Approach to cough and Allergic Rhinitis.pptx

Approach to cough and Allergic Rhinitis

1. Dr. Kamal Kishore MD Consultant Physician Geetanjali Hospital Model Town, Hisar

2. Overview Burden of Cough Chronic Cough management at Primary Care set up- Diagnostic challenges Red Flag Signs Case Scenario Approach towards diagnosis of cough- Diagnostic algorithms Take home message

3. Song WJ et al. Eur Respir J 2015; 45:1479-1481. Apte K et al. Eur Resp J 2016; 48:PA864. BURDEN OF COUGH: INDIAN SCENARIO

4. Current International Guidelines are tailored for specialist practice and do not address unique challenges faced by primary care physicians in countries such as India The recommended diagnostic tests are either too expensive or mostly unavailable. The waiting period for the results is also quite long Self treatment with over the counter medications is rampant which in turn makes the management by a medical professional more challenging Primary care physicians currently do not have an algorithm that follows a simple symptom based approach for the management of cough Guleria R, Dhar R, Mahashur A et al. ‘Indian Consensus on Diagnosis of Cough at Primary Care Setting’. Journal of Association of Physicians of India. 2018; 67: 92- 98 COUGH AND ITS INDIAN STORY

5. Guleria R, Dhar R, Mahashur A et al. ‘Indian Consensus on Diagnosis of Cough at Primary Care Setting’. Journal of Association of Physicians of India. 2018; 67: 92- 98 MULTIPLE ETIOLOGIES OF COUGH

6. Chronic cough Lasts for more than 8 weeks Overlapping causes and thus difficult to diagnose History taking is the key to come to the diagnosis Multiple etiologies

7. RED FLAG SIGNS • Hemoptysis • Prominent dyspnea • Systemic symptoms such as weight loss, fever, sore throat • Hoarseness of voice • History of tuberculosis (self or in a person who is in close contact) • Immunosuppressive state • Smokers’ cough especially in patients >35 years of age • Cough syncope Guleria R, Dhar R, Mahashur A et al. ‘Indian Consensus on Diagnosis of Cough at Primary Care Setting’. Journal of Association of Physicians of India. 2018; 67: 92- 98

8. DRUG INDUCED COUGH Current complaints: Persistent cough since 3 weeks Known hypertensive No other associated symptoms Patient is on Enalapril Mr. Ramesh, Clinical investigation: Normal chest radiography Normal radiography of paranasal sinuses

9. Certain medications such as ACE INHIBITORS, BETA BLOCKERS, AND AMIODARONE can cause cough In case of such history, reconsidering the use of these medicines may help in reducing cough Yes No Cough due to other origins History (history of intake of angiotensin-converting enzyme inhibitors, β-blockers, and amiodarone) and physical examination; normal chest X‑ray Relief? Cough > 2 weeks Reconsider cough-inducing medications after risk-benefit assessment Guleria R, Dhar R, Mahashur A et al. ‘Indian Consensus on Diagnosis of Cough at Primary Care Setting’. Journal of Association of Physicians of India. 2018; 67: 92- 98 DRUG INDUCED COUGH

10. Mrs Vanita , Chronic cough since 4 weeks Fever since 2 weeks Complaints of loss of appetite Significant weight loss Clinical investigations Increased ESR, CBNAAT Lymph Node enlargement on examination Chest X ray reveals Ghons focus and caseous necrosis COUGH DUE TO TB

11. Cough > 2 weeks Symptoms of tuberculosis: Contact with a person with tuberculosis Hemoptysis Fever Suspected pulmonary tuberculosis? No Evaluate and treat for Asthma Upper airway cough syndrome Gastroesophageal reflux disease Post-infectious cough Yes 2 sputum acid‑fast bacilli smears, Elevated ESR, CBNAAT Negative Refer to a specialist/ DOT Centre Positive Treat as pulmonary tuberculosis Relief? Yes No Continue ATT Chest X‑ray/Refer to specialist Relief? Repeat chest X‑ray/Refer to a specialist Continue treatment Yes No ALGORITHIM FOR THE DIAGNOSIS OF PULMONARY TB Presumptive Pulmonary TB: Cough > 2 weeks Fever > 2 weeks Significant weight loss Hemoptysis Guleria R, Dhar R, Mahashur A et al.JAPI . 2018; 67: 92- 98

