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Chronic Cough Presentation by DR Aiswarya Thambi Pulmonologist.pptx

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Chronic Cough Presentation by Dr Aiswarya Thambi Best Pulmonologist, Thrissur, DAYA Hospital, director at Relentcare ENT centre.

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CHRONIC COUGH DR AISWARYA THAMBI MBBS MD DNB PULMONOLOGY CONSULTANT PULMONOLOGIST DAYA HOSPITAL,TCR
OVERVIEW Epidemiology Etiology Red flag signs Evaluation Management Conclusion
WHAT IS COUGH?
A cough is an innate primitive reflex and acts as part of the bodys immune system to protect against foreign materials. It starts as a deep inspiration, followed by a strong expiration against a closed glottis, which then opens with an expulsive flow of air, followed by a restorative inspiration Sharma S, Hashmi MF, Alhajjaj MS. Cough. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
PHASES OF COUGH (1) A DEEP INITIAL INSPIRATION, (2) COMPRESSION OF AIR IN THE LUNGS AND AIRWAYS BY FORCEFUL CONTRACTION OF THE EXPIRATORY MUSCLES COUPLED WITH TIGHT CLOSURE OF THE GLOTTIS AND OPENING OF THE LARYNX, AND (3) SUDDEN EXPLOSIVE EXPIRATION FOLLOWED BY NARROWING OF THE GLOTTIS AND RETURN OF THE LARYNX TO ITS NORMAL INSPIRATORY POSITION. 5
LOCATION OF COUGH RECEPTORS EFFECTOR NOSE PNS PHARYNX LARYNX TRACHEA BRONCHI PLEURA STOMACH EAR CANALS AND EARDRUMS PERICARDIUM DIAPHRAGM ESOPHAGUS 5 9 10 phrenic COUGH CENTRE MEDULLA NTS SPINAL MOTO R PHREN IC VAGUS EXPIRATORY MUSCLE INCLUDING PELVIC SPHINCTERS DIAPHRAGM LARYNX TRACHEA BRONCHI Type c and type 1 fibres
EPIDEMIOLOGY OF COUGH
The community prevalence of chronic cough is unclear, perhaps as high as 10%. Many sufferers dont access medical services, tolerating symptoms or possibly self-medicating. UK based primary care studies suggest chronic cough affecting 1.2-2% of the population but it is most likely under-estimated. BTS Clinical statement on chronic cough in adults- 2022
IMPACT OF CHRONIC COUGH Anxiety Work- absenteeis m Impact on quality of life Multiple health care visits BTS Clinical statement on chronic cough in adults- 2022
TYPES OF COUGH
Acute < 3 weeks Sub Acute 3- 8 weeks Chronic > 8 weeks Irwin RS , Baumann MH , Bolser DC , et al . Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest 2006;129:23S.doi:10.1378/chest.129.1_suppl.1S
WHAT IS NEW?
Refractory chronic cough Cause - identified Persists despite treatment of treatable traits May have symptoms of cough hypersensitivity Refractory unexplained chronic cough Cause- unknown No treatable traits No symptoms suggestive of cough hypersensitivity Cough hypersensitivity syndrome Triggered by low levels of thermal, mechanical, or chemical exposure. mediated by sensitisation of the sensory neuronal pathways controlling cough including the vagus nerve and central nervous system BTS Clinical statement on chronic cough in adults- 2022
When you cough repeatedly it can result in 'overstimulation' of the nerve, causing the nerve to become hypersensitive, which means it triggers more frequently than normal. A number of factors, including viruses and certain medications, can also have a direct impact on the cough reflex nerve, making it more sensitive. COUGH HYPERSENSITIVITY
ETIOLOGY OF COUGH?
