Cough; A Common Sign Cough; A Common Sign to Cough - 4.pdf · ‒Hemoptysis ‒Lack of resolution with antibiotics ‒Pleuritic chest pain ‒Adventitious breath sounds ‒“B”

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Vincent Esguerra, MDAssistant Professor-Clinical MedicineDivision of Pulmonary, Critical Care,

and Sleep MedicineThe Ohio State University Wexner Medical Center

CoughCough; A Common SignCough; A Common Sign

Cough; A Common SignCough; A Common Sign Cough; A Common SignCough; A Common Sign

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“My dear doctor, I am surprised to hear you say that I am coughing very badly, as I have been practicing all night.”

- John Philpot Curran

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Cough as a Societal BurdenCough as a Societal Burden

• Most common cause to seek medical attention

• ~12% of US population suffering from chronic cough

• Cost is approximately 3-10 billion dollars every year

Why Do We cough?Why Do We cough?

• Protective reflex

• Vector for disease spread

Why Do We cough?Why Do We cough?

• Protective reflex

• Vector for disease spread

Cough Reflex ArchCough Reflex Arch• Sensory Component (Vagus Nerve)

‒ Ear Canals

‒ Pharynx

‒ Trachea

‒ Carinas

‒ Pleura

‒ Pericardium

‒ Esophagus and Stomach

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‒ Ear Canals

‒ Pharynx

‒ Trachea

‒ Carinas

‒ Pleura

‒ Pericardium



‒ Ear Canals

‒ Pharynx

‒ Trachea

‒ Carinas

‒ Pleura

‒ Pericardium


Cough Reflex ArchCough Reflex Arch• Motor Component

‒ Diaphragm

‒ Intercostal Muscles

‒ Epiglottis

‒ Pelvic Sphincter Muscles

Cough Reflex ArchCough Reflex Arch• End result is foreign material, mucus, saliva

droplets being expelled at 100-500 mph

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Cough Reflex ArchCough Reflex Arch• End result is foreign material, mucus, saliva

droplets being expelled at 100-500 mph

Excessive coughingExcessive coughing• Headache

• Rib fractures

• Emesis

• Pneumothorax

• Arrhythmias

• Self consciousness

• Urinary Incontinence

• Hoarseness

• Insomnia

• Dizziness

Logical Approach to CoughLogical Approach to Cough

• Duration‒ Acute : 0-3 weeks symptoms duration‒ Subacute : 3-8 weeks symptom duration‒ Chronic : > 8 weeks duration of symptoms

without intervening resolution

• Associated Signs and Symptoms (Red Flags)‒ Hemoptysis‒ Lack of resolution with antibiotics‒ Pleuritic chest pain‒ Adventitious breath sounds‒ “B” symptoms

Cough Questionnaires Cough Questionnaires

• Used mainly for research purposes

• Can be useful in specially designated “cough clinics”

• Helpful in judging the severity of cough but not causation

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Helpful Physical Exam FindingsHelpful Physical Exam Findings

• Pulmonary Exam‒ Egophony (highest +LR ratio for

pneumonia)‒ Wheezes‒ Crackles (wet or dry)‒ Rhonchi‒ Dullness to percussion‒ Chest wall tenderness

Helpful Physical Exam FindingsHelpful Physical Exam Findings

• Extra-Pulmonary Exam

‒ Edema and jugular venous distension

‒ Clubbing

‒ Dental carries

‒ Posterior oropharyngeal erythema and nodularity

‒ Lymphadenopathy

‒ Otoscope exam of the ear and nasal passages

Acute CoughAcute Cough

• Upper respiratory tract infection

• Bronchitis, bronchiolitis, and pneumonia

• Heart failure

• Aspiration

• Inhalational injury or exposure

Acute Cough TreatmentAcute Cough Treatment

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Acute Cough TreatmentAcute Cough Treatment Acute Cough TreatmentAcute Cough Treatment


