That Nagging Cough Common Causes amp Treatment of Chronic Cough CANP 38th Annual Educational Conference

March 21 2015

Jane Wang RN MSN FNP-C Stanford Otolaryngology-HeadNeck Surgery

Stanford Health Care

Cough being one of the most common symptoms sup1sup2

30 million visits $600 millions spent on OTC and Rx drugs for cough in 2010 sup1sup2

Cough being part of the bodyrsquos defense mechanism usually lasts less than 3 weeks

Chronic cough is defined as a cough that lasts more than 8 weeks sup3

A wide range of complications can occur from coughing ⁴⁵⁶

ACCP Guidelines In 1998 the American College of Chest Physician (ACCP) developed evidence-based clinical practice guidelines to provide a systematic approach to diagnosing and managing chronic cough which was subsequently updated and revised in 2006

Case Study

Mr Rosenthal 56-year-old male HR manager presents to his family nurse practitioner with 10-week history of non-productive cough His cough has become worse over the past couple of weeks Itrsquos affecting his sleep embarrassed him at work and various social settings He is now worried that there is something seriously wrong with him

What else to know

Precipitating event Smoking history Medications taking Recent foreign travel or sick contact Significant past and present medical history What has he tried to alleviate the cough

Further history amp exam findings for Mr Rosenthal Smoked cigarette frac14 PPD x 2 years in college Traveled to Tibet 4 months ago Started with a cold Thought at one point he had fever but it broke pretty quickly Most cold symptoms

resolved within a week but cough lingers No significant PMH Never took ACE-I co sensation of mucus being stuck to the back of throat with frequent throat clearing occasional nasal

congestion Tried OTC Robitussin cough syrup no benefit Denies recent weight loss hemoptysis fever chills night sweats Physical exam is largely normal including no abnormalities of the mouth nose pharynx neck heart

Wheezing detected on exhalation

ACCP Guidelines 2 high-yield elements of the history 1 The use of an ACE-I ⁸⁹sup1⁰

2 Cigarette smoking or exposure to second-hand smoking

ACCP Guidelines With a normal CXR in an otherwise healthy adult who doesnrsquot use an ACE-I or cigarettes chronic cough is most commonly caused by 3 conditions Upper airway cough syndrome (UACS) Asthma GERD Current literature suggests that these 3 causes constitute more than 90 of cases of chronic cough sup1sup1sup1sup2

ACCP Guidelines 1 no apparent cause for chronic cough 2 target 3 most common conditions sequentially Upper airway cough syndrome (UACS) Asthma GERD 3 subsequent empiric therapy be added onto the step prior

Upper Airway Cough Syndrome

Post nasal drip

Other symptoms nasal congestion rhinorrhea frequent throat clearing or globus

Oropharyngeal exam mucopurulent secretions or cobblestoning sup1⁷

Underlying inciting factors in UACS

Diagnosis in retrospect by the resolution of the cough in response to empiric therapy sup1⁸

Initial treatment is combination of 1st generation antihistamine and decongestant sup3

Nasal corticosteroids nasal anticholinergic agents or nasal antihistamines may also be effective sup1⁸

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid

3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Normal test results

Cough-Variant Asthma

chronic cough as the only symptom with an otherwise normal physical exam

PFT is the initial test

Methacholine challenge to confirm the diagnosis sup3

Initial treatment ICSs and β-agonist

Addition of a leukotriene receptor inhibitor

For severe and refractory cough a short course of oral corticosteroids can be considered sup3sup1⁹

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results are normal

This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen

Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

GERD

GERD is thought to trigger cough

Physiologic reflux and micro-aspiration vs heightened cough sensitivity sup2⁰

Frequency of GERD as the causative factor in chronic cough is unclear Published reports vary widely ranging between 0 to 73 sup2⁰

GERD can coexist with chronic cough as well as be the result of coughing sup2⁰

Treat despite of no heartburn regurgitation or sour taste

Empiric treatment beginning with lifestyle changes and PPI for at least 8 weeks

23-hour pH monitoring

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

Cough being one of the most common symptoms sup1sup2

30 million visits $600 millions spent on OTC and Rx drugs for cough in 2010 sup1sup2

Cough being part of the bodyrsquos defense mechanism usually lasts less than 3 weeks

Chronic cough is defined as a cough that lasts more than 8 weeks sup3

A wide range of complications can occur from coughing ⁴⁵⁶

ACCP Guidelines In 1998 the American College of Chest Physician (ACCP) developed evidence-based clinical practice guidelines to provide a systematic approach to diagnosing and managing chronic cough which was subsequently updated and revised in 2006

Case Study

Mr Rosenthal 56-year-old male HR manager presents to his family nurse practitioner with 10-week history of non-productive cough His cough has become worse over the past couple of weeks Itrsquos affecting his sleep embarrassed him at work and various social settings He is now worried that there is something seriously wrong with him

