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Learning outcome:
o List causes for acute & chronic cough
o Outline Ix and Rx of patients with chronic cough

General Cough
History






Onset – gradually or suddenly
Characteristic of cough – dry, sputum, blood
Associated features – nocturnal, with eating or talking, hours after eating
food, positional,
recent infection
Timing – duration, frequency, diurnal variation
Exacerbating factors – exercise, temperature, aerosols, dust History of
atopy
PMH – asthma, COPD, bronchiectasis, lung cancer, atopic disease,
cardiovascular disease, etc
DH – ACEi
SH – smoking, occupation, pets

Red flag symptoms


Copius production of sputum – bronchiectasis, COPD
Weight loss, fever, haemoptysis – TB, lymphoma, lung cancer
Considerable breathlessness – acute bronchitis, obstructive airway
disease, fibrotic lung disease, heart failure

Common serious conditions presenting with isolated cough – just to keep in the
back of your mind




Neoplasm
Infection – TB
Foreign body inhalation
Acute allergy – anaphylaxis
Interstitial lung disease

g. Look out for red flag symptoms and investigate their potential causes. influenza.b.b. lozenges Possible medication o Dextromethorphan – non-sedating opiate shown to supress acute cough. e. adenovirus o Bacterial infection – acute bronchitis. linctuses. Component in many OTC cough remedies o Menthol – cough suppression acute and short lived o Sedative antihistamines – n. no greater efficacy than dextromethorphan. increasing breathlessness investigate asthma.g. whooping cough(pertussis) o COPD o Smoking o ACEi o Asthma N. but keep in mind the serious conditions as noted above. causes drowsiness o Codeine or pholcodine – n.Acute Cough     Defined as cough lasting less than 3 weeks Majority of cases unlikely to need any investigations Most self-limiting.B.g. o All patients with red flag symptoms need a CXR Causes of acute cough with normal CXR   Commonly o Viral respiratory tract infection – e. rhinovirus. also common causes of o Post-nasal drip chronic cough o GORD Less commonly o PE o TB o Heart failure o Malignancy o Inhaled foreign body o Inhaled toxic fumes Treatment    Almost always benign and prescribed treatment may be unnecessary Simple advice – o Home remedies – honey and lemon preparations o OTC medications – e. but greater side-effects .

obstructive sleep apnoea o Foreign body in large airways o Idiopathic/ psychogenic – diagnosis of exclusion Red flag symptoms    Copius production of sputum – bronchiectasis. laryngopharyngeal reflux.Chronic Cough  Defined as a cough last 8 weeks Causes    Simply for student level o Asthma o GORD o Post-nasal drip o Smoking o ACEi Most commonly – bit more depth o Asthma syndromes – cough variant asthma. . COPD Weight loss. oesophageal dysmotility o Post-nasal drip o Smoking o Drug induced – i. relapse on stopping and then response again on restarting this strengthens your diagnosis. benign. heart failure Trial of Treatment   Trial of treatment can be used to challenge a diagnosis to see if there is a response. haemoptysis – TB.e. CF. metastatic o Upper airway conditions – chronic tonsil enlargement. PE o Chronic infection – bronchiectasis. emphysema. ACEi Other less common causes o Cardiovascular – LVF. eosinophillic bronchitis o Reflux disease – GORD. TB. sarcoidosis o Tumours – lung cancer. fever. whooping cough o Parenchymal lung diseases – interstitial lung fibrosis. lung abscess o Post-infectious cough – following M. fibrotic lung disease. If there is a response on treatment. lung cancer Considerable breathlessness – obstructive airway disease.Pneumoniae. lymphoma.

 Stop smoking o Stopping smoking leads to a reduction in cough within 2 month. which can cause the cough. cough usually resolves after 1-4 weeks. so need further Ix  CXR  Spirometry  Stop offending drugs o Most commonly ACEi. wheeze  Peak flow variability >20% . but may take up to 3 months  Trial of treatment for asthma and variants o Asthma may manifest solely as a cough  There are different variants that may produce a cough. nocturnal cough.Management  This is an example of a management pathway which can be adopted (from BMJ and is similar to BTS guidelines). o Usually doesn’t resolve the cough though. most commonly  Cough variant asthma  Non asthma eosinophillic bronchitis o Other things pointing to asthma include  Hx – atopy. o Smokers also higher risk for COPD and cancer. o ACEi induced cough can start years after treatment o After stopping.

no need for LABA in step 3. but may take up to 8 weeks If diagnosed with cough variant asthma.g. for 8 weeks  Should respond within 2 weeks. Omeprazole 20/40mg BD  May take 1-3 months for cough to resolve  Trial of treatment for post-nasal drip o Things pointing to post-nasal drip  Persistent nasal obstruction or discharge  Feeling of something dripping in the back of their throat  Recurrent desire to clear their throat o Trial of antihistamines.  Trial of treatment for GORD o Cough may manifest solely as a cough o Other things pointing to GORD  No coughing at night – coughing at night is rare with GORD  Hoarse voice  Cough when eating/ talking  Retrosternal burning  Cough occurs in certain position or hours after food o Trial with high dose PPI  E. use leukotrienes instead.g. gastro. follow national asthma guidelines. Prednisolone 30mg OD. ENT Investigations   Basic investigation o CXR  For all those with red flag symptoms o Spirometry  Consider in all patients with chronic cough  If suggestive of asthma syndromes then offer trial of prednisolone Basic investigations – secondary care o Bronchoscopy  For all patients who foreign body inhalation is suspected  For patients where other more targeted investigations are normal. o o Spirometry showing >20% reversibility pre and post bronchodilators Both variants should respond to trial of inhaled or oral corticosteroids  E. decongestants or nasal corticosteroids  Usually trial of topical corticosteroids first for 1 month  If initial management is unsuccessful refer onto secondary care – respiratory. But note. o High resolution CT of thorax .

Considered in patients with persistent atypical cough where more targeted investigations have been normal.  More sensitive and specific than CXR in diagnosing bronchiectasis and diffuse pulmonary diseases. Specialised investigations o Bronchial provocation test – measuring airway hyperresponsiveness o 24-hr ambulatory oesophageal monitoring o Radiological scanning of the sinuses o Fibreoptic laryngoscopy o Measurement and monitoring cough o Induced sputum   .