ACUTE COUGH SUB-ACUTE COUGH CHRONIC COUGH 1) acute viral upper respiratory infection, 2) acute bronchitis, 3) acute rhinosinusitis, 4) pertussis, 5) acute exacerbations of chronic obstructive pulmonary disorder, 6) allergic rhinitis, 7) asthma, 8) congestive heart failure, 9) pneumonia, aspiration syndromes, and 10)pulmonary embolism 1) most commonly post-infectious secondary to continued irritation of cough receptors via ongoing or resolving bronchial or sinus inflammation from a preceding viral upper respiratory infection. 1) upper airway cough syndrome, 2) gastroesophageal reflux disease, 3) non-asthmatic eosinophilic bronchitis, 4) chronic bronchitis, 5) postinfectious cough, 6) intolerance to angiotensin- converting enzyme inhibitor medication, 7) malignancy, 8) interstitial lung diseases, 9) chronic sinusitis, and 10)psychosomatic cough.
Acute cough may suggest: Upper RT Common cold Sinusitis Lower RT Pneumonia Bronchitis Exacerbation of COPD /asthma Inhalation of bronchial irritant (eg, smoke or fumes CHF PULMONARY EMBOLISM SUDDEN ONSET VIOLENT COUGH ESP IN CHILD INHALATION OF FOREIGN BODY ACUTE COUGH
Chronic Cough Presentation by DR Aiswarya Thambi Pulmonologist.pptx
SUBACUTE COUGH 3-8 WEEKS Postinfectious MC A cough that begins with an acute respiratory tract infection and is not complicated* by pneumonia *Not complicated = Normal lung exam normal chest X-ray Generally cough is non productive Resolve without treatment SINUSITIS Asthma
Chronic Cough Presentation by DR Aiswarya Thambi Pulmonologist.pptx
CHRONIC COUGH 1) Upper Airway Cough Syndrome, 2) Gastroesophageal Reflux Disease, 3) Non-asthmatic Eosinophilic Bronchitis, 4) Chronic Bronchitis, 5) Postinfectious Cough, 6) Intolerance To Angiotensin-converting Enzyme Inhibitor Medication, 7) Malignancy, 8) Interstitial Lung Diseases, 9) Chronic Sinusitis, And 10)Psychosomatic Cough.
COUGH CHARACTERISTICS ACCORDING TO ETIOLOGY UACS [POST NASAL DRIP SX] sensation of throat clearing pharyngitis/sinusitis GERD reflux can be cause of cough -1 of 3 common cause of chronic cough -25% cases may or maynot a/w typical symptoms heartburn or regurgitation
ASTHMA sometimes cough me be its only symptom / atopic history /allergic skin tEsts should be documented DIAGNOSIS confirmed by demonstration of variable airway obstruction FEV1>=12% and >=200ml improvement 15 min after use of bd and >20% after 10 to 14 days of treatment with corticosteroids PEF >=20% improvement postbronchodilator METHACHOLINE CHALLENGE TEST 20% DROP IN FEV1
CHRONIC BRONCHITIS COUGH WITH SPUTUM EXPECTORATION FOR ATLEAST 3 CONSECUTIVE MONTHS FOR ATLEAST 2 CONSECUTIVE YEARS NON ASTHMATIC EOSINOPHILIC BRONCHITIS patient present with bronchial eosinophilia on sputum analysis without bronchial hyperresponsiveness . Cough responds to ICS , just as does in asthma Cough caused by medication non productive resolves within 4 weeks of stopping medication .affects 5-20% pt receiving ACE . BETA BLOCKERS c/c cough often by aggravating underlying asthma POSTINFECTIOUS COUGH Respiratory infection is often the cause of a/c or suba/c cough , accounts for about 15% of c/c cough cases
COUGH WITH POSTURAL VARIATION Sinusitis GERD Bronchectasis Lung abscess Pulmonay edema due to heart failure
COUGH WITH DIURNAL VARIATION Early morning cough ASTHMA , BRONCHIECTASIS ,C/C BRONCHITIS Nocturnal cough -- GERD , PULMONAY EDEMA ,TROPICAL PULMONARY EOSINOPHILIA
MECHANISM OF DRUG INDUCED COUGH ACEI -- Accumulation of bradykinin BETA BLOCKERS Causing bronchospasm BLEOMYCIN , BUSULFAN , AMIODARONE Lung fibrosis
All presumptive tb patients evaluated for sputum smear examination presumptive tb Cough>2weeks Fever>2weeks Significant weight loss hemoptysis TB
Chronic Cough Presentation by DR Aiswarya Thambi Pulmonologist.pptx
Red flag signs!
