Transcript Sangeeta Jain - National Allergy And Asthma

Chronic
Cough
Presented by:
Sangeeta Jain,
MD
Accreditation Information:
The Lowcountry Regional Allergy Update
January 21, 2017
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Target Audience: Physicians and Other Allied Health Professionals
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Objectives
Consider differential
diagnosis of chronic cough.
2. Understand the role of
exhaled nitric oxide test in the
diagnosis of the chronic
cough.
3. Identify the most common
causes and complications of
the chronic cough.
 1.




Case 1
7 year old female with history of eczema as an infant,
recurrent wheezing until the age of 3 presents for acute
onset wheezing. Associated with mild dry cough. Denies
any shortness of breath, dyspnea on exertion, fevers,
chills, productive sputum. Playing normally. Since the
age of 4 has had 2 similar episodes per year which
require albuterol and occasionally oral steroids. mother
denies any allergy symptoms.
Past history noncontributory except strong family history
of allergic rhinitis and asthma
ROS unremarkable
PE: remarkable for allergic shiners bilaterally, 3+ boggy
nasal turbinates, +clear/white mucus present, +nasal
crease, +posterior drainage in his oropharynx, +tonsillar
hypertrophy
Testing
 Prior


skin testing:
Positive for : ash tree, bermuda grass, timothy grass,
alternaria, dog.
Negative for ragweed, dust mite, cat, cockroach,
egg, peanut, milk.
 Chest
xray normal
 FeNo 55ppb
 Pulmonary function test
Pre
Post
% change
FVC
107%
110%
+3
FEV1
106%
112%
+5%
FEV1/FVC
84%
88%
+2%
What is the next best step?
1.
Start inhaled
corticosteroid
therapy
2. Stop peanut
consumption and
give epipen
3. Start antibiotics
4. Remove tonsils
Case 2





60 year old obese, non smoking male presents with mild nasal
congestion, tickling sensation in his throat, cough and wheezing x
6 weeks. Associated with dyspnea on exertion. No fevers, colored
mucus production, sinus pressure. Occurs throughout the day and
night. He has tried albuterol without relief. Does take a nasal
steroid and oral antihistamine daily. Has tried albuterol without
relief. Has also tried a combination of an ICS and a LABA for a past
history of asthma without relief.
Pertinent history: allergic rhinitis, acid reflux and anxiety, asthma,
pre-diabetes, no other atopic history
ROS: +heartburn 3-4 times a week, +fatigue, otherwise negative
Medications: fluticasone 2 sen daily, xanax 0.25 mg prn, loratadine
10 mg daily, previously on omperazole but d/c due to bloating
PE: remarkable for obesity, 3+ boggy nasal turbinates,
+clear/white mucus present, +posterior drainage in his oropharynx
Case 1 continued
 No
prior allergy testing
 Pulmonary function test:
Pre
Post
% change
FVC
99%
98%
-1%
FEV1
88%
92%
+4%
FEV1/FVC
74%
78%
+4%
 FeNO
10 parts per billion (ppb)
What is the next best step?
 1.
Try a corticosteroid:
inhaled or oral
 2. Start lifestyle
modifications for acid
reflux and antacid
therapy
 3. Start antibiotics
 4. Stop nasal steroid
and oral antihistamine
due to possible
medication side effect
Chronic Cough
 5th
most common symptom
presenting in the primary
care office
 OTC cough medications =
$1.6 billion dollar/year
industry
 Complications
 Anxiety, frustration, social
stigma
 Sleep disturbance, fatigue
 Loss of productivity at work
Definition of Cough
 Acute:
lasting less than 3
weeks, typically 8 days.
 Most commonly due to URI
 Subacute: lasting between 38 weeks in duration
 Most commonly due to
post-infectious process
 Chronic: lasting more than 4
weeks in duration
Anatomy of Cough
Most Common Causes
Infants and toddlers
 Post infectious
 Post nasal drip
syndrome
 Reactive
airways/asthma
 Also



Age 3 and above


Structural defects
Reflux
Foreign body
Non-smokers
 Post nasal drip
syndrome
 Asthma/bronchitis
 GERD
 *medication side effect
Smokers
 Above plus
 Lung cancer
 COPD
18-40% of chronic cough is related to >2 conditions
Differential Diagnosis: Think ABC’s
 Aspiration
 Birth
defect
 Cardiac/Compressive
 Defective mucus clearance
 Environmental lung disease
 Foreign body
 Granulomatous disease/GERD
 Hyperactive airways
 Infections
Post nasal drip
(Upper airway cough syndrome)





#1 cause
Overproduction- thin, watery and runny,
 infection may cause yellow/green, thick, sticky mucus
production
Symptoms: tickling in the throat, phlegm in the back of the
throat, worse at night
Many causes: allergic rhinitis, infection, pregnancy,
dryness, cold temperatures, humidity, certain
foods/spices, structural abnormalities
Diagnosis: empiric treatment
 Saline irrigation
 Oral or intranasal antihistamines or anticholinergics
 Oral or intranasal decongestants
Asthma






