Transcript The Unsolved Mystery of The Chronic Cough

The Unsolved Mystery of
The Chronic Cough
Rhonda Hoyer, RN, MS, APRN-BC
Nurse Practitioner
Internal Medicine, University Station
Case Objectives
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Recognize extra-esophageal manifestations of
GERD and the potential complications
Identify differential diagnoses associated with
chronic cough
Identify the most appropriate course of
treatment
Case
CC: Severe cough for 6 days
HPI: 42 yo female severe non-productive cough,
so bad she almost vomits, keeping up at night,
clear rhinitis and laryngitis. Fever 1st night of
illness, nothing now. Appetite and energy good.
Denies SOB, chest pain.
Past Medical History
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Asthma. Mild-intermittent, PRN albuterol. No
maintenance inhalers ever. Hx of 1 exacerbation
requiring prednisone and Advair.
Abd pain thought to be related to gallbladder vs.
uterine fibroids. Resolved s/p cholecystectomy and
TAH in 2006
Hiatal hernia
Depression/Anxiety. Seeing psychiatrist/counselor
regularly.
History (continued)
Surgical History
 TAH
 Cholecystectomy
 Tonsillectomy
 Appendectomy
Social History:
Single, apt living with her cats. NS, no alcohol or drug use.
Warehouse worker.
Family History
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Negative for autoimmune disease
Positive for CAD in her father
No other significant FHx
Medications
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NKDA
Albuterol PRN
Cymbalta 60 mg, 2 capsules qAM
Lamictal 200 mg QD
Lorazepam 1-2 mg qHS PRN
Prilosec 20 mg QD
Seroquel 150 mg qHS
Lexapro 10 mg QD
Objective
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Gen: pleasant, dry, harsh cough throughout visit,
voice nearly absent
VS: WT 248. BP, HR normal. T 98.7, RR 18,
pox 95%
HEENT: all normal
Chest: Dim expiratory phase, cough with forced
expiration; no wheeze, crackles or consolidation
CV: RRR, no MRG
Ext: normal, no edema, cyanosis
Objective (cont)
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Chest x-ray normal
Spirometry:
FVC 3.31, 90%
 FEV1 2.24, 71%
 FEV1/FVC 78 %
 PEF 4.67, 66%
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Assessment/Plan
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Viral URI with asthma exacerbation
Neb tx in clinic with sig improvement in cough.
Repeat chest exam improved exp phase
 Prednisone burst
 Advair 250/50 BID, PRN albuterol – corrected
technique
 F/U appt in 3-4 days
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And it continues . . . 5 days later
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Cont SOB, occasional wheeze
Coughing at night; coughing yellow phlegm
Tired
Denies fevers, chills, chest pain
New: works in dusty warehouse, house dirty
with dust
Spiro today: FEV1 94% pred, PEF 81% pred
New A/P
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Asthma exacerbation, improving. ?Atypical
infection.
Zpac
 Cont pred, Advair
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?Dust allergy given flare of asthma since return
to work at warehouse
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add Loratadine daily
3 days later . . .
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Fever, diaphoretic
SOB, cont coughing
Fatigue, poor energy
Mild ST, very hoarse
Denies abd pain, n/v/d, chest pain. Hx of abn
EKG at Meriter with normal stress test
Objective
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Pale, diaphoretic, HR 101, BP stable, LS clr
CXR peribronchial inflammation, and elevation
of right hemidiaphragm, no pneumo or pleural
effusion
EKG: NSR, tachy 98. Inf Q waves II, III, aVF
with diffuse non-specific T wave abnormalities;
Troponin 0
A/P
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Admit to Inpatient IM services for 3d stay
Change to moxifloxacin
 Given IV steroids while in house, then Advair on
d/c
 Add Flonase for post nasal drip
 Optimize GERD therapy although symptomatically
stable with Prilosec BID
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Follow-up Hospital
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Reports sig improvement after hospitalization
Though, continues to cough during visit
 Cont on prednisone taper
 Dehydrated – given IVF
 Cont Flonase and loratadine
 Check CT sinus to evaluate for underlying disease as
a result of her symptoms which did show acute on
chronic sinusitis of the maxillary sinuses, R>L
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Additional Workup / Treatment
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Chest CT to characterize right hemidiaphragm
elevation with subtle ground glass opacification
in her bilateral lung zones.
Increase GERD therapy with pantoprazole
40mg BID
ENT evaluation for vocal cord dysfunction –
normal; ? laryngeal sensitivity treated with
gabapentin 300 mg TID
And the mystery continues . . .
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While off of antibiotics, within 3 days, patient
again develops fever, coughing, diaphoresis
New labs show elevated ESR of 44, CBC, chem7 normal.
Spiro FEV1 2.32, 73% predicted: FEV1/FVC
110% predicted; PEF 5.33, 75% predicted;
FEF25-75 3.94, 109% predicted; an FVC 2.45,
67% predicted
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Pulmonary Consult
RF, ANA, ANCA negative
 pH study ordered
 Nebulized lidocaine to interrupt cough cycle
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Thoughts: recurrent aspiration
Impedance Study
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Acid exposure data
Total of 136 minutes of acid in the esophagus. This is
significantly abnormal. Similarly, the percent times were
abnormal in both positions.
There was 16.7% of acid in the esophagus in the
upright position and 3.6% in the supine. The total is
9.9% with normal for an individual on acid suppression
is usually less than 1.3%.