WATCH OUT! Impaired general condition, Recurrent infectious syndrome, Exertional dyspnea, Hemoptysis Cough appearance or change in cough in a smoker, Dysphonia, dysphagia, Cervical adenopathy, Abnormal cardiopulmonary / ENT examination Abnormal chest x-ray. L.Guilleminault,S.Demoulin-Alexikova,L.deGaboryetal. RespiratoryMedicineandResearch83(2023)101011
HEMOPTYSIS COUGHING up OF BLOOD Bright red Mixed with frothy sputum Alkaline ph Contains alveolar macrophages laden with hemosiderin
HISTORY & EVALUATION
Cough: onset, duration, character, triggers Sputum-volume & character Postural variation Smoking, occupation Drug history
Chronic Cough Presentation by DR Aiswarya Thambi Pulmonologist.pptx
L.Guilleminault,S.Demoulin-Alexikova,L.deGaboryetal. RespiratoryMedicineandResearch83(2023)101011
L.Guilleminault,S.Demoulin-Alexikova,L.deGaboryetal. RespiratoryMedicineandResearch83(2023)101011
CAN YOU MEASURE COUGH?
Measurement of cough Cough reflex Cough frequency & intensity Quality of life questionnaire Subjective visual analogue scale French CT, Irwin RS, Fletcher KE, Adams TM: Evaluation of a cough specific quality-of-life questionnaire. Chest 121:11231131, 2002
The Leicester Cough Questionnaire uses a seven- point Likert response scale for 19 items from three domains physical, psychological, and social And is shown to be repeatable and sensitive in patients with chronic cough Birring SS, Matos S, Patel RB, et al: Cough frequency, cough sensitivity and health status in patients with chronic cough. Respir Med 100:11051109, 2006
MANAGEMENT
CLINICAL PRACTICE POINTS Establish who needs specialist referral or can be initially managed in general practice with a targeted trial of therapy. Red flags should prompt urgent referral The history should identify possible underlying disease and treatable traits. All patients with chronic cough should have a chest x ray (CXR), full blood count (FBC), diagnostic spirometry and exhaled nitric oxide (FeNO) (if available) BTS Clinical statement on chronic cough in adults- 2022
ACUTE COUGH
Self care Honey Herbal medicines Over the counter antitussives Over the counter expectorants NSAIDS Antihistamines decongestants NICE guidelines 2019 Acute cough
WHAT DOES THE EVIDENCE SAY?
