. Referral To A Cough Specialist
If no cause is found with previous algorithmic approach referral is appropriate
Most involved evaluations involve specialists; GI, ENT, Pulmonary, Cardiology
Consider pulmonary consult for assistance if needed

38. Questions