11/15/2017. Highgate Private Hospital (Royal Free London NHS Foundation Trust) Causes of chronic cough

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1 A whistle stop of Chronic Cough For 10min consultations.. Dr Dean Creer Consultant Chest Physician (MBChB, FRCP) Highgate Private Hospital (Royal Free London NHS Foundation Trust) E: Causes of chronic cough Asthma, cough variant asthma, and non-asthmatic eosinophilic bronchitis. Upper airway cough syndrome, most commonly caused by chronic rhinitis or chronic sinusitis. Gastro-oesophageal reflux. Smoking-related causes, including smoker's cough, chronic bronchitis, and COPD. Angiotensin-converting enzyme (ACE) inhibitors. Clinical evaluation of chronic cough A detailed history including occupational history should be performed. Physical examination should concentrate on the afferent sites identified as most commonly associated with cough. The evaluation of patients with chronic cough should include an assessment of health status and cough severity. CXR and spirometry are mandatory. BTS recommendations for cough management in adults.thorax 2006;61(Suppl I):i1 i24. 1

2 Upper airway cough syndrome (UACS) Several studies suggest that upper airway cough syndrome related to postnasal drip is a common cause of subacute and chronic cough Underlying reasons for postnasal drip include: o Allergic o Perennial nonallergic, o vasomotor rhinitis o Acute nasopharyngitis o Sinusitis Symptoms of postnasal drip include frequent nasal discharge, a sensation of liquid dripping into the back of the throat, and frequent throat clearing 2

3 UACS - treatment Intranasal glucocorticoids are the most effective therapy for symptoms of allergic rhinitis but may take up to two weeks to achieve maximal effect. If the patient responds, therapy is continued for approximately three months. Additional therapies for allergic rhinitis include oral and nasal antihistamines, oral leukotriene receptor antagonists In addition, intranasal glucocorticoids are effective for several types of nonallergic rhinitis, including nonallergic rhinitis with eosinophilia (NARES) and vasomotor rhinitis The diagnosis and management of rhinitis: an updated practice parameter. Wallace et al. J Allergy Clin Immunol. 2008;122(2 Suppl):S1. Cough Variant Asthma Asthma and CVA is the second leading cause of persistent cough in adults Cough due to asthma is commonly accompanied by episodic wheezing and dyspnoea. "cough variant asthma has an isolated cough Is suggested when: o Personal or family history of asthma o Cough is seasonal or follows an URTI o Cough worsens on exposure to cold, dry air, dust, mold, or to certain fumes or fragrances o Cough associated with a beta-blocker FeNO 3

4 Cough variant asthma: treatment Therapy for cough variant asthma follows the same general principles as standard therapy for asthma (but not for LABA s). LTRAs are an alternative among patients who wish to avoid or who have not responded to ICS. For patients with a disabling cough, a short course of prednisolone is often successful Cough is unlikely to be due to eosinophilic airway inflammation if there is no response to a 2 week oral steroid trial BTS recommendations for cough management in adults.thorax 2006;61(Suppl I):i1 i24. GORD GORD is often reported to be the second or third most common cause of persistent cough Many patients complain of symptoms of GORD But symptoms are absent in > 40% in whom cough is due to reflux Gastroesophageal reflux can also contribute to asthma symptoms. A Vicious Cycle 4

5 GORD cough: lifestyle changes Weight loss and smoking cessation Elevation of the head of the bed Avoidance of reflux-inducing foods (eg, fatty foods, chocolate and drinks (eg, colas, red wine, orange juice) Avoidance of meals for two to three hours before lying down (except for medications) Elimination of medications potentially worsening reflux (bisphosphonates, nitrates, CCB s, theophyllines) GORD Cough: treatment PPI s: Omeprazole 20-40mg BD with meals x 8-12 weeks Prokinetics: Metoclopramide 10mg TDS? Nocturnal Ranitidine 300mg (for full suppression) The role of surgery is unclear BTS recommendations for cough management in adults.thorax 2006;61(Suppl I):i1 i24. Cough hypersensitivity syndrome Cough is the primary condition characterised by afferent neuronal hypersensitivity and different aspects of the syndrome are manifest in the different phenotypes of cough The patient does have a disease; it is just that its origin may be mysterious. communicating with the patient is facilitated by the diagnosis of the cough hypersensitivity syndrome. too often an isolated chronic cough is dismissed as psychogenic or worse. Morice, A. Cough. 2013; 9: 14. 5

6 Non-Specific Treatments Several studies have noted a substantial minority of patients who do not respond or respond inadequately to specific interventions and treatments unexplained chronic cough, chronic idiopathic cough, or cough hypersensitivity syndrome Dextromethorphan Amitryptilline Gabapentin Codeine Complications of Cough 6

7 Dr Dean Creer Consultant Chest Physician (MBChB, FRCP) Highgate Private Hospital (Royal Free London NHS Foundation Trust) E: 7