CHRONIC COUGH

1. CHRONIC COUGH William A. Curry, MD UAB GIM Noon Conference April 27, 2010 Today�s speaker has no conflict of interest to disclose. The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. UAB School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit (s) Physicians should only claim credit commensurate with the extent of their participation in the activity.

4. COUGH: CATEGORIES ACUTE: less than three weeks SUBACUTE: three to eight weeks CHRONIC: more than eight weeks

5. COUGH: CATEGORIES ACUTE: less than three weeks SUBACUTE: three to eight weeks CHRONIC: more than eight weeks

10. Complications of Cough

14. CAUSES OF CHRONIC COUGH Upper Airway Cough Syndrome Asthma GERD

15. CAUSES OF CHRONIC COUGH Upper Airway Cough Syndrome Asthma GERD

16. CAUSES OF CHRONIC COUGH Upper Airway Cough Syndrome Asthma GERD Post-infectious Meds (ACEI esp.)

17. CAUSES OF CHRONIC COUGH Upper Airway Cough Syndrome Asthma GERD Post-infectious Meds (ACEI esp.) Airway Diseases (bronchitis, bronchiectasis,neoplasm, foreign body) Pareynchymal Disease (ILD, lung abascess) Others

18. CAUSES OF CHRONIC COUGH Upper Airway Cough Syndrome Asthma GERD Post-infectious Meds (ACEI esp.) Airway Diseases (bronchitis, bronchiectasis,neoplasm, foreign body) Pareynchymal Disease (ILD, lung abascess) Others

20. UPPER AIRWAY COUGH SYNDROME (Postnasal Drip) Common cause of subacute and chronic cough Etiologies Rhinitis: allergic, perennial nonallergic, vasomotor URI Sinusitis Symptoms Classic: sensation of drip, frequent throat clearing Silent

21. UPPER AIRWAY COUGH SYNDROME (Postnasal Drip) Treatment Intranasal steroids: work in 2-14 d Allergic Rhinitis: most effective Nonallergic Rhinitis w/Eo�s (NARES) Vasomotor Rhinitis

22. UPPER AIRWAY COUGH SYNDROME (Postnasal Drip) Treatment Intranasal steroids: work in 2-14 d Allergic Rhinitis: most effective Nonallergic Rhinitis w/Eo�s (NARES) Vasomotor Rhinitis Antihistamines First generation more effective but more sedating (brompheniramine, chlorpheniramine, clemastine) Second generation (ceterizine, fexofenadine, loratadine)

23. UPPER AIRWAY COUGH SYNDROME (Postnasal Drip) Treatment Intranasal steroids: work in 2-14 d Allergic Rhinitis: most effective Nonallergic Rhinitis w/Eo�s (NARES) Vasomotor Rhinitis Antihistamines First generation more effective but more sedating (brompheniramine, chlorpheniramine, clemastine) Second generation (ceterizine, fexofenadine, loratadine) Others: decongenstant, leukotriene antagonist

24. �COUGH VARIANT� ASTHMA May be aggravated by cold, fumes. May be associated with dyspnea.

25. �COUGH VARIANT� ASTHMA May be aggravated by cold, fumes. May be associated with dyspnea. Spirometry May show classic airflow obstruction (beware false +). May be normal.

26. �COUGH VARIANT� ASTHMA May be aggravated by cold, fumes. May be associated with dyspnea. Spirometry May show classic airflow obstruction (beware false +). May be normal. Methacholine Challenge Test May be helpful, but up to 22% false positive.

27. �COUGH VARIANT� ASTHMA May be aggravated by cold, fumes. May be associated with dyspnea. Spirometry May show classic airflow obstruction (beware false +). May be normal. Methacholine Challenge Test May be helpful, but up to 22% false positive. Best dx is response to inhaled Beta agonist w/in one wk, but trial of LTRA or glucocorticoid may be warranted.

