Chronic Cough Presentation by DR Aiswarya Thambi Pulmonologist.pptx

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

1. Chronic COUgH Dr aiswarya thambi Mbbs md dnb pulmonology Consultant pulmonologist Daya hospital,tcr

2. Overview Epidemiology Etiology Red flag signs Evaluation Management Conclusion

3. What is cough?

4. A cough is an innate primitive reflex and acts as part of the body’s immune system to protect against foreign materials. It starts as a deep inspiration, followed by a strong expiration against a closed glottis, which then opens with an expulsive flow of air, followed by a restorative inspiration Sharma S, Hashmi MF, Alhajjaj MS. Cough. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

5. Phases of cough (1) a deep initial inspiration, (2) compression of air in the lungs and airways by forceful contraction of the expiratory muscles coupled with tight closure of the glottis and opening of the larynx, and (3) sudden explosive expiration followed by narrowing of the glottis and return of the larynx to its normal inspiratory position. 5

6. LOCATION OF COUGH RECEPTORS EFFECTOR Type c and type 1 fibres

7. Epidemiology of cough

8. The community prevalence of chronic cough is unclear, perhaps as high as 10%. Many sufferers don’t access medical services, tolerating symptoms or possibly self-medicating. UK based primary care studies suggest chronic cough affecting 1.2-2% of the population but it is most likely under-estimated. BTS Clinical statement on chronic cough in adults- 2022

9. IMPACT OF CHRONIC COUGH BTS Clinical statement on chronic cough in adults- 2022

10. APPROACH TO COUGH DURATION DRY / PRODUCTIVE SEASONAL/ DIURNAL/POSTURAL VARIATION SPECIAL CHARACTER ASSOCIATED COMORBIDITIES

11. Types of cough

12. Irwin RS , Baumann MH , Bolser DC , et al . Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest 2006;129:23S.doi:10.1378/chest.129.1_suppl.1S

13. What is new?

14. BTS Clinical statement on chronic cough in adults- 2022

15. When you cough repeatedly it can result in 'overstimulation' of the nerve, causing the nerve to become hypersensitive, which means it triggers more frequently than normal. A number of factors, including viruses and certain medications, can also have a direct impact on the cough reflex nerve, making it more sensitive. COUGH HYPERSENSITIVITY

16. Etiology of cough?

17. ACUTE COUGH SUB-ACUTE COUGH CHRONIC COUGH acute viral upper respiratory infection, acute bronchitis, acute rhinosinusitis, pertussis, acute exacerbations of chronic obstructive pulmonary disorder, allergic rhinitis, asthma, congestive heart failure, pneumonia, aspiration syndromes, and pulmonary embolism 1) most commonly post-infectious secondary to continued irritation of cough receptors via ongoing or resolving bronchial or sinus inflammation from a preceding viral upper respiratory infection. upper airway cough syndrome, gastroesophageal reflux disease, non-asthmatic eosinophilic bronchitis, chronic bronchitis, postinfectious cough, intolerance to angiotensin-converting enzyme inhibitor medication, malignancy, interstitial lung diseases, chronic sinusitis, and psychosomatic cough.

18. Acute cough may suggest: Upper RT Common cold Sinusitis Lower RT Pneumonia Bronchitis Exacerbation of COPD /asthma Inhalation of bronchial irritant ( eg , smoke or fumes CHF PULMONARY EMBOLISM SUDDEN ONSET VIOLENT COUGH ESP IN CHILD–INHALATION OF FOREIGN BODY ACUTE COUGH

19. Subacute Cough 3-8 Weeks Postinfectious MC A cough that begins with an acute respiratory tract infection and is not complicated* by pneumonia *Not complicated = Normal lung exam normal chest X-ray Generally cough is non productive Resolve without treatment SINUSITIS Asthma

20. CHRONIC COUGH Upper Airway Cough Syndrome, Gastroesophageal Reflux Disease, Non-asthmatic Eosinophilic Bronchitis, Chronic Bronchitis, Postinfectious Cough, Intolerance To Angiotensin-converting Enzyme Inhibitor Medication, Malignancy, Interstitial Lung Diseases, Chronic Sinusitis, And Psychosomatic Cough.

21. Cough characteristics according to etiology UACS [POST NASAL DRIP SX] sensation of throat clearing –pharyngitis/sinusitis GERD – reflux –can be cause of cough -1 of 3 common cause of chronic cough -25% cases –may or maynot a/w typical symptoms –heartburn or regurgitation

22. CHRONIC BRONCHITIS –COUGH WITH SPUTUM EXPECTORATION FOR ATLEAST 3 CONSECUTIVE MONTHS FOR ATLEAST 2 CONSECUTIVE YEARS NON ASTHMATIC EOSINOPHILIC BRONCHITIS –patient present with bronchial eosinophilia on sputum analysis without bronchial hyperresponsiveness . Cough responds to ICS , just as does in asthma Cough caused by medication –non productive resolves within 4 weeks of stopping medication .affects 5-20% pt receiving ACE . BETA BLOCKERS –c/c cough – often by aggravating underlying asthma POSTINFECTIOUS COUGH – Respiratory infection is often the cause of a/c or suba /c cough , accounts for about 15% of c/c cough cases

23. Cough with postural variation Sinusitis GERD Bronchectasis Lung abscess Pulmonay edema due to heart failure

24. Cough with diurnal variation Early morning cough – ASTHMA , BRONCHIECTASIS ,C/C BRONCHITIS Nocturnal cough -- GERD , PULMONAY EDEMA ,TROPICAL PULMONARY EOSINOPHILIA

25. Mechanism of drug induced cough

26. All presumptive tb patients evaluated for sputum smear examination presumptive tb Cough>2weeks Fever>2weeks Significant weight loss hemoptysis TB

