2. Recommended Reading
•The Diagnosis and Treatment of Cough
Richard S. Irwin and J. Mark Madison
NEJM Volume 343, Number 23
Pages 1715-1721. December 2000
•Diagnosis and Management of Cough
Executive Summary. ACCP Evidence-
Based Clinical Practice Guidelines
Chest Volume 129 Supplement 2006
3. Recommended Reading
•Prevalence, pathogenesis, and causes of
chronic cough
Kian F. Chung and Ian D. Pavord
Lancet 371(9621):
Pages 1364-74 April 2008
•Management of chronic cough
Ian D. Pavord and Kian F. Chung
Lancet 371(9621):
Pages 1375-84 April 2008
4. Recommended Reading
•Concise Clinical Review: Controversies in the
Evaluation and Management of Chronic Cough
Surinder S. Birring
Am J Resir Crit Care Med 183(6)
Pages 708-715 March 2011
5. Cough 101
• Acute cough
– Lasting less than 3 weeks
• Sub-acute
– Lasting 3-8 weeks
• Chronic cough
– Lasting 8 weeks or more
Cough is the most common reason
patients seek medical attention in
the United States
6. Acute Cough
• Duration less than 3 weeks
• Most commonly due to:
1. Upper respiratory tract infection
2. Lower respiratory tract infection
3. Pulmonary embolism
7. Acute Cough
• Duration less than 3 weeks
• Most commonly due to:
1. Upper respiratory tract infection
2. Lower respiratory tract infection
3. Pulmonary embolism
9. Cough and Pulmonary Embolism
• Which of the following statements are
true about cough and acute PE
a) Cough associated with PE is usually
productive
b) Cough is present in 50% of patients with PE
c) Cough is the predominant symptom in some
patients with PE
d) The severity of cough predicts the extent of
thromoboembolism in patients with PE
10. Cough and Pulmonary Embolism
• Which of the following statements are
true about cough and acute PE
a) Cough associated with PE is usually
productive
b) Cough is present in 50% of patients with PE
c) Cough is the predominant symptom in some
patients with PE
d) The severity of cough predicts the extent of
thromoboembolism in patients with PE
11. Life-threatening causes of
acute cough
High index of suspicion in the elderly because
classic signs/symptoms may be absent
Pulmonary embolism Heart Failure Pneumonia
14. Post-infectious cough
• Cough more than 3 weeks following an
upper or lower respiratory tract infection
• Usually resolves in 4 weeks
• Anti-tussive medications and steroids
can help with symptoms
15. Chronic Cough
• Chronic cough of undetermined etiology
accounts for 10-40% of a
pulmonologist’s outpatient practice
16. How good can we be
at making a diagnosis?
• Studies show that the etiology of chronic
cough can be determined by a well-
trained pulmonologist…..
a) Less than 50% of the time
b) 60-70% of the time
c) 70-80% of the time
d) 80-90% of the time
e) 90-100% of the time
17. How good can we be
at making a diagnosis?
• Studies show that the etiology of chronic
cough can be determined by a well-
trained pulmonologist…..
a) Less than 50% of the time
b) 60-70% of the time
c) 70-80% of the time
d) 80-90% of the time
e) 90-100% of the time
18. How good can we be
at making a diagnosis?
• Studies show that the etiology of chronic
cough can be determined by a well-
trained pulmonologist…..
a) Less than 50% of the time
b) 60-70% of the time
c) 70-80% of the time
d) 80-90% of the time
e) 90-100% of the time
19. Can you cure your patient?
• Studies show that treatment success rates
for chronic cough can be as high as…..
a) Less than 50%
b) 50-60%
c) 60-70%
d) 70-85%
e) 85-100%
20. Can you cure your patient?
• Studies show that treatment success rates
for chronic cough can be as high as…..
a) Less than 50%
b) 50-60%
c) 60-70%
d) 70-85%
e) 85-100%
21. Chronic Cough- Etiology
• In non-smoking adults with a normal
CXR who are not taking ACE inhibitors,
chronic cough is almost always due to
which of the following 3 conditions?
a) Congestive Heart Failure
b) Upper Airway Cough Syndrome (UACS)
c) Asthma
d) Gastroesophageal reflux disease (GERD)
e) Chronic Bronchitis
22. Chronic Cough- Etiology
• In non-smoking adults with a normal
CXR who are not taking ACE inhibitors,
chronic cough is almost always due to
which of the following 3 conditions?
