COUGH

• One of the most common symptoms for which patients seek medical attention

• Defensive reflex that enhance the clearance of secretions and particles from
the airway

• Protects the lower airways from the aspiration of foreign materials

• Coughing may be initiated either voluntarily or reflexively.

• It has both afferent and efferent pathways .

• The cough starts with a deep inspiration followed by glottic closure, relaxation
of the diaphragm, and muscle contraction against a closed glottis.
CLASSIFICATION
ETIOLOGY
 CHRONIC COUGH
ETILOGY
In non-smoking adults with a normal CXR who are not taking
ACE inhibitors, chronic cough is almost always due to the
following 3 condition
a)Upper Airway Cough Syndrome (UACS)
b) Asthma
c) Gastroesophageal reflux disease (GERD)
 EVALUATION CHRONIC
COUGH
• A systematic, diagnostic approach has been validated in immunocompetent
patients-
5 steps plan:

Step 1: Review history and exam focusing on the most common causes of chronic
cough
 HISTORY TAKING
History Reasons
Onset To determine acute/subacute or chronic causes of
cough

Aggravating factor, relieving factor • Cough due to GERD affected by postural changes,
post meal
• Cold induced or MDI relieved cough in asthma or
COPD

Sputum colour Normal sputum: clear to white colour, thin, odourless n

tasteless
Yellow-green: bacterial infection
Rust-colored: pneumonia

Sputum character Mucoid or mucopurulent: cigarette smokers as a result

of chronic bronchitis
Commonly purulent in bronchiestasis

Sputum amount Significant volumes: more than 1 cup per day

History Reasons

Fever Ongoing infection

SOB Respiratory distress

Noisy breathing Wheezing suggest asthma/COPD

Loss of appetite, loss of weight, hemoptysis Suggesting Tuberculosis, malignancy

Allergy, nasal obstruction or congestion, rhinorrhoea, Suggesting Rhinosinusitis

sneezing, facial pain, post-nasal drip or repetitive throat
clearance

Dyspepsia, heartburn, waterbrash GERD

Medication used ACE-inhibitor

Occupation Exposure to asbestos, chemical or cigarette smoke

Family history Asthma, tuberculosis, lung cancer, cystic fibrosis

Social history Contact with PTB suggesting PTB

 PHYSICAL EXAMINATION
Physical examination Reasons
General condition such as altered conscious level, To assess severity and to look for respiratory distress
accessory muscles usage, cyanosis, grunting, nasal
flaring, clubbing, nicotine stain

Vital signs Fever – infection

Tachycardia, tachypnoea – respiratory distress
Pulsus paradoxus – asthma

Nasal polyps Allergy rhinitis

Pharynx: erythema, a cobblestone appearance of Post nasal drip
posterior pharyngeal mucosa or mucoid secretions
dripping from the nasopharynx

Chest:
Hyperinflated Suggest air trapping due to chronic disease
Respiratory distress
Recession Severe asthma
Silent chest Pneumonia, asthma, heart failure
Crepitations, wheezing
Physical examination Reasons

CVS: Displaced apex beat, raised JVP, loud P2, RV heave Cor pumonale

Eczema, transverse nasal crease, injected conjunctiva Signs of atopic disease

Lymphadenopathy To suggest infection

 EVALUATION CHRONIC
COUGH
• Step 2: Order a CXR in all patients

• Step 3: Do not order additional tests in present smokers or patients taking ACE
inhibitors until the response to smoking cessation or drug discontinuation for at
least 4 weeks can be assessed.
- Cough due to smoking or ACE inhibitors should
improve substantially or disappear during this
time- frame of abstinence.

Step 4: Order additional diagnostic tests or embark on empiric treatment

 INVESTIGATION
• Spirometry:
-demonstrate significant airway reversibility (asthma)
-unavailable or normal and history suggestive: serial
measurement of PEF (diurnal variability)
• Bronchoprovocation test :
- negative: rules out asthma but does not rules out
steroid- responsive cough
• Plain sinus radiography: low specificity but improves with
history and findings
• Sputum eosinophilia
SPIROMETRY
 EVALUATION CHRONIC
COUGH
Step 5: Determine the cause(s) of cough by observing which specific therapy
eliminates cough
• If the evaluation suggests more than one possible cause, initiate treatment in
the same sequence that the abnormalities were discovered
• Since cough can be simultaneously caused by more than one condition, do
NOT stop therapy that appears to be partially successful; rather, sequentially
add to it.
 CASE SCENARIO 1
55 yo school teacher
c/o cough for 3 years Non-smoker
• Cough: Often productive
• Better with abx, but comes back
• “no better” with asthma meds
• Worst in the morning
• Frequent clearing the throat, sensation of
• dripping into throatNasal voice, afebrile,
• looks well
• Pharynx: Mild “cobblestoning”
• Normal heart and lungs
• Normal spirometry
 UPPER AIRWAY COUGH SYNDROME

