Cough. Vincent Esguerra, MD

Transcription

1 Cough Vincent Esguerra, MD Assistant Professor-Clinical Medicine Division of Pulmonary, Critical Care, and Sleep Medicine The Ohio State University Wexner Medical Center Cough; A Common Sign 1

2 Cough; A Common Sign Cough; A Common Sign 2

3 Cough; A Common Sign Cough; A Common Sign 3

4 Cough; A Common Sign Cough; A Common Sign My dear doctor, I am surprised to hear you say that I am coughing very badly, as I have been practicing all night. - John Philpot Curran 4

5 Cough as a Societal Burden Most common cause to seek medical attention ~12% of US population suffering from chronic cough Cost is approximately 3-10 billion dollars every year Why Do We cough? Protective reflex Vector for disease spread 5

6 Why Do We cough? Protective reflex Vector for disease spread Cough Reflex Arch Sensory Component (Vagus Nerve) Ear Canals Pharynx Trachea Carinas Pleura Pericardium Esophagus and Stomach 6

7 Cough Reflex Arch Sensory Component (Vagus Nerve) Ear Canals Pharynx Trachea Carinas Pleura Pericardium Esophagus and Stomach Cough Reflex Arch Sensory Component (Vagus Nerve) Ear Canals Pharynx Trachea Carinas Pleura Pericardium Esophagus and Stomach 7

8 Cough Reflex Arch Motor Component Diaphragm Intercostal Muscles Epiglottis Pelvic Sphincter Muscles Cough Reflex Arch End result is foreign material, mucus, saliva droplets being expelled at mph 8

9 Cough Reflex Arch End result is foreign material, mucus, saliva droplets being expelled at mph Excessive coughing Self consciousness Urinary Incontinence Hoarseness Insomnia Dizziness Headache Rib fractures Emesis Pneumothorax Arrhythmias 9

10 Logical Approach to Cough Duration Acute : 0-3 weeks symptoms duration Subacute : 3-8 weeks symptom duration Chronic : > 8 weeks duration of symptoms without intervening resolution Associated Signs and Symptoms (Red Flags) Hemoptysis Lack of resolution with antibiotics Pleuritic chest pain Adventitious breath sounds B symptoms Cough Questionnaires Used mainly for research purposes Can be useful in specially designated cough clinics Helpful in judging the severity of cough but not causation 10

11 Helpful Physical Exam Findings Pulmonary Exam Egophony (highest +LR ratio for pneumonia) Wheezes Crackles (wet or dry) Rhonchi Dullness to percussion Chest wall tenderness Helpful Physical Exam Findings Extra-Pulmonary Exam Edema and jugular venous distension Clubbing Dental carries Posterior oropharyngeal erythema and nodularity Lymphadenopathy Otoscope exam of the ear and nasal passages 11

12 Acute Cough Upper respiratory tract infection Bronchitis, bronchiolitis, and pneumonia Heart failure Aspiration Inhalational injury or exposure Acute Cough Treatment 12

13 Acute Cough Treatment Acute Cough Treatment 13

14 Acute Cough Treatment Acute Cough Treatment 14

15 Acute Cough Treatment Acute Cough Treatment 15

16 Approach to Cough Carleen Risaliti, MD Assistant Professor-Clinical Medicine Division of Pulmonary, Critical Care, and Sleep Medicine The Ohio State University Wexner Medical Center Case 74 yo man presents as a new patient for evaluation of chronic cough Cough x 5 years progressively worse Productive of clear sputum No hemoptysis No fevers/chills, no night sweats 16

17 Case PMH: DM HTN HLD GERD OSA Chronic sinus disease PSH: Tonsillectomy FH: CAD/MI, DM SH: +Former smoker with a 10 pack-year smoking history; quit 33 years ago Common Causes of Chronic Cough Upper airways cough syndrome (post-nasal drip) Asthma GERD Medication side effects (ACE-i) Eosinophilic bronchitis 17

18 Upper Airways Cough Syndrome Most common cause of chronic cough Signs/symptoms: Nasal congestion/drainage Voice changes Throat-clearing Cobble-stoning of pharynx Testing Usually not necessary treat empirically first if high suspicion CT sinuses mucosal thickening, opacification Allergen testing Upper Airways Cough Syndrome - Treatment Topical/nasal corticosteroids Oral antihistamines Topical/nasal anticholinergic (i.e. ipratropium bromide) Nasal decongestant vasoconstrictor sprays (i.e. afrin/oxymetazoline) Oral leukotriene modifiers (especially if patient also has asthma) 18

19 Asthma Signs/symptoms: History of atopic disease Family history of asthma Nighttime cough Concurrent wheezing/dyspnea Testing Spirometry Asthma - Treatment Treatment based on severity NHLBI