What else to know

Precipitating event Smoking history Medications taking Recent foreign travel or sick contact Significant past and present medical history What has he tried to alleviate the cough

Further history amp exam findings for Mr Rosenthal Smoked cigarette frac14 PPD x 2 years in college Traveled to Tibet 4 months ago Started with a cold Thought at one point he had fever but it broke pretty quickly Most cold symptoms

resolved within a week but cough lingers No significant PMH Never took ACE-I co sensation of mucus being stuck to the back of throat with frequent throat clearing occasional nasal

congestion Tried OTC Robitussin cough syrup no benefit Denies recent weight loss hemoptysis fever chills night sweats Physical exam is largely normal including no abnormalities of the mouth nose pharynx neck heart

Wheezing detected on exhalation

ACCP Guidelines 2 high-yield elements of the history 1 The use of an ACE-I ⁸⁹sup1⁰

2 Cigarette smoking or exposure to second-hand smoking

ACCP Guidelines With a normal CXR in an otherwise healthy adult who doesnrsquot use an ACE-I or cigarettes chronic cough is most commonly caused by 3 conditions Upper airway cough syndrome (UACS) Asthma GERD Current literature suggests that these 3 causes constitute more than 90 of cases of chronic cough sup1sup1sup1sup2

ACCP Guidelines 1 no apparent cause for chronic cough 2 target 3 most common conditions sequentially Upper airway cough syndrome (UACS) Asthma GERD 3 subsequent empiric therapy be added onto the step prior

Upper Airway Cough Syndrome

Post nasal drip

Other symptoms nasal congestion rhinorrhea frequent throat clearing or globus

Oropharyngeal exam mucopurulent secretions or cobblestoning sup1⁷

Underlying inciting factors in UACS

Diagnosis in retrospect by the resolution of the cough in response to empiric therapy sup1⁸

Initial treatment is combination of 1st generation antihistamine and decongestant sup3

Nasal corticosteroids nasal anticholinergic agents or nasal antihistamines may also be effective sup1⁸

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid

3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Normal test results

Cough-Variant Asthma

chronic cough as the only symptom with an otherwise normal physical exam

PFT is the initial test

Methacholine challenge to confirm the diagnosis sup3

Initial treatment ICSs and β-agonist

Addition of a leukotriene receptor inhibitor

For severe and refractory cough a short course of oral corticosteroids can be considered sup3sup1⁹

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results are normal

This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen

Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

GERD

GERD is thought to trigger cough

Physiologic reflux and micro-aspiration vs heightened cough sensitivity sup2⁰

Frequency of GERD as the causative factor in chronic cough is unclear Published reports vary widely ranging between 0 to 73 sup2⁰

GERD can coexist with chronic cough as well as be the result of coughing sup2⁰

Treat despite of no heartburn regurgitation or sour taste

Empiric treatment beginning with lifestyle changes and PPI for at least 8 weeks

23-hour pH monitoring

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

ACCP Guidelines In 1998 the American College of Chest Physician (ACCP) developed evidence-based clinical practice guidelines to provide a systematic approach to diagnosing and managing chronic cough which was subsequently updated and revised in 2006

Case Study

Mr Rosenthal 56-year-old male HR manager presents to his family nurse practitioner with 10-week history of non-productive cough His cough has become worse over the past couple of weeks Itrsquos affecting his sleep embarrassed him at work and various social settings He is now worried that there is something seriously wrong with him

What else to know

Precipitating event Smoking history Medications taking Recent foreign travel or sick contact Significant past and present medical history What has he tried to alleviate the cough

Further history amp exam findings for Mr Rosenthal Smoked cigarette frac14 PPD x 2 years in college Traveled to Tibet 4 months ago Started with a cold Thought at one point he had fever but it broke pretty quickly Most cold symptoms

resolved within a week but cough lingers No significant PMH Never took ACE-I co sensation of mucus being stuck to the back of throat with frequent throat clearing occasional nasal

congestion Tried OTC Robitussin cough syrup no benefit Denies recent weight loss hemoptysis fever chills night sweats Physical exam is largely normal including no abnormalities of the mouth nose pharynx neck heart

Wheezing detected on exhalation

ACCP Guidelines 2 high-yield elements of the history 1 The use of an ACE-I ⁸⁹sup1⁰

2 Cigarette smoking or exposure to second-hand smoking

ACCP Guidelines With a normal CXR in an otherwise healthy adult who doesnrsquot use an ACE-I or cigarettes chronic cough is most commonly caused by 3 conditions Upper airway cough syndrome (UACS) Asthma GERD Current literature suggests that these 3 causes constitute more than 90 of cases of chronic cough sup1sup1sup1sup2

ACCP Guidelines 1 no apparent cause for chronic cough 2 target 3 most common conditions sequentially Upper airway cough syndrome (UACS) Asthma GERD 3 subsequent empiric therapy be added onto the step prior