MEDICATION EVIDENCE 1) Over the counter expectorants there was some evidence that suggests guaifenesin reduced cough symptoms in adults and young people with an acute cough or upper respiratory tract infection, with no increase in adverse effects 2) Over the counter antitussives a) the evidence for dextromethorphan was mixed. b) codeine had no benefit on cough symptoms. 3) Anti histamines and decongestants antihistamines and decongestants had no benefit on cough symptoms, and increased adverse effects 4) Bronchodilators bronchodilators, such as oral or inhaled salbutamol, did not benefit cough symptoms and increased adverse events, such as tremor
Chronic Cough Presentation by DR Aiswarya Thambi Pulmonologist.pptx
TREATABLE TRAITS OF CHRONIC COUGH
BTS Clinical statement on chronic cough in adults- 2022
S.NO Treatable trait Identification marker Treatment Outcome 1) Smoking Patient history. Urinary Cotinine. Exhaled CO. Smoking cessation. Nicotine replacement therapy (NRT). Resolving chronic bronchitis improvement in cough. May get worse initially as nicotine suppresses cough reflex. 2) Irritant exposure: cigarette smoking/vaping, occupational exposures chemical/particulates History Occupational history Reduce exposure May improve cough 3) ACEI Treatment History. Medication records Stop ACEI in all patients with chronic cough. Can use A2RB if needed instead Improvement in cough, may take 4 weeks or more. BTS Clinical statement on chronic cough in adults- 2022
SNO Treatable trait Identification Treatment outcome 4) Airway eosinophilia History FeNO > 25ppb Blood eosinophil counts > 0.3 * 109 / L) Inhaled or oral corticosteroids Improve cough and QoL Reduced exacerbations 5) Productive cough History of significant sputum production. Sputum C&S HRCT ? bronchiectasis Airway Clearance physiotherapy Mucolytics Antimicrobials Macrolides Limited evidence. May improve cough BTS Clinical statement on chronic cough in adults- 2022
SNO TREATABLE TRAIT IDENTIFICATION TREATMENT OUTCOME 6 Chronic rhinosinusitis History of two or more symptoms for 12 weeks, one of which should be either nasal blockage or nasal discharge (anterior or posterior), with or without facial pain/pressure or reduction or loss of smell Nasal steroids Saline douching Consider ENT referral Improvement in rhinosinusitis. Possible improvement in cough. Limited evidence. 7) Inducible laryngeal obstruction History Laryngoscopy Speech therapy May improve cugh BTS Clinical statement on chronic cough in adults- 2022
SNO Treatable traits Identification Treatment Outcome 8) Gastroesophageal reflux disease Clinical history presence of heartburn best indicator of possible response to treatment. Reflux Symptoms Oesophageal manometry Endoscopy PPIs Lifestyle measures Also consider; H2 antagonists, weight loss Fundoplication Limited evidence. May improve cough for a subgroup of patients. Most dont improve. 9) Obstructive sleep apnea History Sleep study CPAP therapy May improve cough Limited evidence BTS Clinical statement on chronic cough in adults- 2022
PSYCHOGENIC COUGH A diagnosis of exclusion Most common in adolescents with concomitant emotional disorders Does not produce sputum Usually does not occur at night Not affected by commonly used cough suppresants
COMPLICATION OF COUGH Chest pain [myalgia] Fractures of ribs [COPD] Urinary incontinence Hernia Sub conjunctival hemorrhage Cough syncope
SUMMARY A detailed history & clinical examination gives clues to the underlying disease Presence of red flag signs warrants thorough investigation. Judicious use of antibiotics is recommended Patients and family members are to be counselled accordingly.
THANK YOU!

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Chronic Cough Presentation by DR Aiswarya Thambi Pulmonologist.pptx

  • 1. CHRONIC COUGH DR AISWARYA THAMBI MBBS MD DNB PULMONOLOGY CONSULTANT PULMONOLOGIST DAYA HOSPITAL,TCR
  • 2. OVERVIEW Epidemiology Etiology Red flag signs Evaluation Management Conclusion
  • 4. A cough is an innate primitive reflex and acts as part of the bodys immune system to protect against foreign materials. It starts as a deep inspiration, followed by a strong expiration against a closed glottis, which then opens with an expulsive flow of air, followed by a restorative inspiration Sharma S, Hashmi MF, Alhajjaj MS. Cough. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
