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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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