Upper Airway Cough Syndrome

Post nasal drip

Other symptoms nasal congestion rhinorrhea frequent throat clearing or globus

Oropharyngeal exam mucopurulent secretions or cobblestoning sup1⁷

Underlying inciting factors in UACS

Diagnosis in retrospect by the resolution of the cough in response to empiric therapy sup1⁸

Initial treatment is combination of 1st generation antihistamine and decongestant sup3

Nasal corticosteroids nasal anticholinergic agents or nasal antihistamines may also be effective sup1⁸

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid

3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Normal test results

Cough-Variant Asthma

chronic cough as the only symptom with an otherwise normal physical exam

PFT is the initial test

Methacholine challenge to confirm the diagnosis sup3

Initial treatment ICSs and β-agonist

Addition of a leukotriene receptor inhibitor

For severe and refractory cough a short course of oral corticosteroids can be considered sup3sup1⁹

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results are normal

This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen

Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

GERD

GERD is thought to trigger cough

Physiologic reflux and micro-aspiration vs heightened cough sensitivity sup2⁰

Frequency of GERD as the causative factor in chronic cough is unclear Published reports vary widely ranging between 0 to 73 sup2⁰

GERD can coexist with chronic cough as well as be the result of coughing sup2⁰

Treat despite of no heartburn regurgitation or sour taste

Empiric treatment beginning with lifestyle changes and PPI for at least 8 weeks

23-hour pH monitoring

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

Case Study

Mr Rosenthal 56-year-old male HR manager presents to his family nurse practitioner with 10-week history of non-productive cough His cough has become worse over the past couple of weeks Itrsquos affecting his sleep embarrassed him at work and various social settings He is now worried that there is something seriously wrong with him

What else to know

Precipitating event Smoking history Medications taking Recent foreign travel or sick contact Significant past and present medical history What has he tried to alleviate the cough

Further history amp exam findings for Mr Rosenthal Smoked cigarette frac14 PPD x 2 years in college Traveled to Tibet 4 months ago Started with a cold Thought at one point he had fever but it broke pretty quickly Most cold symptoms

resolved within a week but cough lingers No significant PMH Never took ACE-I co sensation of mucus being stuck to the back of throat with frequent throat clearing occasional nasal

congestion Tried OTC Robitussin cough syrup no benefit Denies recent weight loss hemoptysis fever chills night sweats Physical exam is largely normal including no abnormalities of the mouth nose pharynx neck heart

Wheezing detected on exhalation

ACCP Guidelines 2 high-yield elements of the history 1 The use of an ACE-I ⁸⁹sup1⁰

2 Cigarette smoking or exposure to second-hand smoking

ACCP Guidelines With a normal CXR in an otherwise healthy adult who doesnrsquot use an ACE-I or cigarettes chronic cough is most commonly caused by 3 conditions Upper airway cough syndrome (UACS) Asthma GERD Current literature suggests that these 3 causes constitute more than 90 of cases of chronic cough sup1sup1sup1sup2

ACCP Guidelines 1 no apparent cause for chronic cough 2 target 3 most common conditions sequentially Upper airway cough syndrome (UACS) Asthma GERD 3 subsequent empiric therapy be added onto the step prior

Upper Airway Cough Syndrome

Post nasal drip

Other symptoms nasal congestion rhinorrhea frequent throat clearing or globus

Oropharyngeal exam mucopurulent secretions or cobblestoning sup1⁷

Underlying inciting factors in UACS

Diagnosis in retrospect by the resolution of the cough in response to empiric therapy sup1⁸

Initial treatment is combination of 1st generation antihistamine and decongestant sup3

Nasal corticosteroids nasal anticholinergic agents or nasal antihistamines may also be effective sup1⁸

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid

3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Normal test results

Cough-Variant Asthma

chronic cough as the only symptom with an otherwise normal physical exam

PFT is the initial test

Methacholine challenge to confirm the diagnosis sup3

Initial treatment ICSs and β-agonist

Addition of a leukotriene receptor inhibitor

For severe and refractory cough a short course of oral corticosteroids can be considered sup3sup1⁹

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results are normal

This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen

Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

GERD

GERD is thought to trigger cough

Physiologic reflux and micro-aspiration vs heightened cough sensitivity sup2⁰

Frequency of GERD as the causative factor in chronic cough is unclear Published reports vary widely ranging between 0 to 73 sup2⁰

GERD can coexist with chronic cough as well as be the result of coughing sup2⁰

Treat despite of no heartburn regurgitation or sour taste

Empiric treatment beginning with lifestyle changes and PPI for at least 8 weeks

23-hour pH monitoring

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

What else to know

Precipitating event Smoking history Medications taking Recent foreign travel or sick contact Significant past and present medical history What has he tried to alleviate the cough

Further history amp exam findings for Mr Rosenthal Smoked cigarette frac14 PPD x 2 years in college Traveled to Tibet 4 months ago Started with a cold Thought at one point he had fever but it broke pretty quickly Most cold symptoms

resolved within a week but cough lingers No significant PMH Never took ACE-I co sensation of mucus being stuck to the back of throat with frequent throat clearing occasional nasal

congestion Tried OTC Robitussin cough syrup no benefit Denies recent weight loss hemoptysis fever chills night sweats Physical exam is largely normal including no abnormalities of the mouth nose pharynx neck heart