a) Congestive Heart Failure
b) Upper Airway Cough Syndrome (UACS)
c) Asthma
d) Gastroesophageal reflux disease (GERD)
e) Chronic Bronchitis
26. Guideline for Evaluating
Chronic Cough
• A systematic, diagnostic approach has
been validated in immunocompetent
patients- 5 step plan:
– Step 1: Review history and exam focusing
on the most common causes of chronic
cough
– Step 2: Order a CXR in nearly all patients
(except perhaps young non-smokers with
presumed UACS)
27. Guideline for Evaluating
Chronic Cough
– Step 3: Do not order additional tests in
present smokers or patients taking ACE
inhibitors until the response to smoking
cessation or drug discontinuation for at least
4 weeks can be assessed. Cough due to
smoking or ACE inhibitors should improve
substantially or disappear during this time-
frame of abstinence.
– Step 4: Order additional diagnostic tests or
embark on empiric treatment
29. Guideline for Evaluating
Chronic Cough
– Step 5: Determine the cause(s) of cough by
observing which specific therapy eliminates
cough as a complaint.
• If the evaluation suggests more than one
possible cause, initiate treatment in the same
sequence that the abnormalities were discovered
• Since cough can be simultaneously caused by
more than one condition, do NOT stop therapy
that appears to be partially successful; rather,
sequentially add to it.
32. Upper Airway Cough Syndrome
• Common cause of chronic cough in all age
groups
– Second most common cause in children
– Most common cause in adults and the elderly
• In addition to cough, UACS can also cause
– Wheeze
– Dyspnea
33. Upper Airway Cough Syndrome
• Clues to UACS
– History of
• Need to frequently clear their throat
• Friend/relative notices that the patient frequently
clears their throat
• Sensation of dripping into throat
• Nasal symptoms
– Physical Exam demonstrating
• Secretions in nose or oropharynx
• Cobblestone appearance of mucosa
35. UACS
• Diagnosis of UACS as a cause of cough
is established when:
a) frequent throat clearing is elicited from
the history
b) cobblestoning and phlegm are present
on physical examination of the posterior
pharyxnx
c) cough responds favorably to specific
therapy aimed at eliminating the drip
36. UACS
• Diagnosis of UACS as a cause of cough
is established when:
a) frequent throat clearing is elicited from
the history
b) cobblestoning and phlegm are present
on physical examination of the posterior
pharyxnx
c) cough responds favorably to specific
therapy aimed at eliminating the drip
38. Treatment-Sinusitis
• Antibiotics directed against H. Flu, S.
Pneumonia, oral anaerobes
• Oral antihistamine/decongestant x 3 weeks
• Intranasal decongestant for maximum of 5
days
– e.g. oxymetazoline 2 sprays each nostril bid
x 3 days only
42. Treatment- other UACS
• Perennial non-allergic, post-infectious,
environmental irritant, vasomotor rhinitis
– Antihistamine/decongestant
– Intranasal steroids
– Intranasal ipratropium bromide for vasomotor rhinitis
– Non-histamine mediated rhinitidies do not respond
as well to newer generation H1-antagonists; try
older ones with anti-cholinergic activity
43. Asthma
• Second most common cause of cough in
adults
• Clues that chronic cough is due to
asthma:
– Episodic wheezing, dyspnea
– Reversible airflow obstruction
– Bronchial hyperresponsiveness
• Confirmed by resolution of cough with
asthma treatment
44. Cough Variant Asthma
• 30-60% of patients presenting with
chronic cough that was due to asthma
had cough as their ONLY symptom
46. Treatment- Asthma
• Inhaled corticosteroid
• ICS/LABA combination
• Oral steroids for empiric trial of
efficacy is not recommended
since oral steroids may improve
cough resulting from any
inflammatory disease
47. GERD
• Suspect GERD when…
– Symptoms of heartburn
or sour taste in mouth
– Reflux demonstrated by
• 24-hour pH-impedance monitoring
• Barium x-ray
• Cough is the only symptom of
GERD in 40-75% of patients
with chronic cough due to GERD
48. GERD
• Cough due to GERD occurs most