12. Master Akshay Dry cough for over 6 weeks Triggered by talking and exposure to cold air History of severe cough past 2 weeks Unable to sleep Missed school for a week COUGH DUE TO ASTHMA Child’s history: History of dyspnea and wheezing Investigations Eosinophilia ESR elevated

13. Mr Prakash - 45 year old patient. - Regular smoker and drinker - Cough mostly during nighttime or when is lying down Clinical investigation - Blood parameters normal - Chest x ray normal COUGH DUE TO GERD

14. Chronic Cough due to GERD GERD is the most likely cause of chronic cough if chest x ray is normal. Cough typically occurs at nighttime or in prone position If therapy with PPI provides relief, the diagnosis of GERD is confirmed. Relief however is seen after 3 weeks Asthma (25%) and non asthamatic eosinophilic bronchitis (10%) are amongst the common causes of chronic cough 7.4% of patients complaining of chronic cough were diagnosed with asthma Chronic Cough due to Asthma

15. UACS as a cause of chronic cough

16. Environmental factors Irritants such as sulfur, ozone, nitrous oxides, and indoor air pollution because of biomass combustions can cause chronic cough and asthma as the exposures are persistent Primary care providers should consider environmental factors as one of the important etiological factors for chronic cough Cardiac origin Should be suspected based on the following: History of cardiac illness Presenting symptoms like paroxysmal nocturnal dyspnea Pulmonary tuberculosis, GERD, UACS, asthma, and post-infectious cause to be ruled out Patient should be immediately referred to a cardiologist OTHER CAUSES OF CHRONIC COUGH

17. Differential diagnosis based on history: Asthma Upper airway cough syndrome Gastrointestinal reflux disease Post‑infectious cough Evaluate and treat for asthma Response to treatment? No Yes Relief? Continue treatment Repeat chest X‑ray/Refer to a specialist Yes No Optimize treatment and consider overlapping etiologies: Upper airway cough syndrome Gastrointestinal reflux disease Post‑infectious cough Guleria R, Dhar R, Mahashur A et al. ‘Indian Consensus on Diagnosis of Cough at Primary Care Setting’. Journal of Association of Physicians of India. 2018; 67: 92- 98 ALGORITHM FOR DIAGNOSIS OF COUGH DUE TO ASTHMA, GERD, UACS AND POST INFECTIOUS COUGH

18. Abbott Healthcare Pvt Ltd. Floor 18, Godrej BKC, Plot No. C- 68, BKC, Near MCA Club, Bandra (E), Mumbai- 400 051 Thank You For the use of registered medical practitioner or Laboratory or Hospital only INDPHR190811

19. Combined algorithm for the diagnosis of cough

20. Cough > 2 weeks History (history of intake of angiotensin-converting enzyme inhibitors, β-blockers, and amiodarone) and physical examination; normal chest X‑ray Reconsider cough-inducing medications after risk-benefit assessment Relief? Yes No Cough due to other origins Symptoms of tuberculosis: Contact with a person with tuberculosis Hemoptysis Fever Suspected pulmonary tuberculosis? No Evaluate and treat for Asthma Upper airway cough syndrome Gastroesophageal reflux disease Post-infectious cough Yes 2 sputum acid‑fast bacilli smears, Elevated ESR, CBNAAT Negative Refer to a specialist/ DOT Centre Positive Treat as pulmonary tuberculosis Relief? Yes No Continue ATT Chest X‑ray/Refer to specialist Differential diagnosis based on history: Asthma Upper airway cough syndrome Gastrointestinal reflux disease Post‑infectious cough Evaluate and treat for asthma Response to treatment? No Yes Optimize treatment and consider overlapping etiologies: Upper airway cough syndrome Gastrointestinal reflux disease Post‑infectious cough Relief? Repeat chest X‑ray/Refer to a specialist Continue treatment Relief? Continue treatment Repeat chest X‑ray/Refer to a specialist Yes No Yes No Guleria R, Dhar R, Mahashur A et al.JAPI . 2018; 67: 92- 98

21. Cough may be treated empirically and may not require aggressive investigations unless it is characterized by “ red flag signs ” or persists for > 2 weeks Pulmonary tuberculosis should be excluded if the cough persists for > 2 weeks after the initial treatment with suggestive signs and symptoms UACS, GERD and cough variant asthma should be diagnosed based on medical history Cough of cardiac origin should be suspected based on history of cardiac illness and should be referred to specialist KEY TAKE HOME MESSAGES…