  • 5. PHASES OF COUGH (1) A DEEP INITIAL INSPIRATION, (2) COMPRESSION OF AIR IN THE LUNGS AND AIRWAYS BY FORCEFUL CONTRACTION OF THE EXPIRATORY MUSCLES COUPLED WITH TIGHT CLOSURE OF THE GLOTTIS AND OPENING OF THE LARYNX, AND (3) SUDDEN EXPLOSIVE EXPIRATION FOLLOWED BY NARROWING OF THE GLOTTIS AND RETURN OF THE LARYNX TO ITS NORMAL INSPIRATORY POSITION. 5
  • 6. LOCATION OF COUGH RECEPTORS EFFECTOR NOSE PNS PHARYNX LARYNX TRACHEA BRONCHI PLEURA STOMACH EAR CANALS AND EARDRUMS PERICARDIUM DIAPHRAGM ESOPHAGUS 5 9 10 phrenic COUGH CENTRE MEDULLA NTS SPINAL MOTO R PHREN IC VAGUS EXPIRATORY MUSCLE INCLUDING PELVIC SPHINCTERS DIAPHRAGM LARYNX TRACHEA BRONCHI Type c and type 1 fibres
  • 8. The community prevalence of chronic cough is unclear, perhaps as high as 10%. Many sufferers dont access medical services, tolerating symptoms or possibly self-medicating. UK based primary care studies suggest chronic cough affecting 1.2-2% of the population but it is most likely under-estimated. BTS Clinical statement on chronic cough in adults- 2022
  • 9. IMPACT OF CHRONIC COUGH Anxiety Work- absenteeis m Impact on quality of life Multiple health care visits BTS Clinical statement on chronic cough in adults- 2022
  • 11. Acute < 3 weeks Sub Acute 3- 8 weeks Chronic > 8 weeks Irwin RS , Baumann MH , Bolser DC , et al . Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest 2006;129:23S.doi:10.1378/chest.129.1_suppl.1S
  • 13. Refractory chronic cough Cause - identified Persists despite treatment of treatable traits May have symptoms of cough hypersensitivity Refractory unexplained chronic cough Cause- unknown No treatable traits No symptoms suggestive of cough hypersensitivity Cough hypersensitivity syndrome Triggered by low levels of thermal, mechanical, or chemical exposure. mediated by sensitisation of the sensory neuronal pathways controlling cough including the vagus nerve and central nervous system BTS Clinical statement on chronic cough in adults- 2022
  • 14. When you cough repeatedly it can result in 'overstimulation' of the nerve, causing the nerve to become hypersensitive, which means it triggers more frequently than normal. A number of factors, including viruses and certain medications, can also have a direct impact on the cough reflex nerve, making it more sensitive. COUGH HYPERSENSITIVITY
  • 16. ACUTE COUGH SUB-ACUTE COUGH CHRONIC COUGH 1) acute viral upper respiratory infection, 2) acute bronchitis, 3) acute rhinosinusitis, 4) pertussis, 5) acute exacerbations of chronic obstructive pulmonary disorder, 6) allergic rhinitis, 7) asthma, 8) congestive heart failure, 9) pneumonia, aspiration syndromes, and 10)pulmonary embolism 1) most commonly post-infectious secondary to continued irritation of cough receptors via ongoing or resolving bronchial or sinus inflammation from a preceding viral upper respiratory infection. 1) upper airway cough syndrome, 2) gastroesophageal reflux disease, 3) non-asthmatic eosinophilic bronchitis, 4) chronic bronchitis, 5) postinfectious cough, 6) intolerance to angiotensin- converting enzyme inhibitor medication, 7) malignancy, 8) interstitial lung diseases, 9) chronic sinusitis, and 10)psychosomatic cough.
  • 17. Acute cough may suggest: Upper RT Common cold Sinusitis Lower RT Pneumonia Bronchitis Exacerbation of COPD /asthma Inhalation of bronchial irritant (eg, smoke or fumes CHF PULMONARY EMBOLISM SUDDEN ONSET VIOLENT COUGH ESP IN CHILD INHALATION OF FOREIGN BODY ACUTE COUGH
  • 19. SUBACUTE COUGH 3-8 WEEKS Postinfectious MC A cough that begins with an acute respiratory tract infection and is not complicated* by pneumonia *Not complicated = Normal lung exam normal chest X-ray Generally cough is non productive Resolve without treatment SINUSITIS Asthma
  • 21. CHRONIC COUGH 1) Upper Airway Cough Syndrome, 2) Gastroesophageal Reflux Disease, 3) Non-asthmatic Eosinophilic Bronchitis, 4) Chronic Bronchitis, 5) Postinfectious Cough, 6) Intolerance To Angiotensin-converting Enzyme Inhibitor Medication, 7) Malignancy, 8) Interstitial Lung Diseases, 9) Chronic Sinusitis, And 10)Psychosomatic Cough.