20 Gastroesophageal Reflux Disease Aspiration Activation of esophageal-bronchial cough reflex Irritation of cough receptors in the larynx/vocal cords and trachea Gastroesophageal Reflux Disease Signs/symptoms: Symptoms worse with laying flat/at night Hoarseness Sore throat Globus sensation Concurrent heartburn Posterior vocal cord inflammation Testing 24-hr esophageal ph monitoring 20

21 Gastroesophageal Reflux Disease - Treatment Proton-pump inhibitor (PPI) Lifestyle modifications Weight loss Avoidance of caffeine, smoking Elevation of the head-of-bed Case PMH: DM HTN HLD GERD OSA Chronic sinus disease PSH: Tonsillectomy FH: CAD/MI, DM SH: +Former smoker with a 10 pack-year smoking history; quit 33 years ago 21

22 Case Physical Exam: VS: BP 130/82; HR 65; O2 sat 94% on RA HEENT: Nose: +Boggy turbinates, no polpys; Oropharynx: No cobble-stoning CV: RRR Lungs: Clear to auscultation. No wheezes, crackles Abd: Distended. Soft, non-tender Extrem: Trace edema Neuro: Non-focal Skin: No rash 22

23 Case EGD (2015): Grade A esophagitis What s the diagnosis? Upper Airways Cough Syndrome Asthma, cough variant GERD Other Chronic sinus disease Symptoms worse at night History of esophagitis History of HTN and DM double check meds +Nasal congestion +Heartburn Symptoms worse at night 23

24 Multi-factorial! Chronic cough: Likely multi-factorial secondary to upper airways cough syndrome (post-nasal drip) +/- obstructive lung disease in the setting of underlying GERD Plan Prescribed Flonase Recommended oral antihistamine Educated about lifestyle modifications for GERD Encouraged PPI Ordered spirometry prior to next visit Non-asthmatic Eosinophilic Bronchitis Signs/symptoms: Cough Normal spirometry/no bronchospasm Sputum with eosinophilia Elevated exhaled nitric oxide Treatment: Inhaled corticosteroids Oral corticosteroids 24

25 Medication Effects ACE-I Can present immediately or months later Cough usually resolves 1-4 weeks after stopping medication Sitagliptin Other Causes of Chronic Cough Chronic bronchitis/copd Bronchiectasis Post-infectious cough (i.e. Bordetella pertussis) Malignancy Primary pulmonary malignancy Metastatic disease Sarcoidosis Chronic aspiration Interstitial lung disease Habit cough/psychogenic cough Unexplained chronic cough ( idiopathic cough) 25

26 Assess for Red Flags! Weight loss Hemoptysis Occupational/environmental exposures Still no luck? Time to refer! 26

27 Still no luck? Time to refer! ENT/Allergy Gastroenterology Pulmonary Still no luck? Time to refer! ENT/Allergy Gastroenterology Pulmonary 27

28 But while you wait If no evidence of GERD, stop PPI Ensure patient is not on an aceinhibitor Consider referral to speech language pathology (SLP) Cough suppression techniques Reduction of laryngeal irritation Education Psychosocial education, counseling Gibson et al, CHEST 2016 Smith and Woodcock, NEJM 2016 Cough Suppression Therapies Should only be considered after therapies directed at etiology of cough have been tried 28

29 Cough Suppression Therapies Class Examples Notes/Caveats Opioids Morphine, codeine Can cause dependency; respiratory depression Non-opioids Local anesthetics (via nebulizer) Expectorants/ Mucolytics Aromatic agents Antidepressants; antiepileptics; antispasmotics Dextromethorphan (synthetic derivative of morphine) Lidocaine Acetylcysteine, carbocisteine Eucalyptus/menthol TCAs; Paroxetine; gabapentin*; baclofen At least as effective as codeine Variable results Alter volume/consistency of secretions Gabapentin is associated with improvement in QoL in RCT Murray and Nadel 2010 References Chung KF, Widdicombe JG. Cough. In: Mason RJ, Broaddus VC, Martin TR et al, editors. Murray and Nadel s Textbook of Respiratory Medicine. 5 th ed. Philadelphia: Saunders Elsevier; 2010, p Gibson P, Wang G, McGarvey L et al. Treatment of unexplained chronic cough: CHEST guideline and expert panel report. CHEST 2016;149(1): Irwin RS, French CL, Chang AB, Altman KW. Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report. CHEST Article in Press. Irwin RS and Madison M. The diagnosis and treatment of cough. NEJM 2000;343: National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda: National Institutes of Health National Heart, Lung, and Blood Institute; 2007, p Available from: Smith JA and Woodock A. Chronic cough. NEJM 2016;375(16):