Wheezing detected on exhalation

ACCP Guidelines 2 high-yield elements of the history 1 The use of an ACE-I ⁸⁹sup1⁰

2 Cigarette smoking or exposure to second-hand smoking

ACCP Guidelines With a normal CXR in an otherwise healthy adult who doesnrsquot use an ACE-I or cigarettes chronic cough is most commonly caused by 3 conditions Upper airway cough syndrome (UACS) Asthma GERD Current literature suggests that these 3 causes constitute more than 90 of cases of chronic cough sup1sup1sup1sup2

ACCP Guidelines 1 no apparent cause for chronic cough 2 target 3 most common conditions sequentially Upper airway cough syndrome (UACS) Asthma GERD 3 subsequent empiric therapy be added onto the step prior

Upper Airway Cough Syndrome

Post nasal drip

Other symptoms nasal congestion rhinorrhea frequent throat clearing or globus

Oropharyngeal exam mucopurulent secretions or cobblestoning sup1⁷

Underlying inciting factors in UACS

Diagnosis in retrospect by the resolution of the cough in response to empiric therapy sup1⁸

Initial treatment is combination of 1st generation antihistamine and decongestant sup3

Nasal corticosteroids nasal anticholinergic agents or nasal antihistamines may also be effective sup1⁸

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid

3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Normal test results

Cough-Variant Asthma

chronic cough as the only symptom with an otherwise normal physical exam

PFT is the initial test

Methacholine challenge to confirm the diagnosis sup3

Initial treatment ICSs and β-agonist

Addition of a leukotriene receptor inhibitor

For severe and refractory cough a short course of oral corticosteroids can be considered sup3sup1⁹

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results are normal

This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen

Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

GERD

GERD is thought to trigger cough

Physiologic reflux and micro-aspiration vs heightened cough sensitivity sup2⁰

Frequency of GERD as the causative factor in chronic cough is unclear Published reports vary widely ranging between 0 to 73 sup2⁰

GERD can coexist with chronic cough as well as be the result of coughing sup2⁰

Treat despite of no heartburn regurgitation or sour taste

Empiric treatment beginning with lifestyle changes and PPI for at least 8 weeks

23-hour pH monitoring

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

Further history amp exam findings for Mr Rosenthal Smoked cigarette frac14 PPD x 2 years in college Traveled to Tibet 4 months ago Started with a cold Thought at one point he had fever but it broke pretty quickly Most cold symptoms

resolved within a week but cough lingers No significant PMH Never took ACE-I co sensation of mucus being stuck to the back of throat with frequent throat clearing occasional nasal

congestion Tried OTC Robitussin cough syrup no benefit Denies recent weight loss hemoptysis fever chills night sweats Physical exam is largely normal including no abnormalities of the mouth nose pharynx neck heart

Wheezing detected on exhalation

ACCP Guidelines 2 high-yield elements of the history 1 The use of an ACE-I ⁸⁹sup1⁰

2 Cigarette smoking or exposure to second-hand smoking

ACCP Guidelines With a normal CXR in an otherwise healthy adult who doesnrsquot use an ACE-I or cigarettes chronic cough is most commonly caused by 3 conditions Upper airway cough syndrome (UACS) Asthma GERD Current literature suggests that these 3 causes constitute more than 90 of cases of chronic cough sup1sup1sup1sup2

ACCP Guidelines 1 no apparent cause for chronic cough 2 target 3 most common conditions sequentially Upper airway cough syndrome (UACS) Asthma GERD 3 subsequent empiric therapy be added onto the step prior

Upper Airway Cough Syndrome

Post nasal drip

Other symptoms nasal congestion rhinorrhea frequent throat clearing or globus

Oropharyngeal exam mucopurulent secretions or cobblestoning sup1⁷

Underlying inciting factors in UACS

Diagnosis in retrospect by the resolution of the cough in response to empiric therapy sup1⁸

Initial treatment is combination of 1st generation antihistamine and decongestant sup3

Nasal corticosteroids nasal anticholinergic agents or nasal antihistamines may also be effective sup1⁸

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid

3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Normal test results

Cough-Variant Asthma

chronic cough as the only symptom with an otherwise normal physical exam

PFT is the initial test

Methacholine challenge to confirm the diagnosis sup3

Initial treatment ICSs and β-agonist

Addition of a leukotriene receptor inhibitor

For severe and refractory cough a short course of oral corticosteroids can be considered sup3sup1⁹

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results are normal

This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen

Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

GERD

GERD is thought to trigger cough

Physiologic reflux and micro-aspiration vs heightened cough sensitivity sup2⁰

Frequency of GERD as the causative factor in chronic cough is unclear Published reports vary widely ranging between 0 to 73 sup2⁰