• Also called “Post-nasal drip syndrome” (PNDS)

• Common cause of chronic cough in all age groups
– Second most common cause in children
– Most common cause in adults and the elderly

• In addition to cough, UACS can also cause

- Wheeze
- Dyspnea
Treatment

Antibiotics – sinusitis
Oral antihistamine/decongestant x 3 weeks
Intranasal decongestant for maximum of 5 days: e.g. oxymetazoline 2
sprays each nostril bid x 3 days only

Allergic Rhinitis
• Allergen avoidance
• Intranasal steroid
• Antihistamine
• Antihistamine/decongestant
 CASE SCENARIO 2
A Computer Programmer, 35 y.o woman
c/o Yearly cough lasted for > 8 weeks
– starts only after a “cold weather” at end of
the year
– severe coughing
– goes away by itself
– has happened last year
- nocturnal cough
• Tried “everything”
Denies: wheezes, PND sx, allergies, heartburn, aspiration
• No: pets, current meds
• Family hx: negative
• PMH: negative
• Physical exam and CXR normal
• Normal spirometry
 ASTHMA/ COUGH VARIANT ASTHMA
Second most common cause of cough in adults
• Clues that chronic cough is due to asthma:
– Episodic wheezing, dyspnea , cold or exercise
induced
– Reversible airflow obstruction
– Bronchial hyperresponsiveness
• Confirmed by resolution of cough with asthma treatment
30-60% of patients presenting with chronic cough that was due to asthma had cough as their ONLY symptom
•Clues:
- nocturnal cough, exercise induced, after allergen
exposure
•Bronchoprovocation test: positive
•Negative test exclude asthma but does not rule out steroid responsive cough
Treatment
• Inhaled corticosteroid
• ICS/LABA combination > 8 weeks
•Leukotrine receptor antagonist
 Non-Asthmatic Eosinophilic Bronchitis (NAEB)

• Eosinophilic airway inflammation WITHOUT variable airflow obstruction or

airway hyperresponsiveness
• Diagnostic tests:
- Spirometry: normal
- Methacholine challenge: normal
- Sputum or BAL eosinophilia: >3% eosinophils
• Diagnostic/Therapeutic trial: inhaled corticosteroid for ≥ 4 weeks
• Characteristically resistant to bronchodilator but reponds ICS
• Confirmed diagnosis if responded to ICS
 CASE SCENARIO 2
The Computer Programmer…
• Aggressive asthma regimen x 8 weeks
•Not feeling better
•Now what??
 GERD
• Suspect GERD when…
– Symptoms of heartburn or sour taste in
mouth
– Reflux demonstrated by
• 24-hour pH-impedance monitoring
• Barium x-ray
• Cough is the only symptom of GERD in 40-75% of patients with chronic cough
due to GERD
• Cough due to GERD occurs most commonly while patients are awake, stooping
posture, meal related, and usually does not occur during the night

• Diagnosis of GERD as cause of chronic cough

requires resolution of cough with GERD treatment
Life-style changes
•Stop smoking
•Avoid alcohol
•Lose weight
•Elevate HOB
•Small meals
•Avoid fatty/acidic foods /low fat diet
•Avoid caffeine
•Avoid – tight clothes, eating < 4 hrs pre-bed, recumbency 3 hrs post meal
TREATMENT
Conservative measures :
• Antacid therapy ≥ 2 months :
– Proton pump inhibitor (high dose)
– H2 blockers less effective
• Motility therapy:
– Metoclopromide
Surgery is last resort
 ACE -INHIBITOR THERAPY
Angiotensin converting enzyme (ACE) inhibitors (enalapril, captopril, lisinopril, ramipril,
etc.)
Dry cough in 3-30% patients
Begins 1 week to 6 months after drug started
Usually resolves 1-7 days after stopping therapy, but can take 4 weeks
Diagnosis is confirmed when cough disappears after drug in discontinued
Minority of patient will have persistent cough even after the medication was off
 CASE SCENARIO 3
• Tony is a bus conductor aged 45 years
• c/o recent exacerbation of his chronic cough with productive of yellow-green sputum
• Heavy smoker for 25 years. He has a long standing smoker’s cough frequently productive in
recent years.
• Last year he suffered many exacerbation of his bronchitis, two of which were severe
enough for him to be admitted to hospital.
• Although he had returned to work, progressive dyspnoea had made his job increasingly
difficult
• Examination: drowsy, plethoric and cyanosed, flapping tremor was elicited.
• RR was 25/min, T: 38.2, PR: 124/min, regular rhythm, BP 120/80mmHg
• JVP raised 8cm, gallop rhythm was heard, sacral oedema present.
• Both lung fields had scattered crepitations and diminished air entry.
• The liver was felt 3 cm below the costal margin.
• No focal neurological deficit.
 CHRONIC OBSTRUCTIVE AIRWAY
DISEASE