  • 22. COUGH CHARACTERISTICS ACCORDING TO ETIOLOGY UACS [POST NASAL DRIP SX] sensation of throat clearing pharyngitis/sinusitis GERD reflux can be cause of cough -1 of 3 common cause of chronic cough -25% cases may or maynot a/w typical symptoms heartburn or regurgitation
  • 23. ASTHMA sometimes cough me be its only symptom / atopic history /allergic skin tEsts should be documented DIAGNOSIS confirmed by demonstration of variable airway obstruction FEV1>=12% and >=200ml improvement 15 min after use of bd and >20% after 10 to 14 days of treatment with corticosteroids PEF >=20% improvement postbronchodilator METHACHOLINE CHALLENGE TEST 20% DROP IN FEV1
  • 24. CHRONIC BRONCHITIS COUGH WITH SPUTUM EXPECTORATION FOR ATLEAST 3 CONSECUTIVE MONTHS FOR ATLEAST 2 CONSECUTIVE YEARS NON ASTHMATIC EOSINOPHILIC BRONCHITIS patient present with bronchial eosinophilia on sputum analysis without bronchial hyperresponsiveness . Cough responds to ICS , just as does in asthma Cough caused by medication non productive resolves within 4 weeks of stopping medication .affects 5-20% pt receiving ACE . BETA BLOCKERS c/c cough often by aggravating underlying asthma POSTINFECTIOUS COUGH Respiratory infection is often the cause of a/c or suba/c cough , accounts for about 15% of c/c cough cases
  • 25. COUGH WITH POSTURAL VARIATION Sinusitis GERD Bronchectasis Lung abscess Pulmonay edema due to heart failure
  • 26. COUGH WITH DIURNAL VARIATION Early morning cough ASTHMA , BRONCHIECTASIS ,C/C BRONCHITIS Nocturnal cough -- GERD , PULMONAY EDEMA ,TROPICAL PULMONARY EOSINOPHILIA
  • 27. MECHANISM OF DRUG INDUCED COUGH ACEI -- Accumulation of bradykinin BETA BLOCKERS Causing bronchospasm BLEOMYCIN , BUSULFAN , AMIODARONE Lung fibrosis
  • 28. All presumptive tb patients evaluated for sputum smear examination presumptive tb Cough>2weeks Fever>2weeks Significant weight loss hemoptysis TB
  • 31. WATCH OUT! Impaired general condition, Recurrent infectious syndrome, Exertional dyspnea, Hemoptysis Cough appearance or change in cough in a smoker, Dysphonia, dysphagia, Cervical adenopathy, Abnormal cardiopulmonary / ENT examination Abnormal chest x-ray. L.Guilleminault,S.Demoulin-Alexikova,L.deGaboryetal. RespiratoryMedicineandResearch83(2023)101011
  • 32. HEMOPTYSIS COUGHING up OF BLOOD Bright red Mixed with frothy sputum Alkaline ph Contains alveolar macrophages laden with hemosiderin
  • 34. Cough: onset, duration, character, triggers Sputum-volume & character Postural variation Smoking, occupation Drug history
  • 38. CAN YOU MEASURE COUGH?
  • 39. Measurement of cough Cough reflex Cough frequency & intensity Quality of life questionnaire Subjective visual analogue scale French CT, Irwin RS, Fletcher KE, Adams TM: Evaluation of a cough specific quality-of-life questionnaire. Chest 121:11231131, 2002
  • 40. The Leicester Cough Questionnaire uses a seven- point Likert response scale for 19 items from three domains physical, psychological, and social And is shown to be repeatable and sensitive in patients with chronic cough Birring SS, Matos S, Patel RB, et al: Cough frequency, cough sensitivity and health status in patients with chronic cough. Respir Med 100:11051109, 2006
  • 42. CLINICAL PRACTICE POINTS Establish who needs specialist referral or can be initially managed in general practice with a targeted trial of therapy. Red flags should prompt urgent referral The history should identify possible underlying disease and treatable traits. All patients with chronic cough should have a chest x ray (CXR), full blood count (FBC), diagnostic spirometry and exhaled nitric oxide (FeNO) (if available) BTS Clinical statement on chronic cough in adults- 2022
  • 45. WHAT DOES THE EVIDENCE SAY?
