Cough

Diagnosis and Management

Dr Paul Plant
Consultant Chest Physician

I’m Coughing my lungs up Doc.

 Areas To Cover
• Why do we Cough? • When and How to
Investigate
• Classification and
Causes of Cough • Management
– Acute
– Subacute • Case Study
– Chronic
 What is Cough?
‘A Cough is a forced expulsive manoevere,
usually against a closed glottis and which is
associated with a characteristic sound’
 Classification of Cough

Three Categories of Cough

• Acute Cough = < 3 Weeks Duration
• Subacute Cough = 3 – 8 Weeks Duration
• Chronic Cough = > 8 Weeks Duration
Acute Cough
 Acute Cough <3/52 Duration
Differential Diagnosis

• Upper Respiratory Tract infections:

Viral syndromes, sinusitis viral / bacterial

• URTI triggering exacerbations of Chronic Lung Disease eg

Asthma/ COPD

• Pneumonia
• Left Ventricular Heart Failure
• Foreign Body Aspiration
 Acute Cough
Epidemiology
• Symptomatic URTI
– 2-5 per adults per year
– 7-10 per child per year
• 40-50% will have cough
• Self medication common -£24million per year
• 20% consult GP (2F:1M)
• Most resolve within 2 weeks
 Duration of Cough in URTI
Primary Care Setting
No antecedent or chronic lung disease

End of Week % Coughing

3 58
4 35
5 17 Sub-acute
6 8
Cough
*Jones FJ and Stewart MA, Aust Family -Post viral
Physician Vol. 31, No. 10, October 2002
cough
Managing Acute Cough

“Don’t just do something

stand there.”
Alice in Wonderland
 Managing Acute Cough
Identify High Risk groups

Acute Cough Can be 1st

Indicator of Serious Disease
eg Lung ca, TB, Foreign Body,
Allergy, Interstitial Lung disease

‘Chronic cough always preceded

by acute cough’.
 Red Flags in Acute Cough

Symptoms Signs
• Haemoptysis Tachypnoea
• Breathlessness Cyanosis
• Fever Dull chest
• Chest Pain Bronchial Breathing
• Weight Loss Crackles

THINK pneumonia, lung cancer, LVF

GET a CHEST X-Ray
 Treatment of Simple Acute Cough

• Benign course -reassure

• Cough can distress
• Patients report OTC
medication helpful
• Voluntary cough suppression
-linctuses/ drinks
• Suppression of cough
-dextromethorphan, menthol,
sedating antihistamines &
codeine
 Which Anti-tussive?
Dextromorphan Sedating Antihistamines
eg Benilyn non-drowsy danger sleepy - nocturnal cough
1 meta-analysis
high dose 60mg
Codeine or Pholcodeine
beware combinations eg
paracetomol No better than dextromorphan
but more side-effects. Not
recommended
Menthol
Steam inhalation. Effect on
reflex short lived
Sub-Acute Cough
 Sub-acute Cough 3-8 weeks
Likely Diagnoses
Postinfectious
•
•
Bacterial Sinusitis ACTIONS
Asthma
•
•
Start of Chronic Cough
•Examine Chest

•
Don’t want to miss lung cancer •Chest X-Ray if signs or smoker
•Measure of airflow obstruction
ie peak flow -one off
peak flow -serial
spirometry
 Post Infectious Cough

A cough that begins with an acute

respiratory tract infection and is not
complicated* by pneumonia

*Not complicated = Normal lung exam and normal chest X-ray

Post Infectious cough will resolve without treatment

Cause = Postnasal drip or Tracheobronchitis

Chronic Cough
 Case Study -CP 2007
• 60yr retd Nurse
• Chest infection 2002 in Spain -mild • Ex-smoker 30 pack yrs
SOB since
• FEV1 0.97 43%
• Chest infection 2006 -hospitalised for
4/7 antibiotics / steroids
• SOB and dry cough since What else would you like to
• No variation know?
• 4 lots of AB and steroids from GP
plus tiotropium & oxis -no help for
cough What causes can you think of?
• Wt climbing
• More SOB over 9/12
 Chronic Cough
Epidemiology
Epidemiology difficult -acute vs chronic