commonly while patients are awake and
upright, and usually does not occur or is
not noted during the night
• Diagnosis of GERD as cause of
chronic cough requires resolution of
cough with GERD treatment
49. Treatment- GERD
• Intensive anti-reflux medical regimen:
– Diet is most important factor
• High protein, low fat anti-reflux diet
• 3 meals per day
• Avoid food, drinks, and meds that lower esophageal
sphincter pressure
• NPO between meals and 2 hours prior to reclining
• Improve compliance by referring to dietician and monitoring
weight at follow-up visit
– Elevate head of bed 4 inches
– Proton pump inhibitors
50. Treatment- GERD
– Successful treatment for GERD takes on
average 161-179 days, vs. 67-70 days for
cough due to UACS or asthma
– Continue treatment for at least 3 months
after cough has disappeared as a complaint,
then gradually discontinue it
– If medical therapy fails
• Consider OSA
• Consider offending med
(CCB, nitrate, progesterone, theo)
• Consider surgery
52. ACE inhibitor cough
• Accounts for 2% of cases of chronic cough
• Non-productive, irritating, tickling, scratching
sensation in the throat
• Can occur after 1st
dose, or weeks to months
later
• Usually will recur with switch to any other ACE
inhibitor
• Diagnosis is confirmed when cough
disappears after drug in discontinued
54. Bronchogenic Carcinoma
• Cough is a common symptom of lung
cancer, but lung cancer is NOT a
common cause of chronic cough
• Suspicion for cancer as a cause of
cough should be heightened
– If CXR shows a central lesion
– In cigarette smokers who develop a new
cough that persists or have a change in
character of their chronic cough
56. Unexplained Chronic Cough
• Middle aged females around the onset of
menopause
• Onset triggered by a viral illness,
Bordetella pertussis, basidiomycetous
fungi
• Concomitant anxiety and depression (due
to the chronic, persistent cough)
• *psychogenic cough is extremely rare
57. Pathogenesis of Unexplained
Chronic Cough
• Cough reflex hypersensitivity
– Increased sensitivity to cough challenge with
capsaicin
– Increased density of sensory nerve fibers in
the airways
– Increased TRPV-1 receptor expression on
sensory c-fibers
59. Cough hypersensitivity syndrome
• Chronic cough > 2 months duration
• Minimal or no sputum production
• One or more cough reflex triggers (cold air,
speech, eating, odors such as perfumes)
• Urge to cough (tickle or itch) located in throat
• Adverse impact of cough on QOL
• Positive cough reflex challenge test (e.g.
capsaicin)
Acute cough algorithm for the management of patients ≥ 15 years of age with cough lasting < 3 weeks. For diagnosis and treatment recommendations refer to the section indicated in the algorithm. PE = pulmonary embolism; Dx = diagnosis; Rx = treatment; URTI = upper respiratory tract infection; LRTI = lower respiratory tract infection. Section 7 = Irwin8; Section 8 = Pratter9; Section 9 = Pratter10; Section 10 = Pratter11; Section 11 = Dicpinigaitis12; Section 12 = Irwin13; Section 13 = Braman14; Section 14 = Braman15; Section 16 = Rosen17; Section 22 = Irwin et al.23
88-100%
88-100%
Other causes of acute cough Pulmonary embolism Pneumonia Congestive heart failure Aspiration High index of suspicion of other causes in elderly b/c classic signs/sx may be absent
Subacute cough algorithm for the management of patients ≥ 15 years of age with cough lasting 3 to 8 weeks. For diagnosis and treatment recommendations refer to the section indicated in the algorithm. AECB = acute exacerbation of chronic bronchitis. See the legend of Figure 1 for abbreviations not used in the text. See Figure 1 for references to Sections.
Subacute cough algorithm for the management of patients ≥ 15 years of age with cough lasting 3 to 8 weeks. For diagnosis and treatment recommendations refer to the section indicated in the algorithm. AECB = acute exacerbation of chronic bronchitis. See the legend of Figure 1 for abbreviations not used in the text. See Figure 1 for references to Sections.