An exacerbation of COPD is:

“an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond
normal day-to-day variations and leads to a change in medication.”
 The goal of treatment is to minimize the impact of the current exacerbation and to
prevent the development of subsequent exacerbations

Arterial blood gas measurements (in hospital): PaO2 < 8.0 kPa with or without PaCO2 > 6.7 kPa
in room air indicates respiratory failure.

Chest X-Ray: useful to exclude alternative diagnoses.

ECG: may aid in the diagnosis of coexisting cardiac problems.

Full blood count: identify polycythemia, anemia, infection

Purulent sputum during an exacerbation: indication to begin empirical antibiotic treatment.

Biochemical tests: detect electrolyte disturbances, diabetes, and poor nutrition.

Spirometric tests: not recommended during an exacerbation.

Oxygen: titrate to improve the patient’s hypoxemia with a target saturation of 88-92%.

Bronchodilators: Short-acting inhaled beta2-agonists with or without short-acting anticholinergics are

preferred.

Systemic Corticosteroids:
- Shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2)
- reduce the risk of early relapse, treatment failure, and length of hospital stay.
- 30-40 mg prednisolone per day for 10-14 days is recommended

Noninvasive ventilation (NIV):

-Improves respiratory acidosis, decreases respiratory rate, severity of dyspnea, complications and length
of hospital stay
 Indications for Hospital Admission
• Marked increase in intensity of symptoms

• Severe underlying COPD

• Failure of an exacerbation to respond to initial medical

management

• Presence of serious comorbidities

• Frequent exacerbations

• Older age

• Insufficient home support

 Management of Stable COPD
KEY POINTS
• Identification and reduction of exposure to risk factors are important steps in prevention and treatment

• Individualized assessment of symptoms, airflow limitation, and future risk of exacerbations should be
incorporated into the management strategy
• All COPD patients benefit from rehabilitation and maintenance of physical activity.

• Pharmacologic therapy is used to reduce symptoms, reduce frequency and severity of exacerbations, and
improve health status and exercise tolerance.

• Long-acting formulations of beta2-agonists and anticholinergics are preferred over short-acting formulations

• Long-term treatment with inhaled corticosteroids added to long-acting bronchodilators is recommended for
patients with high risk of exacerbations
• Long-term monotherapy with oral or inhaled corticosteroids is not recommended in COPD

• The phospodiesterase-4 inhibitor roflumilast may be useful to reduce exacerbations for patients with FEV 1 <
50% of predicted, chronic bronchitis, and frequent exacerbations
Global Strategy for Diagnosis, Management
and Prevention of COPD
Assessment of COPD
Assess symptoms : CAT, mMRC

Assess degree of airflow limitation using spirometry

Assess risk of exacerbations

Assess comorbidities
Rehabilitation
Exercise training programs : improves exercise tolerance and symptoms of dyspnea and fatigue

Pulmonary rehabilitation program: the longer the program continues, the more effective the results

Oxygen Therapy: The long-term administration of oxygen (> 15 hours per day) to patients with
chronic respiratory failure has been shown to increase survival in patients with severe, resting
hypoxemia

Ventilatory Support: Combination of noninvasive ventilation (NIV) with long-term oxygen therapy
may be of some use in a selected subset of patients

Lung volume reduction surgery (LVRS) : more efficacious than medical therapy among patients
with upper-lobe predominant emphysema and low exercise capacity

Lung Transplantation : In appropriately selected patients with very severe COPD, improve quality of
life and functional capacity
REFERENCE

• ACCP Evidence-Based Clinical Practice Guidelines ,

Chest 2006
• Wong CM, Lim KH , Liam CK Assessment and
management of chronic cough, Med J Malaysia
THANK YOU