Multiple phenotypic types
 cough-variant asthma
 Non-eosinophilic bronchitis
+/- wheezing, dyspnea on exertion, shortness of breath
Throughout the day and may begin at night or early
morning hours
May be triggered by environmental allergens including
pollen, dust, mold ,animal dander, cold air exposure,
and exertion
Diagnosis can be difficult
 Spirometry, methacholine challenge, exercise
treadmill test
Treatment: b2 agonists and corticosteroids
GERD



Cough without wheezing or shortness of breath
Stomach contents reach esophagus
 May cause heartburn, belching, sour/metallic taste in mouth,
bad breath
Can be asymptomatic
Acid can irritate nerves in the lower part of the esophagus which
can trigger a cough reflex without any other signs or symptoms
Diagnosis
 Esophageal ph monitoring, endoscopy
 Empiric treatment
Treatment
 Medication: proton pump inhibitors or h2 blockers
 Lifestyle modifications
 Avoid hot,spicy foods and acidic foods, limit caffeine intake,
limit alcohol intake, limit heavy meals, avoid meals 3 hours prior
to bed time, elevate head of bed



Medications
 Ace-inhibitors
 20%
of people on an ace-inhibitor will
experience chronic cough
 First symptom is a throat tickle, then dry cough
 Occurs within 3 weeks-1 year of initiation, can
occur after
 Treatment: stop the medication if possible, use
alternative
 Others



Beta blockers
Vasodilators
OCP’s
What To Do Next?
Oneminuteconsult epub Feb 2011, vol 78:2,84-89
Distinguishing The Three Common Causes
Character of cough
Asthma
Post nasal drip
GERD
type
Dry, non-productive,
hacking, croupy
Dry or wet, productive,
phelmgy, throat
clearing, tickle in throat
Dry or wet, tickle in
throat
trigger
Environmental allergens,
exertion, smoke, cold air
Environmental allergens,
exertion, smoke
Meals
Time of day
Worse between 2-4 am
Worse as the day goes
on, with lying down, or
upon awakening
After large meals,
certain foods or drinks,
or with lying down
Associated features
History of atopy
History of atopy or
recurrent sinusitis
History of obesity or
recent weight gain
PFT results
Normal or may have
obstruction with
reversibility post
bronchodilator
challenge
normal
Normal, may have
restrictive pattern if
obesity is a limiting
factor
Treatment
B2 agonist +/- inhaled
corticosteroids
Steroids, antihistamines,
irrigation,
anticholinergics,
antibiotics
Proton pump inhibitors,
h2 blockers, lifestyle
modifications
Now What?
Perform an exhaled nitric oxide test!
Exhaled Nitric Oxide Test



Measures the level of
nitric oxide gas in the
exhaled sample of your
breath
Help in diagnosis and
treatment of asthma
 Low fractional
excreted nitric oxide
(FeNO) indicates
etiology other than
asthma
Can distinguish chronic
cough due to asthma
from other co-morbid
conditions
Normal
Children: <20 ppb
Adults: <25 ppb
Abnormal
Children: >35 ppb
Adults >50 ppb
Advantages






FENO Disadvantages
Distinguishes
eosinophilic asthma
from non-eosinophilic
asthma
Predict steroid response
Adherence to
treatment and
effectiveness
Assist in diagnosis of
childhood asthma
Predictive of relapses or
exacerbations
Easier to perform than
spirometry
 Limited
use in noneosinophilic asthma
 May have skewed
values

foods, medications,
infection, alcohol,
tobacco use,
exercise, recent
spirometry, ethnicity
How to Prepare?
 Avoid
for 2 hours prior
 Using an asthma inhaler
 Eating and drinking
 Exercising
 Using tobacco, toothpaste or mouthwash
7
Case 1 Revisited
year old female with chronic cough, wheezing
 Allergic rhinitis, positive testing to
environmental allergens
 Responsive to corticosteroid and B2 agonists
 Normal pulmonary function testing
 Elevated FeNO 55 ppb
 What is the next step?
 1. start inhaled corticosteroid therapy
 2. stop peanut consumption and give epipen
 3. start antibiotics
 4. Remove tonsils
Case 2


60 year old obese male, with history of asthma and acid
reflux who presents with chronic cough without wheezing,
does have heart burn symptoms
 Not responsive previously to inhaled corticosteroids and
B2 agonists
 Normal spirometry
 FeNO 10 ppb
What is the next step?
 1. Try a corticosteroid: inhaled or oral
 2. Start lifestyle modifications for acid reflux and antacid
therapy
 3. Start antibiotics
 4. Stop nasal steroid and oral antihistamine due to
possible medication side effect
References
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
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