  • 46. MEDICATION EVIDENCE 1) Over the counter expectorants there was some evidence that suggests guaifenesin reduced cough symptoms in adults and young people with an acute cough or upper respiratory tract infection, with no increase in adverse effects 2) Over the counter antitussives a) the evidence for dextromethorphan was mixed. b) codeine had no benefit on cough symptoms. 3) Anti histamines and decongestants antihistamines and decongestants had no benefit on cough symptoms, and increased adverse effects 4) Bronchodilators bronchodilators, such as oral or inhaled salbutamol, did not benefit cough symptoms and increased adverse events, such as tremor
  • 49. BTS Clinical statement on chronic cough in adults- 2022
  • 50. S.NO Treatable trait Identification marker Treatment Outcome 1) Smoking Patient history. Urinary Cotinine. Exhaled CO. Smoking cessation. Nicotine replacement therapy (NRT). Resolving chronic bronchitis improvement in cough. May get worse initially as nicotine suppresses cough reflex. 2) Irritant exposure: cigarette smoking/vaping, occupational exposures chemical/particulates History Occupational history Reduce exposure May improve cough 3) ACEI Treatment History. Medication records Stop ACEI in all patients with chronic cough. Can use A2RB if needed instead Improvement in cough, may take 4 weeks or more. BTS Clinical statement on chronic cough in adults- 2022
  • 51. SNO Treatable trait Identification Treatment outcome 4) Airway eosinophilia History FeNO > 25ppb Blood eosinophil counts > 0.3 * 109 / L) Inhaled or oral corticosteroids Improve cough and QoL Reduced exacerbations 5) Productive cough History of significant sputum production. Sputum C&S HRCT ? bronchiectasis Airway Clearance physiotherapy Mucolytics Antimicrobials Macrolides Limited evidence. May improve cough BTS Clinical statement on chronic cough in adults- 2022
  • 52. SNO TREATABLE TRAIT IDENTIFICATION TREATMENT OUTCOME 6 Chronic rhinosinusitis History of two or more symptoms for 12 weeks, one of which should be either nasal blockage or nasal discharge (anterior or posterior), with or without facial pain/pressure or reduction or loss of smell Nasal steroids Saline douching Consider ENT referral Improvement in rhinosinusitis. Possible improvement in cough. Limited evidence. 7) Inducible laryngeal obstruction History Laryngoscopy Speech therapy May improve cugh BTS Clinical statement on chronic cough in adults- 2022
  • 53. SNO Treatable traits Identification Treatment Outcome 8) Gastroesophageal reflux disease Clinical history presence of heartburn best indicator of possible response to treatment. Reflux Symptoms Oesophageal manometry Endoscopy PPIs Lifestyle measures Also consider; H2 antagonists, weight loss Fundoplication Limited evidence. May improve cough for a subgroup of patients. Most dont improve. 9) Obstructive sleep apnea History Sleep study CPAP therapy May improve cough Limited evidence BTS Clinical statement on chronic cough in adults- 2022
  • 54. PSYCHOGENIC COUGH A diagnosis of exclusion Most common in adolescents with concomitant emotional disorders Does not produce sputum Usually does not occur at night Not affected by commonly used cough suppresants
  • 55. COMPLICATION OF COUGH Chest pain [myalgia] Fractures of ribs [COPD] Urinary incontinence Hernia Sub conjunctival hemorrhage Cough syncope
  • 56. SUMMARY A detailed history & clinical examination gives clues to the underlying disease Presence of red flag signs warrants thorough investigation. Judicious use of antibiotics is recommended Patients and family members are to be counselled accordingly.