27. Red flag signs!

28. Watch out! Impaired general condition, Recurrent infectious syndrome, Exertional dyspnea , Hemoptysis Cough appearance or change in cough in a smoker, Dysphonia, dysphagia, Cervical adenopathy, Abnormal cardiopulmonary / ENT examination Abnormal chest x-ray. L.Guilleminault,S.Demoulin-Alexikova,L.deGaboryetal . RespiratoryMedicineandResearch83(2023)101011

29. HEMOPTYSIS COUGHING up OF BLOOD Bright red Mixed with frothy sputum Alkaline ph Contains alveolar macrophages laden with hemosiderin

30. History & evaluation

31. Cough: onset, duration, character, triggers Sputum-volume & character Postural variation Smoking, occupation Drug history

32. L.Guilleminault,S.Demoulin-Alexikova,L.deGaboryetal . RespiratoryMedicineandResearch83(2023)101011

33. L.Guilleminault,S.Demoulin-Alexikova,L.deGaboryetal . RespiratoryMedicineandResearch83(2023)101011

34. Can you measure cough?

35. French CT, Irwin RS, Fletcher KE, Adams TM: Evaluation of a cough specific quality-of-life questionnaire. Chest 121:1123–1131, 2002

36. The Leicester Cough Questionnaire uses a seven-point Likert response scale for 19 items from three domains physical, psychological, and social And is shown to be repeatable and sensitive in patients with chronic cough Birring SS, Matos S, Patel RB, et al: Cough frequency, cough sensitivity and health status in patients with chronic cough. Respir Med 100:1105–1109, 2006

37. Management

38. Clinical practice points Establish who needs specialist referral or can be initially managed in general practice with a targeted trial of therapy. ‘Red flags’ should prompt urgent referral The history should identify possible underlying disease and treatable traits. All patients with chronic cough should have a chest x ray (CXR), full blood count (FBC), diagnostic spirometry and exhaled nitric oxide ( FeNO ) (if available) BTS Clinical statement on chronic cough in adults- 2022

39. Acute cough

40. NICE guidelines 2019 – Acute cough

41. What does the evidence say?

42. MEDICATION EVIDENCE 1) Over the counter expectorants there was some evidence that suggests guaifenesin reduced cough symptoms in adults and young people with an acute cough or upper respiratory tract infection, with no increase in adverse effects 2) Over the counter antitussives the evidence for dextromethorphan was mixed. codeine had no benefit on cough symptoms. 3) Anti histamines and decongestants antihistamines and decongestants had no benefit on cough symptoms, and increased adverse effects 4) Bronchodilators bronchodilators, such as oral or inhaled salbutamol, did not benefit cough symptoms and increased adverse events, such as tremor

43. Treatable traits of chronic cough

44. BTS Clinical statement on chronic cough in adults- 2022

45. S.NO Treatable trait Identification marker Treatment Outcome 1) Smoking Patient history. Urinary Cotinine. Exhaled CO. Smoking cessation. Nicotine replacement therapy (NRT). Resolving chronic bronchitis improvement in cough. May get worse initially as nicotine suppresses cough reflex. 2) Irritant exposure: cigarette smoking/vaping, occupational exposures chemical/particulates History Occupational history Reduce exposure May improve cough 3) ACEI Treatment History. Medication records Stop ACEI in all patients with chronic cough. Can use A2RB if needed instead Improvement in cough, may take 4 weeks or more. BTS Clinical statement on chronic cough in adults- 2022

46. SNO Treatable trait Identification Treatment outcome 4) Airway eosinophilia History FeNO > 25ppb Blood eosinophil counts > 0.3 * 10 9 / L) Inhaled or oral corticosteroids Improve cough and QoL Reduced exacerbations 5) Productive cough History of significant sputum production. Sputum C&S HRCT ? bronchiectasis Airway Clearance physiotherapy Mucolytics Antimicrobials Macrolides Limited evidence. May improve cough BTS Clinical statement on chronic cough in adults- 2022

47. SNO TREATABLE TRAIT IDENTIFICATION TREATMENT OUTCOME 6 Chronic rhinosinusitis History of two or more symptoms for ≥12 weeks, one of which should be either nasal blockage or nasal discharge (anterior or posterior), with or without facial pain/pressure or reduction or loss of smell Nasal steroids Saline douching Consider ENT referral Improvement in rhinosinusitis. Possible improvement in cough. Limited evidence. 7) Inducible laryngeal obstruction History Laryngoscopy Speech therapy May improve cugh BTS Clinical statement on chronic cough in adults- 2022

48. SNO Treatable traits Identification Treatment Outcome 8) Gastroesophageal reflux disease Clinical history presence of heartburn best indicator of possible response to treatment. Reflux Symptoms Oesophageal manometry Endoscopy PPIs Lifestyle measures Also consider; H2 antagonists, weight loss Fundoplication Limited evidence. May improve cough for a subgroup of patients. Most don’t improve. 9) Obstructive sleep apnea History Sleep study CPAP therapy May improve cough Limited evidence BTS Clinical statement on chronic cough in adults- 2022

49. Psychogenic cough A diagnosis of exclusion Most common in adolescents with concomitant emotional disorders Does not produce sputum Usually does not occur at night Not affected by commonly used cough suppresants

50. Complication of cough Chest pain [myalgia] Fractures of ribs [COPD] Urinary incontinence Hernia Sub conjunctival hemorrhage Cough syncope

51. SUMMARY A detailed history & clinical examination gives clues to the underlying disease Presence of red flag signs warrants thorough investigation. Judicious use of antibiotics is recommended Patients and family members are to be counselled accordingly.

52. Thank you!