Cullinan 1992 Respir Med 86:143-9

n=9077
16% coughed on >50% days of year
13% coughed sputum on >50% days of year
54% were smokers
 Chronic Cough
Epidemiology
Associations with:
Smoking (dose related)
Pollutants (particulate PM10 ) -occupation
Environmental irritants (eg cat dander)
Asthma
Reflux
Obesity
Irritable bowel syndrome
Female
 Making the Diagnosis
Common Differentials

Lung Disease Gastro

-normal CXR -Oesophageal
-abnormal CXR Reflux

Post-nasal Drip
-allergic rhinitis Non-structural
-bacterial sinusitis ACE-Inhibitors
Tobacco
Habit Cough
 Chronic Cough
Investigating Chronic Cough

Purpose:
• To exclude structural disease
• To identify cause
How
History & Examination inc occupation
& Spirometry
ALWAYS GET A CHEST X-RAY
IN CHRONIC COUGH
 Beware
Cough triggered by:
change in temperature
scent, sprays, aerosols and exercise
indicate
Increased cough reflex sensitivity
and Not just seen in Asthma.
Esp GORD, infection and ACEI
 ACE-Inhibitors and Chronic
Cough
Incidence: 5-20%
Onset: one week to six months
Mechanism
Bradykinin or Substance P increase
Usually metabolized by ACE)
PGE2 accumulates and vagal stimulation.
Treatment: switch to Angiotensin II Receptor
Blockers (ARBs)
 Gastro-oesophageal Reflux
GORD accounts alone or in
combination for 10-40% of
chronic cough

Two Mechanisms
a. Aspiration to larynx/ trachea
b. Acid in distal oesophagus
stimulates vagus and cough
reflex
 Gastro-oesophageal Reflux
Symptoms
Cough Features
GI Symptoms
Throat clearing
If Aspiration main mechanism
Worse at night / rising
Heart burn
On eating
Waterbrash/ Sour taste
Reflex hypersensitivity
Regurgitation
Morning Hoarseness
CXR -normal or hiatus hernia
Spirometry normal
If Vagal - NO GI symptoms
 Gastro-oesophageal Reflux
Reflux may be due to Medications or Foods

Drugs and foods that reduce lower esophageal

sphincter (LES) pressure and can cause increased
reflux include:

Theophylline Chocolate
Oral β adrenergic agonists Caffeine
NSAIDs Peppermint
Ascorbic acid Alcohol
Calcium Channel Blockers Fat
 Gastro-oesophageal Reflux
Investigation
• Oesophageal pH monitoring for 24 hours (+diary)
– 95% sensitive and specific 95%

• Ba swallow not sensitive enough

• Endoscopy - may confirm but false -ve rate

Endoscopy can show GORD, but cannot
confirm GORD as the cause of cough.

© Slice of Life and Suzanne S. Stensaas

GED
GED
 Gastro-oesophageal Reflux
Treatment
Trial of Therapy
• High dose twice daily PPI for min 8weeks
• + prokinetic eg domperidone or metoclopramide
• Eliminate contributing drugs.
• Baclofen rarely