Cause of cough prospectively determined in 99% of patients (n=131) Single cause 73% of patients Multiple causes in 23% of patients Spectrum and frequency of cough: -PNDS,asthma,GERD made up 86% of causes -chronic bronchitis and bronchiectasis next -misc= bronchogenic ca in 2, LV dysfunction in 1, stage III sarcoid in 1, ACEI in 1, and aspiration from a Zenker’s diverticulum in 1
88-100%
88-100%
88-100%
88-100%
84-98%
84-98%
PNDS = UACS
Cause of cough prospectively determined in 99% of patients (n=131) Single cause 73% of patients Multiple causes in 23% of patients Spectrum and frequency of cough: -PNDS,asthma,GERD made up 86% of causes -chronic bronchitis and bronchiectasis next -misc= bronchogenic ca in 2, LV dysfunction in 1, stage III sarcoid in 1, ACEI in 1, and aspiration from a Zenker’s diverticulum in 1
When we evaluate the sinuses for sinusitis, we look for thickening of the lining of the sinus. Note on the patient's left side (your right) at the + sign, there is a very sharp distinct border between the black air in the maxillary sinus and the white bone. As you will see later, sinusitis is manifested by grayish thickening of the lining of the sinus. LEGEND: + - border of maxillary sinus, * - maxillary sinus ostium, U - uncinate process, E - ethmoid sinuses, IT- inferior turbinate, MT- middle turbinate, S - septum, C - concha bullosa. Note that the CT scan is a computerized X-Ray taken in the same way as the first diagram is drawn, as if you were able to look head on into the sinuses. Note that the patient's right side is on your left as indicated by the "right" mark in the upper left hand corner. On the CT scan, bone appears white, air appears black, and soft tissue, fluid, or muscle is varying shades of gray. Of note in the bottom portion of the scan is a ray pattern emanating from the teeth. This is as a result of poor penetration of the x-rays through the metal in the teeth. The asterisk (*) is at the point where drainage occurs from the maxillary sinus into the nose through part of the ostiomeatal unit . The maxillary sinus ostia is bounded below by the uncinate process (U) and above by the lower bony portion of the ethmoid sinuses (E). A narrowing in this area obviously can be very critical. The ethmoid sinuses, as can be seen, are much smaller than the maxillary sinuses. On the right side (your left), one can see the middle turbinate (MT) as well as inferior turbinate (IT). There is a slight deviation of the septum (S) to the right side (your left), but in this case it is unlikely that it is causing any obstruction. Of note is that there is air contained in the middle turbinate on the left (C-short for concha bullosa). This represents a normal anatomical variant in which the ethmoid sinuses have pushed down into the middle turbinate. In this case, it does not appear to have caused a problem, but often it will cause a significant enlargement of the middle turbinate and consequently an obstruction on one side of the nose. LEGEND: M - maxillary sinus, + - thickening of the maxillary sinus, E - ethmoid sinuses, P - polyp, O - maxillary sinus ostium, * - middle meatus . Attention should first be directed to the + sign on the right side. Compared to the previous scan, there is a significant amount of grayish thickening between the white bone and the black sinuses. Any thickening over 3 mm is definitely abnormal. Note that this thickening involves almost the entire maxillary sinus on both sides, but more so on the right side. Compare the area on the right side where the maxillary sinus ostium (O) was observed on the previous CT scan. There is no opening now, only the gray tissue completely blocking the ostium. Not surprisingly, this patient had a great deal of pain as a result of that blockage. Although there is more thickening of the sinus lining on the right, there is more room to breathe through the nose on the right side (*) than on the left side. This is largely as a result of the deformity of the middle turbinate, located just above the asterisk (compare to the opposite side). This may have contributed to the sinus disease in this case, causing obstruction of the ostiomeatal unit. Not surprisingly the ethmoid sinuses were involved as well. The ethmoid sinuses are either filled with polyps (P) or the lining is thickened. There is very little air left in the ethmoid sinuses (E).
