THE MANAGEMENT OF COUGH
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1 THE MANAGEMENT OF COUGH Dr. Lo Iek Long Department of Respiratory Medicine, CHCSJ 1 Apr 2012
2 Cough
3 Complications of cough Insomnia Lower ribs fracture Prolapsed uterine Hernia Urinary incontinence
4 Classification of cough Acute < 3 weeks Sub-acute 3-8 weeks Chronic > 8 weeks
5 ACUTE COUGH < 3 weeks
6 Acute cough Common cold Severe illness Pneumonia (chest pain, SOB) CHF (SOB, pedal edema; rales heard) Pulmonary embolism (hemoptysis, chest pain, SOB) Exacerbation of chronic illness Smoking COPD Atopy Asthma Recurrent lung infection (childhood) Bronchiectasis
7 Our management for common cold Symptoms Runny nose / sneezing medication Antihistamine (1 st, 2 nd, 3 rd generation) Stuffy nose Decongestant (pseudoephedrine, 偽麻黃 ): Telfast D / Clarinase Cough Sore throat Fever Anti-tussive (dry cough) Expectorant (productive) Tantum verde, Serratiopeptidase ( 蛋白質分解酵素 ) Paracetamol
8 Antihistamine ( 抗敏感藥 ) Sedating Non-sedating Generation 1 st 2 nd 3 rd Medication Diphenhydramine (Benylin) Fexofenadine (Telfast) Cetirizine (Zyrtec) Hydroxyzine Loratadine Desloratadine (Atarax) (Claritin) (Aerius) Ketotifen Remarks Anti-cholinergic effect Comes with Pseudoephedrine Once daily
9 Non-sedating antihistamine for common cold? Non-sedating antihistamine has not been proven to be effective! De Sutter AIM, et al. Antihistamines for the common cold (archive). accessed 23/03/121
10 Although antihistamines are commonly prescribed for the common cold, there is little evidence as to whether these drugs are effective. Antihistamines do not alleviate nasal congestion, rhinorrhea and sneezing, or subjective improvement of the common cold. Combinations of antihistamine with decongestant show a beneficial effect on general recovery as well as on nasal symptoms (but not cough). First-generation antihistamine is better for cough. Published Online: 8 JUL 2009
11 OTC medication
12 Composition of the OTC Medication Day Night Antipyretic( 退燒 ) Anti-tussive( 止咳 ) Expectorant( 化痰 ) Decongestant( 通鼻塞 ) Paracetamol 300mg Carbetapentane 15mg Bromhexine 4mg Phenylephrine 10mg Other Caffeine 30mg Chlorpheniramine 4mg
13 Common cold summary Newer generation antihistamines alone should not be prescribed for patients with common cold. A combination of antihistamine and decongestant (e.g. Telfast D and Clarinase) may alleviate nasal symptoms, but not cough. If cough is the major symptom, first-generation antihistamine (e.g. Atarax, Benylin) or anti-tussive /expectorant should be used.
14 Anti-tussive ( 止咳 ) & expectorant ( 化痰 ) Anti-tussive Expectorant indication Dry cough Productive cough Common medications Dextromethorphan with Gauifenesin (Robitussin) Codeine Bromhexine Ambroxol Carbocysteine Acetylcysteine
15 SUBACUTE COUGH 3-8 weeks
16 Post-infectious (viral) cough 1. URTI symptoms Antihistamine + decongestant x 1 week 2. Sinusitis? Antibiotics (Cefuroxime or Azithromycin) x 1 week 3. Allergy? Inhaled steroid + bronchodilator x 4 weeks, or Leukotriene antgonist (Montelukast) x 4 weeks
17 CHRONIC COUGH > 8 weeks
18 Guidelines on chronic cough American College of Chest Physician (ACCP) 1998, 2006 European Respiratory Society (ERS) 2004 British Thoracic Society (BTS) 2006 Japanese Respiratory Society (JRS) 2006 Chinese Society of Respiratory Disease (CSRD) 2005
19 Rule out serious causes Red flag: hemoptysis, chest pain, breathlessness Suspicion of lung cancer Suspicion of tuberculosis Suspicion of inhaled foreign body
20 First things to do Smoking status Medication review: Angiotensin-converting enzyme inhibitor (ACE-I) Cough should improve or resolve within 4 weeks Chest radiograph Lung mass Cardiomegaly with lung congestion Bronchiectasis / Tb sequela / ILD
21 Pathogenic triad of chronic cough In non-smokers who have normal CXR and are not taking ACE-I: (Post nasal drip syndrome ) 鼻水倒流 (Gastro-esophageal reflux disease) 胃酸倒流 Palombini BC, et al. A pathogenic triad in chronic cough: asthma, postnasal drip syndrome, and gastroesophageal reflux disease. Chest 1999;116:
22 Common causes of chronic cough ¼ 1/5 1/3 ERS Task Force. The diagnosis and management of chronic cough. Eur Respir J 2004; 24:
23 Other causes of chronic cough Eosinophilic bronchitis ( 嗜酸粒细胞性支气管炎 )accounts for 13 to 31% of patients with chronic cough Pratter MR. Chest 2006; 129: 59S 62S
24 Eosinophilic airway diseases Eosinophilic bronchitis Eosinophilia Eosinophilia Cough Cough-variant asthma (CVA) Asthma Cough BHR Eosinophilia Cough BHR Wheeze/SOB Treatment Inhaled steroid Leukotriene antagonist ± bronchodilator in CVA and asthma BHR: bronchial hyper-responsiveness
25 History and physical examination Allergic rhinitis Asthma / CVA GERD Risk factors Atopy Obesity Medical history Allergic diseases, e.g. allergic conjunctivitis, rhinitis, asthma, eczema, urticaria, etc. Hiatal hernia Symptoms and signs Runny nose Sneezing / Itching Congestion Throat clearing Breathlessness Chest tightness Wheezing Heart-burn Acid regurgitation Remark Poor association between nasal symptoms and cough Cough can be the only symptom, investigate the trigger Reflux associated cough may occur in the absence of GI symptoms CVA: cough variant asthma; GERD: gastro-esophageal reflux disease
26 Further testing Allergic rhinitis Asthma / CVA GERD Allergy testing General: Eosinophil count, Total IgE Specific: RAST, skin-prick test N/A Further testing N/A Lung function test Peak flow meter Specific test N/A Methacholine challenge test Upper endoscopy (esophagitis) 24-hour ambulatory esophagus ph monitoring Complications Nasal polyp Turbinate hypertrophy Sinusitis Respiratory failure CVA: cough variant asthma; GERD: gastro-esophageal reflux disease Esophagitis Barret's esophagus
27 Therapeutic trial Allergic rhinitis Asthma / CVA GERD Therapeutic trial Antihistamine + decongestant, or Nasal steroid Oral or Inhaled corticosteroid + bronchodilator Lifestyle modification + high dose PPI Duration 2 weeks, 4 weeks 2 weeks, 4 weeks 8-12 weeks Second-line Leukotriene receptor antagonist x 2-4 weeks Prokinetic agents Referral ENT Pneumology GI team / surgery CVA: cough variant asthma; GERD: gastro-esophageal reflux disease
28 Steroid Nasal steroid Inhaled steroid Indications Allergic rhinitis Asthma / CVA / eosinophilic bronchitis Medication Beclomethasone (Beconase) Fluticasone (Avamys) Mometasone (Nasonex) Beclomethasone (Becotide) Budesonide (Pulmicort) Fluticasone (Seretide)
29 Therapeutic algorithm ERS task force. The diagnosis and management of chronic cough. Eur Respir J 2004;24:
30 Referral
31 Pneumology referral Sputum should be collected before referral Acid-Fast Bacilli x 3 Sputum cytology (atypical cells) x 3 Eosinophil count (> 3%) Further investigations High-resolution computed tomography (HRCT) Bronchoscopy Bronchial challenge test
32 ENT referral (chronic pharyngitis) Nasal block Throat discomfort Foreign body sensation Alteration of voice
33 Causes of chronic pharyngitis Nasal block Nasal polyp Turbinate hypertrophy Sinusitis Local infection Tonsillitis Irritation Smoke Alcohol Dust GERD Faulty voice production
34 Management of chronic pharyngitis Causes Local infection (sinusitis, tonsillitis) Nasal block (mouth breathing) Management Antibiotics Tonsillectomy, improve sinus drainage Treat allergic rhinitis Resection of polyp, turbinate, or adenoids Environmental irritation Avoid smoking, alcohol, spicy food and cold drinks Faulty voice production Voice rest, speech therapy GERD Life-style change, PPI
35 中醫理論 : 五臟六腑皆令人咳 同病異治
36 Experts in treating chronic cough 異病同治
37 Take home messages Acute cough (common cold): Antihistamine + decongestant for nasal symptoms First-generation antihistamine or anti-tussive for cough Sub-acute (post infectious) cough: Antihistamine + decongestant Antibiotics Leukotriene antagonist / ICS Chronic cough Smoking, ACE-I, CXR Allergic rhinitis, asthma, GERD Referral
38 Thank you!
39 Further reading PowerPoint: Download at: Review article (HKMA): download at: 2.pdf
40 Special consideration in children Respiratory tract infections, asthma, and gastroesophageal reflux disease are the most common causes of chronic cough in children. Foreign body aspiration should be considered in young children. Congenital conditions, cystic fibrosis, and immune disorders are possible diagnoses in children with chronic cough and recurrent infection. Am Fam Physician 2004;69: ,2169
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