Improves in 75-100% of cases

 Post-Nasal Drip
Symptoms: Causes
• ‘something dripping’ • Allergic rhinitis
• frequent throat • Non-allergic rhinitis
clearing • Vasomotor rhinitis
• nasal congestion / • Chronic bacterial
discharge sinusiits
• posture
 Post Nasal Drip Treatment
Options:
1. Exclude /treat infection
2. Nasal steroid for 8/52
3. Sedating antihistamines
4. Antileukotrienes eg
montelukast
5. Saline lavage
6. ENT opinion
 Lung Diseases inc Tobacco
Favouring Lung Disease
Shortness of breath
Wheeze
Sputum production
Haemoptysis
Chest signs eg crackles
 Chest X-Ray
and Differential of Cough
Normal CXR Abnormal CXR
• Gastro-oesophageal reflux • Left ventricular failure
• Post-nasal Drip • Lung cancer
• Smokers cough/ Chronic • Infection/ TB
Bronchitis • Pulmonary fibrosis
• Asthma • Pleural effusion
• COPD
• Bronchiectasis
• Foreign body
Left Ventricular Failure
Idiopathic Pulmonary Fibrosis
TB
Lung Cancer
 Chest X-Ray
and Differential of Cough
Normal CXR
• Gastro-oesophageal reflux
• Post-nasal Drip
• Smokers cough/ Chronic
Bronchitis
• Asthma
• COPD
• Bronchiectasis
• Foreign body
Smoking and the Healthy Lung
 The Development of
Chronic Bronchitis
(Daily Cough)
Smoking

Neutrophil Infiltration
Goblet hyperplasia
(mucous production)

Release of Proteinases
Normal Spirometry and Flow
Volume Loops
 Normal Values
• Depend on Age/ Sex / Height / Race
• Tables and slide rules available
• Asians decrease value by 7%
• Afro-Caribbean decrease by 13%

• Report results as Absolute and % predicted

• Normal is 80-120%
 Obstructed Spirometry
FEV1 reduced
FVC largely preserved
FEV1/FVC low <70%

FEV1 =1.0

‘FVC’ =2.0
FEV1/FVC=50%
FVC =3.0 FEV1/FVC
=33%
Peak Flow Measurement
Single or Repeated Measures
 Definition of COPD
Chronic obstructive pulmonary disease
is characterized by

•airflow limitation that is not fully reversible.

FEV1always <80% with

•airflow limitation that is usually progressive

•associated with an abnormal inflammatory response

to noxious particles or gases.
Development of Emphysema
Proteinases diffuse out

Neutralised by Anti-
proteinases
eg a1 Anti-trypsin

If balance incorrect
alveolar walls destroyed
How Emphysema causes Airway
Narrowing
 Stopping smoking
slows decline in lung function
Smoked regularly
and susceptible to
its effects Never smoked or not
100
FEV1 (% of value at age 25)

susceptible to smoke

75

50 Stopped at 45

25 Stopped at 65

Death
0
25 50 75
Age (years)

Adapted from: Fletcher et al, Br Med J 1977.

Step 1 Make Sure Patient Has COPD

EXPOSURE TO RISK
SYMPTOMS
FACTORS
cough
tobacco
sputum
occupation
dyspnea indoor/outdoor pollution

REMEMBER:
➨

•Only 1/3 smokers get

COPD
SPIROMETRY •Need 15 pack years min
•Asthma/ Bronchiectasis
Inhaled Steroids in COPD
Steroid Reversibility
 C hronic D isease Managem ent
Main Algorithm

All C O PD PAT IEN T S

Stop Sm oking -use Leeds Sm oking Services G uidelines
Short-acting bronchodilator prn (see note 1)
Annual flu vaccination
5 yearly pneum onia vaccination (see note 2)
Encourage regular exercise (5x 30m ins walking at breathless pace p
Maintain weight in healthy range

Is patient breathless w alking on level ground at a normal pace?

YES – LONG-ACTING BRONCHODILATOR
 CAN PATIENT USE AN MDI?

