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Chronic Cough

By Evelyn Warren,2014-06-26 19:48
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Chronic Cough ...

    CHRONIC COUGH

    Karen Brown, M.D.

    WEEK 20

    Learning Objectives:

    1. Clarify definition of “chronic” cough

    2. List most common etiologies

    3. Develop diagnostic strategy to diagnose and treat chronic cough

CASE ONE:

Mrs. Annie Tussif, a 38-year-old new patient, presents with a cough that she has noticed for

    four weeks. She describes the cough as hacking, with coughing “spells” that can last up to

    five minutes and causes her embarrassment in meetings and interrupts her sleep. She has

    never had any similar problems, has no sick contacts, and is otherwise very healthy.

    Guaifenesin (Robitussin) is not helping enough.

Questions:

    1. Does she meet criteria for chronic cough?

    Because her cough is lasting between three and eight week,s it is classified as subacute

    rather than chronic cough.

    2. What are the most common underlying causes of her cough?

    The most common cause of subacute cough is bacterial sinusitis or asthma (e.g. cough

    variant asthma). It is also commonly post-infectious. Finally, a subacute cough may be

    the new onset of what will become a chronic cough. The most common causes of chronic

    cough are listed on the second page of the article and, also, later in this answer key.

    3. What further history and exam findings are necessary to complete her evaluation

    today?

    History of recent viral illness, presence of sinusitis symptoms such as fever, facial

    pressure, or purulent nasal drainage. History of any prior episodes or family history of

    asthma. GERD sx? Occupational and environmental history with focus on airway

    irritants (bleach, paint fumes, cigarette smoke) or allergens (dust, red cedar, animals).

CASE ONE CONTINUED:

Upon further history you learn that she has no chronic medical problems, does not take

    any medications daily, has longstanding environmental allergies, and cleans houses for a

    living. She has occasional symptoms of heartburn. She does not smoke, does not drink

    alcohol, and does not use any nonprescription or illicit medications. She recalls that the

    cough started during an upper respiratory illness, but has simply not resolved. Her

    examination is normal except for a slight wheeze in one lung field.

    4. How would you proceed in order to complete the visit?

    a. Testing?

    Testing is not likely indicated. The most likely etiology is a post-infectious cough.

    If there were ongoing fevers or generalized fatigue then a CXR would be

    indicated to look for “walking” (e.g. atypical) pneumonia. If she were a smoker

    or had high-risk occupational exposure, this would also be indicated.

    b. Prescriptions?

    While the cough will almost certainly resolve on its own, both bronchodilators

    and steroid inhalers can be used to treat a post-infectious cough (in addition to

    the cough syrup). If these episodes occurred frequently then cough variant

    asthma should be considered.

    c. Advice?

    Exposure to airway irritants can delay healing of her airway and prolong the

    cough. In this case the cleaning solutions may be perpetuating the cough. She

    should be advised to avoid airway irritants as much as possible.

CASE ONE CONTINUED:

She returns six weeks later and reports NO improvement in her cough with the inhalers

    that you prescribed. She continues to have coughing spells 4-5 times daily and now

    confides that her cough is so severe that she is suffering from urinary incontinence as well.

    Her examination is normal.

    5. What are the most common causes of chronic cough?

    Post-nasal drip syndrome, asthma, and GERD are the most common causes of chronic

    cough in patients who do not take ACE inhibitors and have a normal CXR. Often one

    patient has two or more of these causes.

    ACE inhibitors induce cough in 5-20% of patients who take them, and it can begin

    several months after the initiation of the medication. The cough SHOULD subside within

    a few days of stopping the medication or switching to ARB.

6. Outline a diagnostic strategy. Review the one presented in the reference article. Do

    you agree with their sequential approach?

    Clearly CXR is now indicated. As long as the CXR is normal, this article recommends

    sequential two-week trials of treatment for the three common causes of chronic cough.

    Assuming that she can demonstrate adequate meter dose inhaler technique, you have

    already completed a trial of asthma treatment. This algorithm differs from some others

    in that the response to therapeutic interventions is accepted as diagnostic of the

    underlying disorder. For example, an alternative approach might be to test for asthma

    using PFTs (even methacholine challenge), to test for GERD using 24-hour pH probe,

    and to refer for ENT evaluation. The other main difference from other articles is the lack

    of empiric course of antibiotics (usually azithro/doxy/erythro) early in the algorithm to

    treat tracheobronchitis. This approach seems to be endorsed by the American College of

    Chest Physicians. Make sure to point out the necessity for CXR in this algorithm. Other

    causes of cough such as sarcoid, pneumonia, TB, interstitial lung disease, mesothelioma,

    and lung cancer need to be excluded as they are not that rare. Also, point out that this

    algorithm is for immunocompetent patients only.

7. How would you proceed in order to complete the visit?

    a. Testing?

    Chest X-ray

    b. Prescriptions?

    You can try nasal steroids for post-nasal drip if there is evidence on exam

    (cobblestone posterior pharynx or throat clearing). Note that the drip may be

    clinically “silent”. Could also try PPI for GERD. The GERD can be causing a

    cough or frank asthma without typical heartburn symptoms. According to the

    article one should prescribe a two-week trial of each to determine which works.

    CASE ONE CONTINUED:

    She returns five months later for an annual physical. She has no new medical concerns,

    but is most interested in discussing bone density, mammography, and immunizations

    today. When you inquire about her cough she replies “Oh yes, the cough. I had almost

    forgotten—it’s gone.” She is no longer taking any prescribed medications.

8. Would you recommend restarting medications at this point?

    NO!

9. If she hadn’t stopped them on her own, would you have advised her to discontinue

    medications now that her cough has been resolved for four months?

     Yesan irritated airway can heal.

    References:

1. Holmes R.L. and Fadden C.T. Evaluation of the patient with chronic cough. American

    Family Physician. 2004; 69(9):2159-2166.

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