Transcript Cough Diagnosis and Management

Cough
Diagnosis 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 URTI
Primary Care Setting
No antecedent or chronic lung disease
End of Week
3
4
5
6
% Coughing
58
Sub-acute
35
Cough
17
8
-Post viral
cough
*Jones FJ and Stewart MA, Aust Family
Physician Vol. 31, No. 10, October 2002
Managing Acute Cough
“Don’t just do something
stand there.”
Alice in Wonderland
Managing Acute Cough
Identify 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?
Dextromorphan
Sedating Antihistamines
eg Benilyn non-drowsy
1 meta-analysis
high dose 60mg
beware combinations eg
paracetomol
danger sleepy - nocturnal cough
Menthol
Steam inhalation. Effect on
reflex short lived
Codeine or Pholcodeine
No 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
ACTIONS
•Examine Chest
•Chest X-Ray if signs or smoker
•Measure of airflow obstruction
ie peak flow -one off
peak flow -serial
• Don’t want to miss
lung cancer
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 Cough
Epidemiology
Associations with:
Smoking (dose related)
Pollutants (particulate PM10) -occupation
Environmental irritants (eg cat dander)
Asthma
Reflux
Obesity
Irritable bowel syndrome
Female
Making the Diagnosis
Common Differentials
Lung Disease
-normal CXR
-abnormal CXR
Gastro
-Oesophageal
Reflux
Post-nasal Drip
-allergic rhinitis
-bacterial sinusitis
Non-structural
ACE-Inhibitors
Tobacco
Habit Cough
Chronic Cough
Investigating 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
Cough Features
GI Symptoms
Throat clearing
Worse at night / rising
On eating
Reflex hypersensitivity
If Aspiration main mechanism
Heart burn
Waterbrash/ Sour taste
Regurgitation
Morning Hoarseness
CXR -normal or hiatus
hernia
Spirometry normal
If Vagal - NO GI symptoms
Gastro-oesophageal Reflux
Reflux may be due to Medications or Foods
Drugs and foods that reduce lower esophageal
sphincter (LES) pressure and can cause increased
reflux include:
Theophylline
Oral β adrenergic agonists
NSAIDs
Ascorbic acid
Calcium Channel Blockers
Chocolate
Caffeine
Peppermint
Alcohol
Fat
Gastro-oesophageal Reflux
Investigation
• Oesophageal pH monitoring for 24 hours (+diary)
– 95% sensitive and specific 95%
• Ba swallow not sensitive enough
• Endoscopy - may confirm but false -ve rate
Endoscopy can show GORD, but cannot
confirm GORD as the cause of cough.
© Slice of Life and Suzanne S. Stensaas
GED
GED
Gastro-oesophageal Reflux
Treatment
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
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•
•
•
•
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
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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
=33%
FEV1/FVC
Peak Flow Measurement
Single or Repeated Measures
Definition of COPD
Chronic 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.
Development of Emphysema
Proteinases diffuse out
Neutralised by Antiproteinases
eg a1 Anti-trypsin
If balance incorrect
alveolar walls
destroyed
FEV1 (% of value at age 25)
Stopping smoking
slows decline in lung function
Smoked regularly
and susceptible to
its effects
100
Never smoked or not
susceptible to smoke
75
Stopped at 45
50
25
Stopped at 65
Death
0
25
50
Age (years)
Adapted from: Fletcher et al, Br Med J 1977.
75
Step 1
Make Sure Patient Has COPD
EXPOSURE TO RISK
FACTORS
tobacco
occupation
indoor/outdoor pollution
SYMPTOMS
cough
sputum
dyspnea

SPIROMETRY
REMEMBER:
•Only 1/3 smokers get
COPD
•Need 15 pack years min
•Asthma/ Bronchiectasis
Chronic Disease Management
Main Algorithm
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?
YES – LONG-ACTING BRONCHODILATOR
CAN PATIENT USE AN MDI?
Yes
No
Long-acting beta agonist
salmeterol 50mcg bd (MDI/ accuhaler)
or formoterol 12 mcg bd (turbohaler)
(see note 3)
Plus short acting bronchodilator prn
Longacting anticholinergic
Tiotropium 18mcg od
(see note 3)
Plus short acting beta agonist prn
(breathe actuated or dry powder)
£30
No benefit
Stop longacting drug and try the
alternative
£34
Partial Response
Add ipratropium bromide 40
mcg qds via MDI + spacer
(see notes 3 & 4)
£43
£47
See Pulmonary
Rehabilitation algorithm
Partial Response
Add shortacting beta agomist 2puffs
qds via breathe-actuated inhaler or
dry powder device
(see note4)
Acute Management
Increase
short acting
beta agonist
1st Line
Antibiotic
for duration of
exacerbation
eg 2-8 puffs
upto 4 hourly
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?
No
No additional
therapy
Yes
Add 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 asthma
“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.”
Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92
Asthma
• Variable airflow obstruction
– Symptoms vary
– Measurements of airflow obstruction vary
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•
•
•
•
Associated with atopy (hayfever, eczema, urticaria)
Occupational links eg bakers, isocyanates, wood-dust
Dry cough, worse at night
Episodic breathlessness
Effects all ages
Asthma
Allergens
• Tree
• Grass
• Fungi
• House dust mite
• Pets
• Occupational
Triggers
• Exercise
• Fumes/ Smoke
• Cold air
• Oesophageal Reflux
• Occupational
Proving Variability
Looking for 20% variation
in PEFR or 15% in FEV1
1. Opportunistic single low peak flow in surgery
Give 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 Measurement
Single or Repeated Measures
Stepwise management of
asthma in adults
Step 5: Continuous or frequent
use of oral steroids
Step 4: Persistent poor control
Step 3: Add-on therapy
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
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)