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Carleen Risaliti, MDAssistant Professor-Clinical MedicineDivision of Pulmonary, Critical Care,

and Sleep MedicineThe Ohio State University Wexner Medical Center

Approach to CoughCaseCase

• 74 yo man presents as a new patient for evaluation of chronic cough• Cough x 5 years – progressively

worse• Productive of clear sputum• No hemoptysis• No fevers/chills, no night sweats

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CaseCase• PMH:

• DM

• HTN

• HLD

• GERD

• OSA

• Chronic sinus disease

• PSH:

• Tonsillectomy

• FH: CAD/MI, DM

• SH: +Former smoker with a 10 pack-year smoking history; quit 33 years ago

Common Causes of Chronic Cough

Common Causes of Chronic Cough

• Upper airways cough syndrome (post-nasal drip)

• Asthma

• GERD

• Medication side effects (ACE-i)

• Eosinophilic bronchitis

Upper Airways Cough SyndromeUpper Airways Cough Syndrome

• Most common cause of chronic cough

• Signs/symptoms:

• Nasal congestion/drainage

• Voice changes

• Throat-clearing

• Cobble-stoning of pharynx

• Testing

• Usually not necessary – treat empirically first if high suspicion

• CT sinuses – mucosal thickening, opacification

• Allergen testing

Upper Airways Cough Syndrome - TreatmentUpper Airways Cough Syndrome - Treatment

• Topical/nasal corticosteroids

• Oral antihistamines

• Topical/nasal anticholinergic (i.e. ipratropium bromide)

• Nasal decongestant vasoconstrictor sprays (i.e. afrin/oxymetazoline)

• Oral leukotriene modifiers (especially if patient also has asthma)

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AsthmaAsthma• Signs/symptoms:

• History of atopic disease• Family history of asthma• Nighttime cough• Concurrent wheezing/dyspnea

• Testing• Spirometry

Asthma - TreatmentAsthma - Treatment• Treatment based on severity

NHLBI 2007

Gastroesophageal Reflux DiseaseGastroesophageal Reflux Disease

• Aspiration

• Activation of esophageal-bronchial cough reflex

• Irritation of cough receptors in the larynx/vocal cords and trachea

Gastroesophageal Reflux DiseaseGastroesophageal Reflux Disease

• Signs/symptoms:• Symptoms worse with laying flat/at

night• Hoarseness• Sore throat• Globus sensation• Concurrent heartburn• Posterior vocal cord inflammation

• Testing• 24-hr esophageal pH monitoring

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Gastroesophageal Reflux Disease - Treatment

Gastroesophageal Reflux Disease - Treatment

• Proton-pump inhibitor (PPI)

• Lifestyle modifications• Weight loss• Avoidance of caffeine, smoking• Elevation of the head-of-bed

CaseCase• PMH:

• DM• HTN• HLD• GERD• OSA• Chronic sinus disease

• PSH:• Tonsillectomy

• FH: CAD/MI, DM• SH: +Former smoker with a 10 pack-year

smoking history; quit 33 years ago

CaseCase• Physical Exam:

• VS: BP 130/82; HR 65; O2 sat 94% on RA

• HEENT: Nose: +Boggy turbinates, no polpys; Oropharynx: No cobble-stoning

• CV: RRR

• Lungs: Clear to auscultation. No wheezes, crackles

• Abd: Distended. Soft, non-tender

• Extrem: Trace edema

• Neuro: Non-focal

• Skin: No rash

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CaseCase

• EGD (2015): Grade A esophagitis

What’s the diagnosis?What’s the diagnosis?