28. COUGH DUE TO REFLUX: Dx GERD Up to 40% may lack heartburn or sour taste Hoarseness common, also �globus pharyngeus� Barium swallow, EGD limited sensitivity/specificity 24 esophageal pH monitoring is optimal, 90% sens but rarely needed. Motility often abnormal but role of testing unclear. LARYNGOPHARYNGEAL REFLUX 35% have heartburn Worse upright during exertion, stooping (UES problem)

29. COUGH DUE TO REFLUX: Rx LIFESTYLE Weight loss, smoking cessation Elevation of head of bed 3-4 inches Avoid reflux-inducers: fat, chocolate, EtOH xs Avoid acidic: colas, red wine, OJ No food w/in 3 hrs of lying down ACID SUPPRESSION PPI 8 Wks, if no better consider pH monitoring PROKINETICS: weak data, extrapyramidal AE SURGERY: Nissen fundoplication 83% effective in one small study.

30. COUGH AFTER INFECTION Etiologies Viral, Mycoplasma, Chlamydia Bordatella pertusssis: under-appreciated 21% of 75 adults w/ cough > 2 wks JAMA 1995; 273:1044 AB (emycin,t/s) effective only early Counsel re exposing young children. Rx Inhaled beta agonist Inhaled ipratropium ( + small trial) Respir Med 1992;86:425

32. COUGH: Less Common Causes ACE Inhibitors Up to 15% of those taking, probably from bradykinin Usually starts w/in one wk of Rx but can be 6 mo Usually resolves in 1-4 days after d/c, up to 4 w No more frequent in pts with asthma, no obstruction Bronchiectasis Typically productive cough Consider CF, previous pertussis, other infections

33. COUGH: Less Common Causes Lung CA New or changing cough in smoker Cough persisting > 1 mo after smoking cessation Hemoptysis w/out airway infection Nonasthmatic Eosinophilic Bronchitis Tend to be atopic, + sputum eo�s No PFT obstruction (like variant asthma) Definitive Dx by bronchial bx, but presumptive by trial of inhaled corticosteroid

35. BEFORE DOING�. Sputum studies Modified BA swallow 24 hr. esophageal pH monitoring EGD Gastric emptying study HRCT of chest Bronchoscopy MIBI TTE

36. BEFORE DOING� Sputum studies Modified BA swallow 24 hr. esophageal pH monitoring EGD Gastric emptying study HRCT of chest Bronchoscopy MIBI TTE

37. Common Pitfalls in Chronic Cough UPPER AIRWAY COUGH SYNDROME Failing to recognize sx can be cough and phlegm. Assuming all H1 blockers are equal. Failing to consider sinusitis if not obvious. Failing to consider allergic rhinitis if sx perennial. ASTHMA Failing to recognize sx can be cough and phlegm Failing to recognize inhaled meds can exacerbate cough. Assuming + methacholine challenge = dx of asthma.

38. Common Pitfalls in Chronic Cough GASTROESOPHAGEAL REFLUX Failing to recognize sx can be cough and phlegm. Failing to recognize �silent� GERD Failing to appreciate that sx may not improve for 2-3 mo even with intensive Rx and can last 5-6 mo. Assuming GERD not the cause if cough persists despite GERD sx improving. Overlooking effects of coexisting diseases (OSA, CAD) COMBINED UACS, ASTHMA, and GERD Overlooking that more than one may be involved. Overlooking one of these b/o another possible cause (e.g., interstitial pneumonia) (= �anchoring�)

39. COUGH: Symptomatic Rx Centrally acting Dextromethorphan: may be more effective than codeine; use enough (20-60 mg in adults) Codeine: typically 30 mg, more adverse events Peripherally acting Benzonatate (Tessalon Perles) 100-200 mg tid Anesthetizes (?) stretch receptors of lungs and pleura Guaifenesin (Mucinex, Robitussin) increases secretions Need to give enough (Mucinex = 600 mg, Robitussin = 100 mg/5cc) Works well combined with dextromethorphan, maybe benzonatate Inhaled steroids: conflicting results for nonspecific Inhaled ipratropium: for post-infectious, ? nonspecific

40. CHRONIC COUGH: SUMMARY Careful history including: ACEI, recent URI Coexisting asthma, drip, GERD, bronchitis, bronchiectasis Targeted exam CXR if > 8 wks Thoughtful therapeutic trials for UACS, asthma, GERD, post-infectious Other eval as indicated

41. CHRONIC COUGH: SUMMARY Careful history including: ACEI, recent URI Coexisting asthma, drip, GERD, bronchitis, bronchiectasis Targeted exam CXR if > 8 wks Thoughtful therapeutic trials for UACS, asthma, GERD, post-infectious Other eval as indicated