22. ALLERGIC RHINITIS Physicians’ Perception on Allergic Rhinitis and its Management A Questionnaire Based Survey

23. Allergic Rhinitis An immunologic nasal response, primarily mediated by immunoglobulin E ( IgE )

24. Symptoms 24 Nasal congestion Rhinorrhea Sneezing Itching of the nose and/or post-nasal discharge

25. PREVALENCE 25 10% to 40% Affects population worldwide AR allergy cases seen in India 50% 20% and 30% Reported incidence in India ranges between

26. Allergic Rhinitis and Associated Airway diseases 26 Allergic Rhinitis Upper Respiratory infection Nasal Polyposis Otitis Media with Effusion Asthma Sinusitis

27. Patient Approach AR is one of the top-ten reasons for a visit to the primary care clinics General practitioners (GP) are often their first source of medical advice 10-40% of the total patient visits in about 50% of the primary care clinics Wang et al in a population-based survey reported that only 53% of rhinitis patients seek for medical help. Of these, 71% patients visited a primary care physician and only 18% visited a specialist (otolaryngologist). 27

28. OBJECTIVES To understand physicians’ perception about association between AR and URTI To understand the real-world management practices for AR based on specialty, qualification and years of experience To understand profiles of patients with AR

29. MATERIALS AND METHODS Study Design Prospective, cross-sectional, Pan-India survey Study Period April to May 2018 Study Sites West : Mumbai, Pune, Ahmedabad, Jaipur North : Delhi, Chandigarh, Lucknow, Allahabad South : Chennai, Bengaluru, Kochi, Vizag East : Kolkata, Guwahati, Patna, Ranchi Central : Bhopal, Indore, Hyderabad, Nagpur Sample Size 300 physicians Inclusion Criteria Physicians with a clinical experience of ≥ 5 years in treating AR patients

30. Survey Questionnaire was developed based on the literature review and expert group discussion. The survey was carried out by personal telephonic interviewing, and the information was collected on a real-time basis via online survey link data capture. Interviews were in English and conducted by qualified and trained physicians across India who were a part of physician panel of the contracted Healthcare/Medical fieldwork Organization.

31. Medical Specialty vs. Frequency of Patients Treated in a Month 31 Frequency of Patients Treated in a Month; Number (%) of physicians (N = 300) 6 3 4 3 1 5 6 25 Allergy specialists ENT surgeons 33 47 98 General Physician (MBBS) 97 Consulting Physicians (MD Internal Medicine) Pediatricians 301-500 patients > 500 patients 151-200 patients < 150 patients 201-300 patients

32. Allergic Rhinitis and Upper Respiratory Tract Infection: Physicians’ Responses 32 Percentage of patients with allergic rhinitis who develop URTI in a month AR to be a Predisposing Factor for Increased Risk of URTI Recurrent URTI to be an indicator of undiagnosed AR Prompt Diagnosis and Treatment of AR Reduce the Risk of Complications URTI: Upper Respiratory Tract Infection; AR: Allergic Rhinitis 35.7% 1.0% 0.3% 62.0% 1.0% Agree Disagree Neutral Strongly agree Strongly disagree 39.3% 0.7% 0.0% 58.7% 1.3% Agree Disagree Neutral Strongly agree Strongly disagree 39.3% 1.0% 0.0% 58.7% 1.0% Agree Disagree Neutral Strongly agree Strongly disagree 7.7% 17.7% 38.0% 36.7% 10 – 25  More than 50 26 – 50  Less than 10

33. Management of Allergic Rhinitis 33 First-line Management; Number of Physicians (%) Second-line Management; Number of Physicians (%) 16.0% 39.0% 41.0% 13.0% 4.0% 5.0% Intranasal antihistamines Oral antihistamines Intranasal corticosteroids Oral corticosteroids Nasal decongestant Leukotriene receptor antagonist 17.0% 40.0% 31.0% 13.0% 22.0% 11.0% Intranasal antihistamines Oral antihistamines Intranasal corticosteroids Oral corticosteroids Nasal decongestant Leukotriene receptor antagonist