GERD can coexist with chronic cough as well as be the result of coughing sup2⁰

Treat despite of no heartburn regurgitation or sour taste

Empiric treatment beginning with lifestyle changes and PPI for at least 8 weeks

23-hour pH monitoring

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

ACCP Guidelines 2 high-yield elements of the history 1 The use of an ACE-I ⁸⁹sup1⁰

2 Cigarette smoking or exposure to second-hand smoking

ACCP Guidelines With a normal CXR in an otherwise healthy adult who doesnrsquot use an ACE-I or cigarettes chronic cough is most commonly caused by 3 conditions Upper airway cough syndrome (UACS) Asthma GERD Current literature suggests that these 3 causes constitute more than 90 of cases of chronic cough sup1sup1sup1sup2

ACCP Guidelines 1 no apparent cause for chronic cough 2 target 3 most common conditions sequentially Upper airway cough syndrome (UACS) Asthma GERD 3 subsequent empiric therapy be added onto the step prior

Upper Airway Cough Syndrome

Post nasal drip

Other symptoms nasal congestion rhinorrhea frequent throat clearing or globus

Oropharyngeal exam mucopurulent secretions or cobblestoning sup1⁷

Underlying inciting factors in UACS

Diagnosis in retrospect by the resolution of the cough in response to empiric therapy sup1⁸

Initial treatment is combination of 1st generation antihistamine and decongestant sup3

Nasal corticosteroids nasal anticholinergic agents or nasal antihistamines may also be effective sup1⁸

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid

3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Normal test results

Cough-Variant Asthma

chronic cough as the only symptom with an otherwise normal physical exam

PFT is the initial test

Methacholine challenge to confirm the diagnosis sup3

Initial treatment ICSs and β-agonist

Addition of a leukotriene receptor inhibitor

For severe and refractory cough a short course of oral corticosteroids can be considered sup3sup1⁹

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results are normal

This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen

Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

GERD

GERD is thought to trigger cough

Physiologic reflux and micro-aspiration vs heightened cough sensitivity sup2⁰

Frequency of GERD as the causative factor in chronic cough is unclear Published reports vary widely ranging between 0 to 73 sup2⁰

GERD can coexist with chronic cough as well as be the result of coughing sup2⁰

Treat despite of no heartburn regurgitation or sour taste

Empiric treatment beginning with lifestyle changes and PPI for at least 8 weeks

23-hour pH monitoring

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

ACCP Guidelines With a normal CXR in an otherwise healthy adult who doesnrsquot use an ACE-I or cigarettes chronic cough is most commonly caused by 3 conditions Upper airway cough syndrome (UACS) Asthma GERD Current literature suggests that these 3 causes constitute more than 90 of cases of chronic cough sup1sup1sup1sup2

ACCP Guidelines 1 no apparent cause for chronic cough 2 target 3 most common conditions sequentially Upper airway cough syndrome (UACS) Asthma GERD 3 subsequent empiric therapy be added onto the step prior

Upper Airway Cough Syndrome

Post nasal drip

Other symptoms nasal congestion rhinorrhea frequent throat clearing or globus

Oropharyngeal exam mucopurulent secretions or cobblestoning sup1⁷

Underlying inciting factors in UACS

Diagnosis in retrospect by the resolution of the cough in response to empiric therapy sup1⁸

Initial treatment is combination of 1st generation antihistamine and decongestant sup3

Nasal corticosteroids nasal anticholinergic agents or nasal antihistamines may also be effective sup1⁸

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid

3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Normal test results

Cough-Variant Asthma

chronic cough as the only symptom with an otherwise normal physical exam

PFT is the initial test

Methacholine challenge to confirm the diagnosis sup3

Initial treatment ICSs and β-agonist

Addition of a leukotriene receptor inhibitor

For severe and refractory cough a short course of oral corticosteroids can be considered sup3sup1⁹

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results are normal

This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen

Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

GERD

GERD is thought to trigger cough

Physiologic reflux and micro-aspiration vs heightened cough sensitivity sup2⁰

Frequency of GERD as the causative factor in chronic cough is unclear Published reports vary widely ranging between 0 to 73 sup2⁰

GERD can coexist with chronic cough as well as be the result of coughing sup2⁰

Treat despite of no heartburn regurgitation or sour taste

Empiric treatment beginning with lifestyle changes and PPI for at least 8 weeks

23-hour pH monitoring

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

ACCP Guidelines 1 no apparent cause for chronic cough 2 target 3 most common conditions sequentially Upper airway cough syndrome (UACS) Asthma GERD 3 subsequent empiric therapy be added onto the step prior

Upper Airway Cough Syndrome

Post nasal drip

Other symptoms nasal congestion rhinorrhea frequent throat clearing or globus

Oropharyngeal exam mucopurulent secretions or cobblestoning sup1⁷

Underlying inciting factors in UACS

Diagnosis in retrospect by the resolution of the cough in response to empiric therapy sup1⁸