She had 52 acid reflux events despite the medication.
The longest reflux event lasted 20 minutes. There were
8 of these such longer lasting reflux events of over 5
minutes in duration.
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For the impedance data
57 minutes of acid in the esophagus, which corroborates with
that of the pH probe.
88 minutes of non or mild acid liquid in the esophagus.
298 reflux events, which is significantly high. These were
predominantly nonacid in character, but as well, there were still
acid reflux events occurring.
113 of the 298 were acidic in nature, and 185 of the 298 were
nonacid in nature. These occurred equally in the upright as well
as the supine position. 194 of these reflux events reached the
proximal esophagus, which is greater than 50%.
There were 17 coughing episodes of which 11 were correlated to
reflux events. There were 18 episodes of sensing food in her
throat of which all 18 were correlated to reflux. Therefore, the
reflux symptom index was 82% with coughing and 100% for
regurgitation.
Figure 8 Combined multichannel intraluminal impedance and pH catheter.
GI Motility online (May 2006) | doi:10.1038/gimo31
Figure 9 Gastroesophageal reflux detected by combined multichannel
intraluminal impedance and pH (MII-pH) monitoring.
GI Motility online (May 2006) | doi:10.1038/gimo31
pH Impedance Testing
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Discriminates acid, nonacid reflux, gas
Acid: classical GERD, responds to PPI
 Nonacid: i.e. pancreaticobiliary secretions
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Best used with atypical symptoms
Usually endoscopy is normal
 24 hour pH testing may not reveal significant acid
reflux
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Advantages/Disadvantages
of MII-pH
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Highest sensitivity for detecting all reflux
episodes
Assess location, distribution and composition
Example: Mainie, et al showed that 37% of
patients on PPI therapy had nonacid reflux and
would have originally tested negative on
conventional pH testing
Disadvantage: considerable training for
interpretation; not widely available
Long story short . . .
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CXR in f/u showed new lung opacities which
were corroborated on CT
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Bronchoscopy with BAL was normal
Cardiac ECHO to evaluate for endocarditis was
negative
Further ENT evaluation with LandmarX
protocol negative for sinus disease
And she lived happily ever after
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Dr. Gould referral for Nissen with persistent
reflux, aspiration pneumonia, chronic cough
Surgery felt ideal option would be Nissen given
paraesophageal hernia and GERD with
significantly positive pH impedance study
Surgery successful – no preoperative symptoms
remained, voice normal
Extraesophageal Symptoms
Pulmonary
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Asthma – nonseasonal, nonallergenic
Chronic bronchitis
Aspiration pneumonia
Bronchiectasis
Pulmonary fibrosis
COPD
Pneumonia
Nord, 2004.
Extraesophageal Symptoms
ENT
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Chronic cough
Laryngitis
Hoarseness
Globus
Pharyngitis
Sinusitis
Vocal cord granuloma
Laryngeal carcinoma (possible)
Extraesophageal Symptoms
Others
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Noncardiac chest pain
Dental erosion
Sleep apnea
GERD and Sinonasal Symptom
Association
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1878 adults, community dwelling
Sinonasal sx in 71% of subjects
 Reflux in 59%
 Co-occurrence of symptoms in 45%
 Those with both GERD and sinus sx scored
significantly worse on disease-specific and general
physical and mental QOL questionnaires than those
with either symptom alone
 CONCLUSION: Dual diagnoses sx are common
and co-occur to a greater degree than chance alone
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Pasic, T., et al. 2007
How do you know it’s not just plain asthma?
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Asthma manifesting in adulthood
No FH of asthma
Dx of GERD predates asthma dx
Asthma worsened with exercise, eating or supine
posture
Nocturnal resp sx
Pharmacologic agents such as B2 agonists no effect or
worsen sx
Difficult-to-control symptoms requiring steroids
Absence of allergic component to asthma symptoms
Nord, 2004.
Management of Atypical GERD
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Require longer therapy AND/OR increased
dosages
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However nonacid reflux usually persists despite
PPI therapy
GERD and Asthma management
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May require double the standard dose of
treatment
Requires 2-3 months minimally
Kiljander, T, 2003
Controversy with Management
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Controversial thoughts on best management:
Surgery with fundoplication – may not reliably
improve laryngeal sx
 Referral to taste/swallow center, speech or diet
counseling
 Psychoactive medications
 Promotility agents seemed to provide partial sx
improvement in 25% of patients
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Pasic. T., et al, 2007
References
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Nord, H. J. (2004). Extraesophageal symptoms:
What role for the proton pump inhibitors? The
American Journal of Medicine, 117 (5), 56S.
Malhotra, A., Freston, J. & Aziz, K. (2008). Use of pHImpedance testing to evaluate patients with
suspected estraesophageal manifestations of
gastroesophageal reflux disease. Journal of Clinical
Gastroenterology, 42(3), 271.
Kiljander, T. (2003). The role of proton pump
inhibitors in the management of GERD-related
asthma and chronic cough. The American Journal of
Medicine, 115 (3A).
References, cont
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Pasic, T., et al. (2007). Association of extraesophageal
reflux disease and sinonasal symptoms: Prevalence
and impact on quality of life. Laryngoscope, 117,
2218.
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Tutuian, R., et al. (2006). Nonacid reflux in patients
with chronic cough on acid-suppressive therapy.
Chest, 130 (2).