34. Medical Specialty vs. First-line and Second-line of Treatment 34 First-line Management; Number of Physicians 13 34 43 Nasal decongestant 1 15 2 Oral corticosteroids Leukotriene receptor antagonist 38 Intranasal antihistamines 117 44 37 Intranasal corticosteroids 2 Oral antihistamines 2 124 47 Consulting Physicians (MD Internal Medicine)  ENT surgeons Allergy specialists  General Physician (MBBS)  Pediatricians  Second-line Management; Number of Physicians 40 50 45 121 Intranasal antihistamines 39 Leukotriene receptor antagonist 34 Nasal decongestant 94 32 Intranasal corticosteroids 1 65 Oral antihistamines Oral corticosteroids ENT surgeons Consulting Physicians (MD Internal Medicine)  Allergy specialists  General Physician (MBBS)  Pediatricians 

35. Years of Experience vs. First-line and Second-line of Treatment 35 First-line Management; Number of Physicians 124 2 47 Intranasal antihistamines Intranasal corticosteroids Oral antihistamines 117 13 38 Leukotriene receptor antagonist 15 Oral corticosteroids Nasal decongestant 1 More than 10 years 5-10 years Second-line Management; Number of Physicians 121 Intranasal corticosteroids 2 50 Intranasal antihistamines 39 34 65 2 3 Leukotriene receptor antagonist Oral corticosteroids 94 Oral antihistamines Nasal decongestant More than 10 years 5-10 years

36. CONCLUSION 36 Majority of physicians (98%) believed that recurrent URTI can be considered as an indicator of undiagnosed AR. About 10-50% of AR patients seen by physicians develop URTI in a month. Most preferred first-line treatment was oral antihistamines (alone or in combination) Most preferred second-line treatment was intranasal corticosteroids (alone or in combination) Similar treatment preferences were observed irrespective of physicians’ specialization and years of experience. This survey sheds light on the need to implement clear guidelines for the diagnosis and management of allergic rhinitis.  

37. Impact of AR on Sleep Quality June 29, 2019 Allergic Rhinits & Sleep disturbance | 37

38. EFFECT ON SLEEP DISTURBANCE 57% of adult patients and up to 88% of pediatric patients with AR have sleep problems. 10-fold increase in the number of microarousals during sleep that are attributable to disordered breathing, upper airway resistance, and increased nasal discharge. Sleep disturbance has a profound effect on mental health, including increased psychiatric disorders, depression, anxiety, and alcohol abuse. Sleep-disordered breathing in childhood and adolescence is associated with increased disorders of learning performance, behavior , and attention. An independent study also indicated that AR adversely affects childhood learning. June 29, 2019 Allergic Rhinits & Sleep disturbance | 38

39. CHILDREN & ALLERGIC RHINITIS Sleep Disordered Breathing is well documented to occur in children and adolescents with AR. Most common symptom is nasal obstruction. In children there are typical appearances associated with AR including mouth breathing, allergic shiners, allergic crease, allergic facies and these may be reversed by treatment of the rhinitis. Rhinitis has frequently been considered to be a benign condition in children and one that does not need treating. deleterious effects of the condition on their performance. Specifically in children studies have shown reduced examination performance in the spring season and reduced participation in skill based, social and informal activities. Habitual snoring is increased in children with AR June 29, 2019 Allergic Rhinits & Sleep disturbance | 39 Rimmer J, Hellgren J. Allergic Rhinitis and Its Impact on Sleep. InAllergic Rhinitis 2012. InTech .

40. Significance of sleep disturbance in AR The presence of abnormal sleep in association with AR categorises the disease as moderate to severe according to the ARIA classification of AR (Allergic Rhinitis and its Impact on Asthma) guidelines June 29, 2019 Allergic Rhinits & Sleep disturbance | 40 Rimmer J, Hellgren J. Allergic Rhinitis and Its Impact on Sleep. InAllergic Rhinitis 2012. InTech .

41. Nasal function and sleep Nasal obstruction is considered the most important factor that links nasal inflammation to poor sleep Other factors such as the presence of inflammatory mediators affecting the CNS may also contribute. Nasal obstruction due to nasal inflammation is probably multi factorial including altered neurovascular control of the sinusoids, formation of sub mucous edema , secretion of excessive nasal secretions and circadian changes following the serum cortisol cycle with a peak of nasal congestion in the morning. June 29, 2019 Allergic Rhinits & Sleep disturbance | 41 Rimmer J, Hellgren J. Allergic Rhinitis and Its Impact on Sleep. InAllergic Rhinitis 2012. InTech .