Upper Airways Cough

Syndrome

Asthma, cough variant

GERD Other

Chronic sinus disease

Symptoms worse at night

History of esophagitis

History of HTN and DM – double check meds

+Nasal congestion

+Heartburn

Symptoms worse at night

Multi-factorial!Multi-factorial!• “Chronic cough: Likely multi-factorial secondary

to upper airways cough syndrome (post-nasal drip) +/- obstructive lung disease in the setting of underlying GERD”

• Plan

• Prescribed Flonase

• Recommended oral antihistamine

• Educated about lifestyle modifications for GERD

• Encouraged PPI

• Ordered spirometry prior to next visit

Non-asthmatic EosinophilicBronchitis

Non-asthmatic EosinophilicBronchitis

• Signs/symptoms:• Cough• Normal spirometry/no

bronchospasm• Sputum with eosinophilia• Elevated exhaled nitric oxide

• Treatment:• Inhaled corticosteroids• Oral corticosteroids

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Medication EffectsMedication Effects

• ACE-I• Can present immediately or months

later• Cough usually resolves 1-4 weeks

after stopping medication

• Sitagliptin

Other Causes of Chronic CoughOther Causes of Chronic Cough• Chronic bronchitis/COPD

• Bronchiectasis

• Post-infectious cough (i.e. Bordetella pertussis)

• Malignancy

• Primary pulmonary malignancy

• Metastatic disease

• Sarcoidosis

• Chronic aspiration

• Interstitial lung disease

• Habit cough/psychogenic cough

• Unexplained chronic cough (“idiopathic” cough)

Assess for Red Flags!Assess for Red Flags!

• Weight loss

• Hemoptysis

• Occupational/environmental exposures

Still no luck?Still no luck?• Time to refer!

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ENT/AllergyENT/Allergy

PulmonaryPulmonaryGastroenterologyGastroenterology


ENT/AllergyENT/Allergy

PulmonaryPulmonaryGastroenterologyGastroenterology?

But while you wait…But while you wait…• If no evidence of GERD, stop PPI• Ensure patient is not on an ace-

inhibitor

• Consider referral to speech language pathology (SLP)• Cough suppression techniques• Reduction of laryngeal irritation• Education• Psychosocial education, counseling

Gibson et al, CHEST 2016 Smith and Woodcock, NEJM 2016

Cough Suppression TherapiesCough Suppression Therapies

• Should only be considered after therapies directed at etiology of cough have been tried

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Cough Suppression TherapiesCough Suppression TherapiesClass Examples Notes/CaveatsOpioids Morphine, codeine Can cause

dependency;respiratory depression

Non-opioids Dextromethorphan (synthetic derivative of morphine)

At least as effective as codeine

Local anesthetics (via nebulizer)

Lidocaine Variable results

Expectorants/MucolyticsAromatic agents

Acetylcysteine,carbocisteineEucalyptus/menthol

Alter volume/consistency of secretions

Antidepressants; antiepileptics;antispasmotics

TCAs; Paroxetine; gabapentin*; baclofen

Gabapentin is associated with improvement in QoLin RCT

Murray and Nadel 2010

ReferencesReferences• Chung KF, Widdicombe JG. Cough. In: Mason RJ, Broaddus VC, Martin TR

et al, editors. Murray and Nadel’s Textbook of Respiratory Medicine. 5th ed. Philadelphia: Saunders Elsevier; 2010, p. 628-646.

• Gibson P, Wang G, McGarvey L et al. Treatment of unexplained chronic cough: CHEST guideline and expert panel report. CHEST 2016;149(1):27-44.

• Irwin RS, French CL, Chang AB, Altman KW. Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report. CHEST 2017. Article in Press.

• Irwin RS and Madison M. The diagnosis and treatment of cough. NEJM 2000;343:1715-21.

• National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda: National Institutes of Health – National Heart, Lung, and Blood Institute; 2007, p.349-75. Available from: https://www.ncbi.nlm.nih.gov/books/NBK7232/

• Smith JA and Woodock A. Chronic cough. NEJM 2016;375(16):1544-51.

Documents

Cough; A Common Sign Cough; A Common Sign to Cough - 4.pdf · ‒Hemoptysis ‒Lack of resolution with antibiotics ‒Pleuritic chest pain ‒Adventitious breath sounds ‒“B”