Initial treatment is combination of 1st generation antihistamine and decongestant sup3

Nasal corticosteroids nasal anticholinergic agents or nasal antihistamines may also be effective sup1⁸

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid

3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Normal test results

Cough-Variant Asthma

chronic cough as the only symptom with an otherwise normal physical exam

PFT is the initial test

Methacholine challenge to confirm the diagnosis sup3

Initial treatment ICSs and β-agonist

Addition of a leukotriene receptor inhibitor

For severe and refractory cough a short course of oral corticosteroids can be considered sup3sup1⁹

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results are normal

This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen

Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

GERD

GERD is thought to trigger cough

Physiologic reflux and micro-aspiration vs heightened cough sensitivity sup2⁰

Frequency of GERD as the causative factor in chronic cough is unclear Published reports vary widely ranging between 0 to 73 sup2⁰

GERD can coexist with chronic cough as well as be the result of coughing sup2⁰

Treat despite of no heartburn regurgitation or sour taste

Empiric treatment beginning with lifestyle changes and PPI for at least 8 weeks

23-hour pH monitoring

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

Upper Airway Cough Syndrome

Post nasal drip

Other symptoms nasal congestion rhinorrhea frequent throat clearing or globus

Oropharyngeal exam mucopurulent secretions or cobblestoning sup1⁷

Underlying inciting factors in UACS

Diagnosis in retrospect by the resolution of the cough in response to empiric therapy sup1⁸

Initial treatment is combination of 1st generation antihistamine and decongestant sup3

Nasal corticosteroids nasal anticholinergic agents or nasal antihistamines may also be effective sup1⁸

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid

3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Normal test results

Cough-Variant Asthma

chronic cough as the only symptom with an otherwise normal physical exam

PFT is the initial test

Methacholine challenge to confirm the diagnosis sup3

Initial treatment ICSs and β-agonist

Addition of a leukotriene receptor inhibitor

For severe and refractory cough a short course of oral corticosteroids can be considered sup3sup1⁹

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results are normal

This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen

Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

GERD

GERD is thought to trigger cough

Physiologic reflux and micro-aspiration vs heightened cough sensitivity sup2⁰

Frequency of GERD as the causative factor in chronic cough is unclear Published reports vary widely ranging between 0 to 73 sup2⁰

GERD can coexist with chronic cough as well as be the result of coughing sup2⁰

Treat despite of no heartburn regurgitation or sour taste

Empiric treatment beginning with lifestyle changes and PPI for at least 8 weeks

23-hour pH monitoring

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid

3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Normal test results

Cough-Variant Asthma

chronic cough as the only symptom with an otherwise normal physical exam

PFT is the initial test

Methacholine challenge to confirm the diagnosis sup3

Initial treatment ICSs and β-agonist

Addition of a leukotriene receptor inhibitor

For severe and refractory cough a short course of oral corticosteroids can be considered sup3sup1⁹

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results are normal

This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen

Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

GERD

GERD is thought to trigger cough

Physiologic reflux and micro-aspiration vs heightened cough sensitivity sup2⁰

Frequency of GERD as the causative factor in chronic cough is unclear Published reports vary widely ranging between 0 to 73 sup2⁰

GERD can coexist with chronic cough as well as be the result of coughing sup2⁰

Treat despite of no heartburn regurgitation or sour taste

Empiric treatment beginning with lifestyle changes and PPI for at least 8 weeks

23-hour pH monitoring

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

Cough-Variant Asthma

chronic cough as the only symptom with an otherwise normal physical exam

PFT is the initial test

Methacholine challenge to confirm the diagnosis sup3

Initial treatment ICSs and β-agonist

Addition of a leukotriene receptor inhibitor

For severe and refractory cough a short course of oral corticosteroids can be considered sup3sup1⁹

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results are normal

This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen

Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

GERD

GERD is thought to trigger cough

Physiologic reflux and micro-aspiration vs heightened cough sensitivity sup2⁰

Frequency of GERD as the causative factor in chronic cough is unclear Published reports vary widely ranging between 0 to 73 sup2⁰

GERD can coexist with chronic cough as well as be the result of coughing sup2⁰

Treat despite of no heartburn regurgitation or sour taste

Empiric treatment beginning with lifestyle changes and PPI for at least 8 weeks

23-hour pH monitoring

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results are normal

This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen

Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

GERD

GERD is thought to trigger cough

Physiologic reflux and micro-aspiration vs heightened cough sensitivity sup2⁰

Frequency of GERD as the causative factor in chronic cough is unclear Published reports vary widely ranging between 0 to 73 sup2⁰

GERD can coexist with chronic cough as well as be the result of coughing sup2⁰

Treat despite of no heartburn regurgitation or sour taste

Empiric treatment beginning with lifestyle changes and PPI for at least 8 weeks

23-hour pH monitoring

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

GERD

GERD is thought to trigger cough

Physiologic reflux and micro-aspiration vs heightened cough sensitivity sup2⁰

Frequency of GERD as the causative factor in chronic cough is unclear Published reports vary widely ranging between 0 to 73 sup2⁰

