Prevalence Evaluation and Management of All types of cough Cough - PDF document

Prevalence Evaluation and Management of • All types of cough Cough � 3.6% of visits to primary care � 29.5 million visits per year Karen Wood, MD and Arick Forrest, MD • Chronic Cough � One of the most common reasons for Ohio State University Medical Center new patient visits to a pulmonologist. October 19, 2007 Objectives Complications • Recognize causes and complications of • Embarrassment / self consciousness subacute and chronic cough. • Urinary incontinence • Examine treatments for post-infectious • Disturbed sleep / fatigue cough. • Dizziness / syncope • Review a standard diagnostic approach and treatment strategy to apply to chronic cough. 1

Definitions Acute Cough • Acute cough - < 3 weeks • Other � Infectious • Subacute cough – 3-8 weeks � Exacerbation of pre-existing condition • Chronic cough - > 8 weeks • Asthma • Bronchiectasis • Upper Airway Cough Syndrome (UACS) • COPD Subacute cough algorithm >= 15 years old Acute Cough • Severe or life threatening disease � Pneumonia � PE � Heart Failure � Severe exacerbation of asthma or COPD Irwin, R. S. et al. Chest 2006;129:1S-23S 2

Bordetella pertussis Subacute Cough “whooping cough” • May be a postinfectious etiology • Mechanisms include: • Highly contagious � Postviral airway inflammation • Vaccination but increasing incidence • Bronchial hyperresponsiveness (especially 10-19 yr old) due to waning • Mucus hypersecretion of immunity • Impaired mucociliary clearance � UACS (upper airway cough syndrome) � Asthma � GERD Treatment – Bordetella pertussis Postinfectious “whooping cough” • Paroxysms of coughing, posttussive 1) No role for antibiotics (unless sinusitis or pertussis) vomiting, inspiratory whooping sound (often absent in adults) 2) Inhaled ipratropium • B. parapertussis – similar but shorter 3) Inhaled corticosteroids duration 4) Investigate concomitant UACS, Asthma, GERD • Diagnosis – nasopharyngeal swab or 5) Brief trial of steroids (prednisone 30-40mg day) for aspirate severe paroxysms 6) Codeine or dextromethorphan • Treatment – macrolide 3

Approach to Chronic Diagnosis and Cough Management 1) History, Exam, CXR, ? Spirometry • If history, exam, or CXR reveals 2) If cause apparent - treat a potential cause – investigate and treat 3) If no obvious cause: � UACS (upper airway cough syndrome) • If smoker – QUIT � Asthma � NAEB (nonasthmatic eosinophilic bronchitis) • If on an ACE Inhibitor – stop it! � GERD (gastroesophageal reflux disease) Chronic Cough Normal History, PE, CXR • History Most common causes of cough are: � Smoking, ACE Inhibitor? � Immunocompromised? 1) UACS (upper airway cough syndrome) � Fever, sweats, weight loss? 2) Asthma � Dyspnea, wheezing? 3) GERD (gastroesophageal reflux disease) � Cancer, TB, AIDS 4) NAEB (nonasthmatic eosinophilic bronchitis) • Examination � Not as common as GERD, but may be • CXR evaluated after asthma in the workup. • ? Spirometry 4

Considerations: Diagnosis (asthma) • Reversible airflow obstruction on spirometry. • Optimize therapy for each diagnosis • If nondiagnostic– perform methacholine • Check compliance inhalation challenge testing (MIC) or peak flow • Step wise approach (PEF) monitoring. • Maintain all partially effective treatment • If MIC (-) asthma is unlikely. � Can have more than one cause of chronic • If MIC (+) may be asthma, but can only be diagnosed by resolution of cough with asthma cough! treatment. Asthma Treatment (asthma) • Inhaled corticosteroid and inhaled • May be the cause of chronic cough in bronchodilators. 25% of patients. • If still coughing – assess airway inflammation to look for eosinophils. • Usually associated with other symptoms of asthma, but doesn’t • Leukotriene receptor antagonist have to be! • Short course (1-2 weeks) of systemic • Cough variant asthma – distinct corticosteroids followed by inhaled subgroup. steroids. 5

ACE Inhibitor-Induced Nonasthmatic Eosinophilic Bronchitis (NAEB) Cough • first described 1989 • Cough can occur at any time after initiation of ACE Inhibitor (1 st dose to months) • normal CXR • After cessation of medication – cough • normal spirometry usually resolves in 1-4 weeks, but can take up to 3 months. • no airway hyperresponsiveness • Can try switching to angiotensin- • ++ airway eosinophilia (>3%) receptor blocker. Nonasthmatic Eosinophilic Miscellaneous - ILD Bronchitis (NAEB) • Cough can be a prominent symptom of • Treatment: interstitial lung disease � Inhaled corticosteroids • Consider UACS, asthma, GERD may also contribute and attempt to treat. � Rarely trial of oral corticosteroids � Avoidance if an allergen or • For cough 2º to IPF or sarcoidosis, oral steroids are often effective but have occupational sensitizer is identified. many systemic side effects. � Bronchodilators don’t work. 6

