Cough The Challenge of a Targeted Diagnosis

Michael A. Venditto DO, FACOI, FCCP

Cough - History
Some controversy over definitions Arguably the best
Acute: less than 3 weeks Sub acute: 3 to 8 weeks Chronic: more than 8 weeks
Richard Irwin, NEJM, Volume 343, Dec 7, 2000

Cough - Acute
Most common causes
Common cold Acute bacterial sinusitis Pertussis Exacerbation of COPD Allergic rhiniits Rhinitis 2 to environmental irritants

Cough Viral Infection

Upper respiratory viral infections are the most common cause of cough
83% within first 48 hours 26% on day 14

Arises from the stimulation of the cough reflex in upper airway by postnasal drip and/or clearing of the throat

Cough Viral Infection

Signs and symptoms include: rhinorrhea, sneezing, nasal obstruction, post nasal drip, irritation of the throat, +/- fever and normal chest exam
Diagnostic testing is not indicated in a immunocompetent patient as there is a very low yieldover 97% of CXR are normal

Acute Cough - Treatment

Dexbrompheniramine with pseudoephedrine
Curley, Am Rev Respir Dis, 1988, 138:305-311

Naproxen
Sperber, Ann Intern Med, 1992; 117:37-41

Ipratropium bromide No evidence of beneficial effects:

Intranasal steroids, systemic steroids, zinc lozenges, nonsedating antihistamines (H1 blocker) URI is not mediated by histamine

Cough - Acute
Bronchitis diagnosed incorrectly too often
Gonzales, JAMA, 1997; 278:901-904

Viral rhinosinusitis can present with cough and phlegm Think bacterial bronchitis and use antibiotics if
Exacerbation of COPD with worsening SOB or wheezing Cough and vomiting suggestive of Bordetella pertussis

Acute Cough - Treatment

Bacterial sinusitis can present like a viral rhinitis or rhinosinusitis Use antibiotics only if they fail to respond to the above therapy and two of the following:
Maxillary toothache Purulent nasal discharge, discolored nasal discharge Abnormal transillumination of any sinus

Usually not necessary to perform imaging studies

Cough - Acute
In elderly, classic signs and symptoms may be minimal, so consider
Pneumonia CHF Asthma Aspiration

Cough - Subacute
Most common etiologies
Postinfectious cough Bacterial sinusitis asthma

Postinfectious Cough
Postinfectious cough
Begins with respiratory tract infection NOT pneumonia Ultimately resolves without treatment Results from PND or clearing of throat With or without bronchial hyperresponsiveness

Postinfectious Cough - Treatment

Begin with treatment similar to the common cold If wheezing use bronchodilators
This does not make the diagnosis of asthma

If not resolved in one week

Imaging studies of the sinuses
Nasal decongestant for 5 days Antibiotics for 21 days

Chronic Cough
In immunocompetent patients, 95% caused by
Postnasal drip Asthma Gastroesophageal reflux Chronic bronchitis due to cigarette smoking Bronchiectasis Use of angiotensin-converting enzymes inhibitors

Chronic Cough

Evaluation of Chronic Cough

History
Character of cough, quality of the sound and the timing of cough (except the absence during sleep) have not shown to be useful

Physical
Oropharyngeal mucous or cobblestone appearance suggests postnasal-drip syndrome silent postnasal-drip syndrome

Evaluation of Chronic Cough

Heartburn and regurgitation suggest Gastroesophageal reflux disease
silentGERD in up to 75% of patients
Irwin,Chest 1993;104:1511-1517

Wheezing suggests asthma

silentasthma (cough variant asthma) in up to 57% of cases
Irwin, Am Rev Respir Dis 1981;123:413-417

Evaluation of Chronic Cough

Where to start
CXR: normal is consistent with PND, GERD, asthma, chronic bronchitis. Unlikely : bronchogenic carcinoma, sarcoid, TB and bronchiectasis Since PND syndromes are most common---start there
Sinusitis or rhinitis of the following varieties: nonallergic, allergic, postinfectious, vasomotor, drug-induced and environmental-irritant induced

Chronic Cough - PND

PND is by far the most common cause of chronic cough Since the signs and symptoms are nonspecific, the definitive diagnosis cannot be made by H and P alone Therapy
1st generation antihistamine and a decongestant

Therapy
Remember
The newer-generation H1 antagonist do not appear to be effective when cough induced by postnasal drip is not mediated by histamine
Irwin, Consensus Report of the American College of Chest Physicians. Chest 1998;114:suppl:133S-181S.

Chronic Cough Asthma

Cough can be the only symptom of asthma in up to 57% of patientscough-variant asthma +/- airflow obstruction on PFTs Therapy
If severe, PO steroids followed by inhaled steroids for 6-8 weeks with 2 agonist If mild, inhaled steroids with 2 agonists

Chronic Cough
Asthma
Response to asthma therapy does not make the diagnosis of asthma since allergic rhinitis will respond to anti-inflammatory therapy also Consider methacholine challenge testing
Negative predictive value is 100% Positive predictive value is 60-88%

Chronic Cough -- GERD

Etiology
Gross aspiration including pulmonary aspiration syndromes, abscess, chronic bronchitis, bronchiectasis, and pulmonary fibrosis Laryngeal inflammation Vagally mediated distal esophagealtracheobronchial reflex

Chronic Cough -- GERD

When GERD is cause of chronic cough, up to 75% of patients have no GI symptoms 24-h esophageal pH monitoring is best
Negative predictive value is less than 100%
Positive predictive value is 89 Inconvenient for the patient Non consensus about the best way to interpret the results

Chronic Cough
GERD
24-hour esophageal monitoring is not routinely recommended

Empiric therapy can if tried if

GI complaints compatible with GERD or No GI complaints with normal CXR, no ACEI, who do not smoke and in whom PND and asthma have been eliminated.

Chronic Cough -- GERD

Therapy should include: H2 blockers, dietary (high-protein, low fat diet) and life style changes (weight reduction, no caffeine or smoking) Improvement may take 2-3 months to begin and the MEAN TIME TO RECOVERY IS 161-179 DAYS.

Chronic Cough -- ACEI

Class effect of drug; not drug related Incidence of 0.2 to 33%; true incidence 10% Cough may appear within a few hours up to months after taking the first dose Pathogenesis seems be an accumulation of inflammatory mediators: bradykinin, substance P and/or prostaglandins

Chronic Cough

Chronic Cough -- ACEI

Therapy
STOP ACEI Other therapies include oral sulindac, indomethacin, ASA and even oral iron

Chronic Cough -- ACEI

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Chronic Cough

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