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Chronic Cough

The Size of the Problem. Prevalence of 10% in the communityApproximately 30 million physician visits annually (US)5th most common symptom for outpatient careUp to 40 percent of an outpatient chest clinicsCost of treating exceeds 500 million annually, excluding cost of diagnostic tests and m

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Chronic Cough

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    1. Chronic Cough

    2. The Size of the Problem Prevalence of 10% in the community Approximately 30 million physician visits annually (US) 5th most common symptom for outpatient care Up to 40 percent of an outpatient chest clinics Cost of treating exceeds 500 million annually, excluding cost of diagnostic tests and medications Multiple effects on patients: exhaustion, self-consciousness, insomnia, headache, dizziness, musculoskeletal pain, hoarseness, excessive perspiration, urinary incontinence, "something is wrong"

    3. Complications

    4. MEDULLARY COUGH CENTRE

    13. Symptoms of GORD in Asthma Oesophageal symptoms Heartburn, Regurgitation, Dysphagia Extra-Oesophageal symptoms Coughing Sore-throat, Choking Hoarseness Chest Pain Odour Worsened Asthma symptoms with Eating, Alcohol, Supine position, Theophyllines, Systemic b2 agonists Anti-cholinergic drugs Clinically Silent

    15. Pulmonary Indications for 24hr Oesophageal pH monitoring Unexplained Persistent Cough Cough associated with other symptoms of GORD, not responding to anti-reflux therapy Chronic Cough with proven aetiology not responding to specific therapy Difficult to control asthma despite maximal therapy Poor response in confirmed GORD, monitoring while ON anti-reflux Rx to determine persistent acid reflux (2-3% may require reflux surgery)

    20. GORD Therapy for Difficult Asthma High-protein, low-fat anti-reflux diet Weight loss Eat only 3 meals per day Do not eat or drink 2-3 hours before lying down except for medications Elevate head of bed H2 antagonists: cimetidine, ranitidine, PPIs: (es)omeprazole, lansoprazole, Pro-kinetic agents MST Surgery

    21. Specific Therapy for Common Causes of Chronic Cough Postnasal Drip Rhinitis - allergic, - perennial non-allergic, - post-infectious, environmental irritant - vasomotor Avoidance of environmental irritants Intranasal steroid spray Antihistamine-decongestant combination Intranasal ipratropium bromide (Atrovent), for non-responsive vasomotor rhinitis Sinusitis Antibiotics Decongestant nasal spray Antihistamine-decongestant combination

    22. Specific Therapy for Common Causes of Chronic Cough Asthma Bronchodilators Inhaled corticosteroids Other asthma therapy COPD Local Guidelines Gastroesophageal reflux disease High-protein, low-fat anti-reflux diet eat 3 meals per day Do not eat or drink 2-3 hours before lying down except for medications elevate head of bed Histamine H2-receptor antagonists: cimetidine, ranitidine, famotidine, Acid (proton) pump inhibitors: omeprazole, lansoprazole, Pro-kinetic agents

    25. 10 mins for a Chronic Cougher History 42 yrs female, 8 month cough, good health, embarrassed, prolapse What issues you should cover Take a brief history Ask about symptoms of asthma Ask about post nasal drip - repeated throat clearing - nasal discharge - excessive phlegm Ask about heartburn and regurgitation Smoker? Quality of Life? ACE Inhibitor? Explain that several consultations needed ! WARNING symptoms

    26. 10 mins for a Chronic Cougher What you should do Examine the patient: URT and LRT - examine for signs of asthma (lung sounds!) and PNDS - remember examination usually normal Arrange CXR if WARNING symptoms; smokers, wt. loss, haemoptysis etc. Perform spirometry - treat for asthma or COPD if obstruction - Treat with nasal corticosteroids Treat with acid suppressants Ask the patient to make another appointment to assess response

    27. Case Studies first presentation Case 1 35 yr old male from Congo, cough for 6 weeks, wt. loss half stone Case 2 42 yr old female, cough for 8 weeks, recurrent ear infections, phlegm in the morning, chest clear, spirometry normal Case 3 16 yr old female, cough for 8 weeks, poor concentration at school, night sweats, phlegm in the morning, chest clear, spirometry normal Case 4 65 yr old male, cough for 2 months, pain in left shoulder, spirometry 1.0/2.8

    28. Case Studies further visits Case 5 32 yr old female, recurrent childhood infections, phlegm most mornings, blocked nose, face-aches, wheezy when exerting, better with bronchodilators, spirometry 1.7/2.9 Case 6 79 yr old male, cough for 3 months, breathless when exerting, waking at night with cough and breathlessness, phlegm in the morning, chest clear, spirometry 0.9/3.2, partially better with bronchodilators Case 7 42 yr old female, cough for 8 years, smoker, CXR normal, phlegm in the morning, chest wheezy, spirometry 1.7/2.8, inhalers useless, coughed ++ after VV surgery, anaesthetist comments alright in op, worse in recovery Case 8 38 yr old female, cough for 6 months, allergic to cats, breathless and wheezy, PEFs variable, watery and itchy eyes

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