Miscellaneous - Chronic Uncommon Causes Bronchitis • If common causes evaluated and cough • Stable • Exacerbation persists, consider uncommon causes. � No smoking � Antibiotics � B-agonists • Most involve airways or interstitium and � B-agonists can be evaluated with: � Anticholinergics � Anticholinergic � Theophylline (?) � CT scan of chest � Systemic steroids � Long acting b- � No role for agonist and � Bronchoscopy expectorants inhaled corticosteroids � Codeine and dextromethorphan Miscellaneous Cough Suppressants • Peritoneal dialysis associated with increased cough – may be 2º to GERD • Conflicting data on efficacy of most or ACEI, B blocker, pulmonary edema, cough suppressants. infection. • Short term use • Lung cancer – treat the cancer. Centrally acting opioid cough • Doesn’t treat the cause of the cough. suppressants are often effective. 7

Upper Airway Cough Chronic cough algorithm >= 15 yrs old Syndrome • Formally known as post nasal drip syndrome • “One airway” • Causes: � Allergic rhinitis � Vasomotor rhinitis � Chronic sinusitis Irwin, R. S. et al. Chest 2006;129:1S-23S Chronic cough algorithm >= 15 yrs old Sinusitis • 35 million Americans with at least one episode of acute sinusitis • Number one chronic illness in all age groups in U.S. 14% of population • Most common health care complaint Irwin, R. S. et al. Chest 2006;129:1S-23S 8

Sinusitis: Diagnosis Paranasal Sinus CT • Mucosal thickening • History � Semters triad • Physical exam • CT scan Diagnostic Nasal Sinusitis: Diagnosis Endoscopy • Blood work � Quantitative Immunoglobulins � IgE • Allergy testing 9

Irritable Larynx Microbiology Syndrome Acute Sinusitis • Laryngeal based cough � Non-productive • H. influenza 38% cough � “Tickle” • Strep. Pneumoniea 37% • Laryngeal mucosal • Strep. Pyogenes 6% irritation � Laryngeal Sicca • Moraxella catarrhalis 5% � Chronic laryngitis • Gram neg. bacilli and anaerobes 5% � Reflux • Vocal cord dysfunction Microbiology Laryngeal Sicca Chronic Sinusitis • Sjogrens • Anaerobes more common Syndrome � 51% sole isolate • Medication � 31% mixed induced • Pseudomonas • Aging � Polyps � HIV • Previous radiation therapy � CF 10

Chronic Laryngitis Pathophysiology • Decreased LES tone � Smoking • Vocal misuse � ETOH • Fungal laryngitis � Hiatal hernia � Medication � Steroid inhaler use • Theophyline • Calcium channel blockers • Anti-cholinergics LaryngoPharyngeal Pathophysiology Reflux (LPR) • Gastric acid • Proteolytic enzymes • Atypical GERD � Pepsin • First recognized in 1968 • Primary injurious component in refluxate � Delahanty Syndrome � Capsaicin • Most common inflammatory disorder of • Bile the larynx • Duration of exposure 11

Diagnosis pH Probe • History • Abnormal findings • Physical exam Esophageal probe � Indirect laryngoscopy � 8% upright � Transnasal fiberoptic � 3% supine � EGD � Pharyngeal probe - any event • 72% are “normal” • LPR • Barium swallow - 20% detected � upright daytime reflux 2.5 times more • Scintigraphy common than supine nocturnal LPR Symptoms pH Probe • Throat clearing (90%) • Need double probe • Hoarseness (90%) � 4 cm above LES • Increased mucous production (90%) � Pharynx just above upper sphincter • Chronic cough (55%) • Percent of time with pH below 4 • Globus pharyngeus (40%) 12

Physical Findings LPR Symptoms posterior larynx • Interarytenoid thickening/pachyderma • Cervical dysphagia (40%) � Mild - concave • Heartburn (33%) � Moderate - straight • Laryngospasm � Severe - convex • Rhinitis/post nasal drip • Posterior erythema • Halitosis LPR Physical Findings posterior larynx • Why larynx and pharynx without esophagus? � Upper sphincter problem • Postcricoid edema / erythema � Mucosal sensitivity • Thin • Fragile � Devoid of acid clearing mechanism � Proton Pump receptors found in the larynx 13

Physical Findings Treatment true vocal cords • 40% treatment failure with H2 blockers • Edema � Most common • Need to use proton pump inhibitors finding � Esomeprazole � Omeprazole • Infraglottic erythema � Pantoprazole • Mucosal thickening � Lansoprazole � Rabeprazole Physical Findings Treatment true vocal cords • Often require twice a day PPI � Frequently under treated • Ulceration • Minimal treatment period of 6 months • Granuloma vocal for uncomplicated LPR process • Wean medication when asymptomatic and exam normal 14