Yes No

Long-acting beta agonist Longacting anticholinergic

salmeterol 50mcg bd (MDI/ accuhaler) Tiotropium 18mcg od
or formoterol 12 mcg bd (turbohaler) (see note 3)
(see note 3) Plus short acting beta agonist prn
Plus short acting bronchodilator prn (breathe actuated or dry powder)

£30 No benefit £43

Stop longacting drug and try the
alternative

£34 £47
Partial Response Partial Response
Add ipratropium bromide 40 Add shortacting beta agomist 2puffs
See Pulmonary
mcg qds via MDI+ spacer qds via breathe-actuated inhaler or
Rehabilitation algorithm
(see notes 3 & 4) dry powder device
(see note4)
 Acute Management

Increase 1st Line Steroids

short acting Antibiotic
beta agonist Prednisolone
amoxycillin 30mg od for 1
for duration of 250-500mg tds week
exacerbation or doxycycline
eg 2-8 puffs 100mg bd for
upto 4 hourly 1 week
(see note 6)

No
Improvement
at 1 week

2nd line antibiotic if

sputumstill
purulent Continue
prednisolone 30mg
ciprofloxacin 750mg od upto 2 weeks
bd maximum
(Half maintenance
theophylline dose)
(see note 7)
 Prevention of Future
Exacerbations

Is the
FEV1 <50% predicted
and
has the patient had >2 exacerbations in the last 12
months requiring oral steroids or antibiotics?

No Yes
No additional Add budesonide 400mcg bd or fluticasone
therapy 500mcg bd.
If on a longacting beta agonist -prescribe as
symbicort 200/6 2 clicks bd or seretide 500
1 click bd (cheaper than separates)
(see note 8)

>2 exacerbations in next 12 months

after starting the above
add carbocisteine 750mg bd
(see note 9)
 Definition of asthma

“A chronic inflammatory disorder of the airways …

in susceptible individuals, inflammatory symptoms
are usually associated with widespread but variable
airflow obstruction and an increase in airway
response to a variety of stimuli. Obstruction is often
reversible, either spontaneously or with treatment.”

Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92

 Asthma
• Variable airflow obstruction
– Symptoms vary
– Measurements of airflow obstruction vary
• Associated with atopy (hayfever, eczema, urticaria)
• Occupational links eg bakers, isocyanates, wood-dust
• Dry cough, worse at night
• Episodic breathlessness
• Effects all ages
 Asthma

Allergens Triggers
• Tree • Exercise
• Grass • Fumes/ Smoke
• Fungi • Cold air
• House dust mite • Oesophageal Reflux
• Pets • Occupational
• Occupational
 Proving Variability
Looking for 20% variation
in PEFR or 15% in FEV1
1. Opportunistic single low peak flow in surgery
Give bronchodilator and repeat in 20 mins
Give trial of therapy and repeat next visit
2. Opportunistic single normal peak flow in surgery
Measure on subsequent visits -hope for variability naturally
Home peak flow measurements
Induce an asthma attack! -histamine challenge
Peak Flow Measurement
Single or Repeated Measures
 Stepwise management of
asthma in adults

Step 5: Continuous or frequent

use of oral steroids

Step 4: Persistent poor control

Step 3: Add-on therapy

Step 2: Regular preventer therapy

Step 1: Mild intermittent asthma

Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
 Can Asthma become COPD?
Different location.
Different cells 30% Smoke
5-10% Asthma
Different cause
10% COPD
Different prognosis

Similar clinical pictures

Similar treatments

Can Co-exist Chronic

0.5-1% Asthma
 Case Study -CP 2007
• Ex-smoker 30 pack yrs
• 60yr retd Nurse • FEV1 0.97 43%
• Chest infection 2002 in Spain -mild
SOB since What else would you like to know?
• Chest infection 2006 -hospitalised for History positional /reflux
4/7 antibiotics / steroids
• SOB and dry cough since What causes can you think of?
• No variation COPD
• 4 lots of AB and steroids from GP Obesity with Reflux
plus tiotropium & oxis -no help for 8/52 omeprazole 20mg bd + domperdone 10mg
cough tds -asymptomatic
• Wt climbing
• More SOB over 9/12
 Conclusions
Acute Cough < 3/52 Chronic Cough >3/12
Usually URTI CXR and Spirometry
CXR if worried
Symptomatic therapy Consider
GORD
Subacute Cough 3-8/52 Post -Nasal Drip
Usually post-viral Lung - Abnormal CXR
CXR if smoker or - Normal CXR
worried (asthma/ COPD)