GERD can coexist with chronic cough as well as be the result of coughing sup2⁰

Treat despite of no heartburn regurgitation or sour taste

Empiric treatment beginning with lifestyle changes and PPI for at least 8 weeks

23-hour pH monitoring

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

FNPrsquos recommendations 1 2-view CXR TB skin test PFT 2 Benadryl qhs Sudafed prn Flonase qd Nasal saline rinse bid 3 weeks later cough hasnrsquot changed Sleep quality has deteriorated Test results normal This time Albuterol prn Flovent bid Robitussin AC q4h and a short burst of Prednisone taper are added to regimen Another 3 weeks later patient returned with persistent cough All prescribed medications havenrsquot helped Now he is frustrated and depressed

FNP prescribed Prevacid 30mg bid for 8 weeks Lifestyle modifications are discussed as well

Patient returns after a month with that same nagging cough Now he has this cough for 5 months in total FNP orders a chest CT and refers him to ENT for further evaluation

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

Algorithm by Terasaki amp Paauw ⁷

Chronic cough gt= 8 weeks History amp exam bull Possible serious condition bull Risk factors (cancer or HIV)

Use of ACE-I or cigarettes

Abnormal 2-view CXR

Common causes bull UACS bull Asthma bull GERD

Empiric treatment starting with UACS then asthma and finally GERD sequentially

Evaluate as appropriate

bull Discontinue ACE-I bull Counsel to quit smoking

Evaluate as appropriate

UACS 1st generation H1 blocker amp decongestant

Asthma bull PFT bull ICS amp inhaled beta agonist

GERD Trial of PPI for 8 weeks

If no response to empiric treatment evaluate for less common causes or refer to a specialist

No

No

No

No

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

ALLERGIC RHINITIS

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

NASAL POLYPS

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

ACUTE SINUSITIS

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

List of potential causes of chronic cough in adult Common conditions ACE-I cough Chronic bronchitis caused by cigarette smoking Upper airway cough syndrome (formerly postnasal drip) Asthma GERD Less common conditions Non-asthmatic eosinophilic bronchitis Post-infectious cough (pertussis mycoplasma) Bronchiectasis Interstitial lung disease OSA Primary lung cancer Heart failure TB Environmental exposures Zenkerrsquos diverticulum

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

Uncommon conditions Sarcoidosis Environmental exposures (pneumoconiosis from asbestosis) Chronic tonsillar enlargement Chronic irritation to auditory canal (cerumen or foreign body) Idiopathic pulmonary fibrosis Aspirated foreign body Endemic fungi Paragonimiasis Peritoneal dialysis Cystic fibrosis Tracheomalacia Aberrant innominate artery Habit or tic cough

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

Cough hypersensitivity Syndrome

Our body can modulate the sensitivity of the cough reflex sensors sup2sup2

ldquoUnexplained chronic coughrdquo

Reset the sensitivity of cough reflex with Gabapentin or Amitriptyline sup2sup3

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

Summary

Systematic approach

ACE-I and smoking history

Red flags and risk factors for life-threatening disease

CXR

More than 90 of cases of chronic cough are diagnosed as being caused by UACS asthma or GERD To address these conditions sequentially

Less common causes

Cough hypersensitivity syndrome

Proper referrals to specialists including pulmonology or ENT when yoursquove done all you can

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

References

1 Sawin G Pendleton M Cough (subacute and chronic) In D Slawson ME Lin K editors Essential Evidence John Wiley amp Son Inc 2013 Available at httpwwwessetialevidencepluscom Accessed August 1 2013

2 National Hospital Ambulatory Medical Care Survey 2010 Outpatient Department Summary Tables Bureau USC 2010

3 Irwin RS Baumann MH Bolser DC et al Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines Chest 2006 129 1S-23S

4 Irwin RS Complications of cough ACCP evidence-based clinical practice guidelines Chest 2006 129 54S-8S 5 Smyrnios NA Irwin RS Curley FJ et al From a prospective study of chronic cough diagnostic and therapeutic

aspects in older adults Arch Intern Med 1998 158 1222-8 6 Polley L Yaman N Heaney L et al Impact of cough across different chronic respiratory diseases comparison of

two cough-specific health-related quality of life questionnaires Chest 2008 134 295-302 7 Terasaki G Paauw DS Evaluation and Treatment of Chronic Cough Med Clin N Am 98 (2014) 391-403 8 Bangalore S Kumar S Messerli FH Angiotensin-converting enzyme inhibitor associated cough deceptive

information from the Physiciansrsquo Desk Reference Am J Med 2010 123 1016-30

9 Woo KS Nicholls MG High prevalence of persistnt cough with angiotensin converting enzyme inhibitors in Chinese Br J Clin Pharmacol 1995 40 141-4