42. AR and obstructive sleep apnea Section 04 June 29, 2019 Allergic Rhinits & Sleep disturbance | 42

43. Sleep apnoea syndrome There is an increased prevalence of perennial allergic rhinitis in patients with the obstructive sleep apnea syndrome (OSAS). Nasal obstruction, enlarged adenoids and tonsils, and an elongated face cause reduced upper airway size and, thus, increase the risk of OSAS. Allergic rhinitis appears to increase the risk of OSAS in children. Adequate treatment of allergic rhinitis can reduce the severity of OSAS and prevent the emergence of an elongated face, which predisposes patients to OSAS. It may also reduce the severity of existing OSAS. Intranasal fluticasone is of benefit to some patients with OSAS and rhinitis. Data suggest that this form of nasal obstruction may contribute to the pathophysiology of OSAS June 29, 2019 Allergic Rhinits & Sleep disturbance | 43

44. Obstructive sleep apnoea First-line treatment for OSAS is usually based on nasal continuous positive airway pressure (CPAP). However, nasal CPAP can induce nasal discomfort to such an extent that as many as 50% of patients are unable to tolerate therapy. In addition, nasal CPAP has induced early nasal inflammation while nasal airway obstruction correlated with CPAP tolerance. Using nasal peak inspiratory flow measurements has revealed the efficacy of adding heated humidification during nasal CPAP in the treatment of OSAS Based on subjective criteria (snoring loudly everyday and daytime sleepiness), sleep apnea syndrome has also been found to be more prevalent in allergic rhinitis than in controls June 29, 2019 Allergic Rhinits & Sleep disturbance | 44

45. Sleep disorder and AR Sleep disorders are also common and have a significant impact on quality of life. Studies have shown a correlation between asthma and sleep disorders, which can result in daytime sleepiness, fatigue, and decreases in cognitive function. However, the relationship between allergic rhinitis and sleep disturbances has not been explored in well-designed studies June 29, 2019 Allergic Rhinits & Sleep disturbance | 45

46. Sleep disorder and AR June 29, 2019 Allergic Rhinits & Sleep disturbance | 46 Distribution of the population of patients with insomnia who also have allergic rhinitis (AR) (n = 19) according the type of Allergic Rhinitis and Its Impact on Asthma classification. NS indicates nonsignificant impact of AR frequency on insomnia Léger, D., Annesi-Maesano , I., Carat, F., Rugina , M., Chanal , I., Pribil , C., El Hasnaoui , A. and Bousquet , J., 2006. Allergic rhinitis and its consequences on quality of sleep: an unexplored area.  Archives of internal medicine ,  166 (16), pp.1744-1748.

47. CONCLUSION 47 Majority of physicians (98%) believed that recurrent URTI can be considered as an indicator of undiagnosed AR. About 10-50% of AR patients seen by physicians develop URTI in a month. Most preferred first-line treatment was oral antihistamines (alone or in combination) Most preferred second-line treatment was intranasal corticosteroids (alone or in combination) Similar treatment preferences were observed irrespective of physicians’ specialization and years of experience. This survey sheds light on the need to implement clear guidelines for the diagnosis and management of allergic rhinitis.  

48. Patients consulting for their AR should be routinely questioned about their sleep quality and existing daytime somnolence. This could lead to early detection and treatment of sleep disorders in these patients. The onus is on health care professionals to make the link between AR and sleep problems in their patients. Treating AR or other nasal symptoms may improve dramatically the quality of sleep In the long term, such a strategy would have positive repercussions on a societal level; for example, the numbers of road and work accidents would be reduced. Considering the high incidence of AR and the high rate of associated sleep disorders, the issue is one of public health. June 29, 2019 Allergic Rhinits & Sleep disturbance | 48

49. Abbott Healthcare Pvt Ltd. Floor 18, Godrej BKC, Plot No. C- 68, BKC, Near MCA Club, Bandra (E), Mumbai- 400 051 Thank You For the use of registered medical practitioner or Laboratory or Hospital only INDPHR190811