Cause of cough prospectively determined in 99% of patients (n=131) Single cause 73% of patients Multiple causes in 23% of patients Spectrum and frequency of cough: -PNDS,asthma,GERD made up 86% of causes -chronic bronchitis and bronchiectasis next -misc= bronchogenic ca in 2, LV dysfunction in 1, stage III sarcoid in 1, ACEI in 1, and aspiration from a Zenker’s diverticulum in 1
Cause of cough prospectively determined in 99% of patients (n=131) Single cause 73% of patients Multiple causes in 23% of patients Spectrum and frequency of cough: -PNDS,asthma,GERD made up 86% of causes -chronic bronchitis and bronchiectasis next -misc= bronchogenic ca in 2, LV dysfunction in 1, stage III sarcoid in 1, ACEI in 1, and aspiration from a Zenker’s diverticulum in 1
Cause of cough prospectively determined in 99% of patients (n=131) Single cause 73% of patients Multiple causes in 23% of patients Spectrum and frequency of cough: -PNDS,asthma,GERD made up 86% of causes -chronic bronchitis and bronchiectasis next -misc= bronchogenic ca in 2, LV dysfunction in 1, stage III sarcoid in 1, ACEI in 1, and aspiration from a Zenker’s diverticulum in 1
Cause of cough prospectively determined in 99% of patients (n=131) Single cause 73% of patients Multiple causes in 23% of patients Spectrum and frequency of cough: -PNDS,asthma,GERD made up 86% of causes -chronic bronchitis and bronchiectasis next -misc= bronchogenic ca in 2, LV dysfunction in 1, stage III sarcoid in 1, ACEI in 1, and aspiration from a Zenker’s diverticulum in 1
Cause of cough prospectively determined in 99% of patients (n=131) Single cause 73% of patients Multiple causes in 23% of patients Spectrum and frequency of cough: -PNDS,asthma,GERD made up 86% of causes -chronic bronchitis and bronchiectasis next -misc= bronchogenic ca in 2, LV dysfunction in 1, stage III sarcoid in 1, ACEI in 1, and aspiration from a Zenker’s diverticulum in 1
Non-asthmatic eosinophilic bronchitis
Cause of cough prospectively determined in 99% of patients (n=131) Single cause 73% of patients Multiple causes in 23% of patients Spectrum and frequency of cough: -PNDS,asthma,GERD made up 86% of causes -chronic bronchitis and bronchiectasis next -misc= bronchogenic ca in 2, LV dysfunction in 1, stage III sarcoid in 1, ACEI in 1, and aspiration from a Zenker’s diverticulum in 1
Meds to avoid: nitrates, calcium channel blockers, progesterone, theophylline
Meds to avoid: nitrates, calcium channel blockers, progesterone, theophylline
Chronic cough algorithm for the management of patients ≥ 15 years of age with cough lasting > 8 weeks. ACE-I = ACE inhibitor; BD = bronchodilator; LTRA = leukotriene receptor antagonist; PPI = proton pump inhibitor. See the legend of Figure 1 for abbreviations not used in the text.
Cause of cough prospectively determined in 99% of patients (n=131) Single cause 73% of patients Multiple causes in 23% of patients Spectrum and frequency of cough: -PNDS,asthma,GERD made up 86% of causes -chronic bronchitis and bronchiectasis next -misc= bronchogenic ca in 2, LV dysfunction in 1, stage III sarcoid in 1, ACEI in 1, and aspiration from a Zenker’s diverticulum in 1
Cause of cough prospectively determined in 99% of patients (n=131) Single cause 73% of patients Multiple causes in 23% of patients Spectrum and frequency of cough: -PNDS,asthma,GERD made up 86% of causes -chronic bronchitis and bronchiectasis next -misc= bronchogenic ca in 2, LV dysfunction in 1, stage III sarcoid in 1, ACEI in 1, and aspiration from a Zenker’s diverticulum in 1
Cause of cough prospectively determined in 99% of patients (n=131) Single cause 73% of patients Multiple causes in 23% of patients Spectrum and frequency of cough: -PNDS,asthma,GERD made up 86% of causes -chronic bronchitis and bronchiectasis next -misc= bronchogenic ca in 2, LV dysfunction in 1, stage III sarcoid in 1, ACEI in 1, and aspiration from a Zenker’s diverticulum in 1
Cause of cough prospectively determined in 99% of patients (n=131) Single cause 73% of patients Multiple causes in 23% of patients Spectrum and frequency of cough: -PNDS,asthma,GERD made up 86% of causes -chronic bronchitis and bronchiectasis next -misc= bronchogenic ca in 2, LV dysfunction in 1, stage III sarcoid in 1, ACEI in 1, and aspiration from a Zenker’s diverticulum in 1
Meds to avoid: nitrates, calcium channel blockers, progesterone, theophylline
Meds to avoid: nitrates, calcium channel blockers, progesterone, theophylline
Meds to avoid: nitrates, calcium channel blockers, progesterone, theophylline