10 Dicpinigaitis PV Angiotensin-converting enzyme inhibitor-induced cough ACCP evidence-based clinical practice guidelines Chest 2006 129 169S-73S

11 Mello CJ Irwin RS Curley FJ Predictive values of the character timing and complications of chronic cough in diagnosing its cause Arch Intern Med 1996 156 997-1003

12 Pratter MR Overview of common causes of chronic cough ACCP evidence-based clinical practice guidelines Chest 2006 129 59S-62S

13 Sundar KM Daly SE Willis AM A longitudinal study of CPAP therapy for patients with chronic cough and obstructive sleep apnea Cough 2013 9 19

14 Cornia PB Hersh AL Lipsky BA et al Does this coughing adolescent or adult patient have pertussis JAMA 2010 304 890-6

15 Pertussis (whooping cough) diagnosis confirmation 2012 Available at httpwwwedegovpertussisclinicaldiagnostic-testingdiagnosis-confirmationhtml Accessed August 28 2013

16 Altunaiji S Kukuruzovic R Curtis N et al Antibiotics for whooping cough (pertussis) Cochrane Database Syst Rev 2007 (3) CD004404

17 Ryan MW The patient with ldquopostnasal driprdquo Med Clin North Am 2010 94 913-21

18 Pratter MR Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome) ACCP evidence-based clinical practice guidelines Chest 2006 129 63S-71S

19 Dicpinigaitis PV Chronic cough due to asthma ACCP evidence-based clinical practice guidelines Chest 2006 129 75S-9S

20 Chung KF Pavord ID Prevalence pathogenesis and causes of chronic cough Lancet 2008 371 1364-74

21 Kahrilas PJ Howden CW Hughes N et al Response of chronic cough to acid-suppressive therapy in patients with gastroesophageal reflux disease Chest 2013 143 605-12

22 McGarvey LP Elder J Future directions in treating cough Otolarygol Clin North Am 2010 43 199-211 xii

23 Chung KF Chronic cough hypersensitivity syndrome a more precise label for chronic cough Pulm Pharmacol Ther 2011 24 267-71

Many thanks to Dr Edward Damrose of Stanford Otolaryngology-HeadNeck Surgery for his support on this presentation

Jane Wang RN MSN FNP-C

Stanford Otolaryngology-HeadNeck Surgery

801 Welch Rd

Stanford CA 94305

Office 650-725-6667

Email jawangstanfordhealthcareorg

• That Nagging Cough Common Causes amp Treatment of Chronic CoughCANP 38th Annual Educational ConferenceMarch 21 2015Jane Wang RN MSN FNP-CStanford Otolaryngology-HeadNeck SurgeryStanford Health Care
• Slide Number 2
• Slide Number 3
• Case Study
• What else to know
• Slide Number 6
• Slide Number 7
• Slide Number 8
• ACCP Guidelines1 no apparent cause for chronic cough2 target 3 most common conditions sequentiallyUpper airway cough syndrome (UACS)AsthmaGERD3 subsequent empiric therapy be added onto the step prior
• Upper Airway Cough Syndrome
• Slide Number 11
• Cough-Variant Asthma
• Slide Number 13
• GERD
• Slide Number 16
• Slide Number 17
• Slide Number 18
• Allergic rhinitis
• Nasal polyps
• Acute sinusitis
• Slide Number 22
• Slide Number 23
• Cough hypersensitivity Syndrome
• Summary
• References
• Slide Number 27
• Slide Number 28
• Slide Number 29
• Slide Number 30

Many thanks to Dr Edward Damrose of Stanford Otolaryngology-HeadNeck Surgery for his support on this presentation

Jane Wang RN MSN FNP-C

Stanford Otolaryngology-HeadNeck Surgery

801 Welch Rd

Stanford CA 94305

Office 650-725-6667

Email jawangstanfordhealthcareorg

• That Nagging Cough Common Causes amp Treatment of Chronic CoughCANP 38th Annual Educational ConferenceMarch 21 2015Jane Wang RN MSN FNP-CStanford Otolaryngology-HeadNeck SurgeryStanford Health Care
• Slide Number 2
• Slide Number 3
• Case Study
• What else to know
• Slide Number 6
• Slide Number 7
• Slide Number 8
• ACCP Guidelines1 no apparent cause for chronic cough2 target 3 most common conditions sequentiallyUpper airway cough syndrome (UACS)AsthmaGERD3 subsequent empiric therapy be added onto the step prior
• Upper Airway Cough Syndrome
• Slide Number 11
• Cough-Variant Asthma
• Slide Number 13
• GERD
• Slide Number 16
• Slide Number 17
• Slide Number 18
• Allergic rhinitis
• Nasal polyps
• Acute sinusitis
• Slide Number 22
• Slide Number 23
• Cough hypersensitivity Syndrome
• Summary
• References
• Slide Number 27
• Slide Number 28
• Slide Number 29
• Slide Number 30