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cough the challenge of a targeted diagnosis

Cough - History. Some controversy over definitionsArguably the bestAcute: less than 3 weeksSub acute: 3 to 8 weeks Chronic: more than 8 weeksRichard Irwin, NEJM, Volume 343, Dec 7, 2000. Cough - Acute. Most common causesCommon coldAcute bacterial sinusitisPertussisExacerbation of COPDAllergic rhiniitsRhinitis 2

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cough the challenge of a targeted diagnosis

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    1. Cough – The Challenge of a Targeted Diagnosis Michael A. Venditto DO, FACOI, FCCP

    3. Cough - Acute Most common causes Common cold Acute bacterial sinusitis Pertussis Exacerbation of COPD Allergic rhiniits Rhinitis 2° to environmental irritants

    4. Cough – Viral Infection Upper respiratory viral infections are the most common cause of cough 83% within first 48 hours 26% on day 14 Arises from the stimulation of the cough reflex in upper airway by postnasal drip and/or clearing of the throat

    5. Cough – Viral Infection Signs and symptoms include: rhinorrhea, sneezing, nasal obstruction, post nasal drip, irritation of the throat, +/- fever and normal chest exam Diagnostic testing is not indicated in a immunocompetent patient as there is a very low yield—over 97% of CXR are normal

    6. Acute Cough - Treatment Dexbrompheniramine with pseudoephedrine Curley, Am Rev Respir Dis, 1988, 138:305-311 Naproxen Sperber, Ann Intern Med, 1992; 117:37-41 Ipratropium bromide No evidence of beneficial effects: Intranasal steroids, systemic steroids, zinc lozenges, nonsedating antihistamines (H1 blocker) URI is not mediated by histamine

    7. Cough - Acute Bronchitis diagnosed incorrectly too often Gonzales, JAMA, 1997; 278:901-904 Viral rhinosinusitis can present with cough and phlegm Think bacterial bronchitis and use antibiotics if Exacerbation of COPD with worsening SOB or wheezing Cough and vomiting suggestive of Bordetella pertussis

    8. Acute Cough - Treatment Bacterial sinusitis can present like a viral rhinitis or rhinosinusitis Use antibiotics only if they fail to respond to the above therapy and two of the following: Maxillary toothache Purulent nasal discharge, discolored nasal discharge Abnormal transillumination of any sinus Usually not necessary to perform imaging studies

    9. Cough - Acute In elderly, classic signs and symptoms may be minimal, so consider Pneumonia CHF Asthma Aspiration

    10. Cough - Subacute Most common etiologies Postinfectious cough Bacterial sinusitis asthma

    11. Postinfectious Cough Postinfectious cough Begins with respiratory tract infection NOT pneumonia Ultimately resolves without treatment Results from PND or clearing of throat With or without bronchial hyperresponsiveness

    12. Postinfectious Cough - Treatment Begin with treatment similar to the common cold If wheezing – use bronchodilators This does not make the diagnosis of asthma If not resolved in one week Imaging studies of the sinuses Nasal decongestant for 5 days Antibiotics for 21 days

    13. Chronic Cough In immunocompetent patients, 95% caused by Postnasal drip Asthma Gastroesophageal reflux Chronic bronchitis due to cigarette smoking Bronchiectasis Use of angiotensin-converting enzymes inhibitors

    14. Chronic Cough

    15. Evaluation of Chronic Cough History Character of cough, quality of the sound and the timing of cough (except the absence during sleep) have not shown to be useful Physical Oropharyngeal mucous or cobblestone appearance suggests postnasal-drip syndrome “silent” postnasal-drip syndrome

    16. Evaluation of Chronic Cough Heartburn and regurgitation suggest Gastroesophageal reflux disease “silent”GERD in up to 75% of patients Irwin,Chest 1993;104:1511-1517 Wheezing suggests asthma “silent”asthma (cough variant asthma) in up to 57% of cases Irwin, Am Rev Respir Dis 1981;123:413-417

    17. Evaluation of Chronic Cough Where to start CXR: normal is consistent with PND, GERD, asthma, chronic bronchitis. Unlikely : bronchogenic carcinoma, sarcoid, TB and bronchiectasis Since PND syndromes are most common---start there Sinusitis or rhinitis of the following varieties: nonallergic, allergic, postinfectious, vasomotor, drug-induced and environmental-irritant induced

    18. Chronic Cough - PND PND is by far the most common cause of chronic cough Since the signs and symptoms are nonspecific, the definitive diagnosis cannot be made by H and P alone Therapy 1st generation antihistamine and a decongestant

    19. Therapy Remember “The newer-generation H1 antagonist do not appear to be effective when cough induced by postnasal drip is not mediated by histamine” Irwin, Consensus Report of the American College of Chest Physicians. Chest 1998;114:suppl:133S-181S.

    20. Chronic Cough – Asthma Cough can be the only symptom of asthma in up to 57% of patients—cough-variant asthma +/- airflow obstruction on PFT’s Therapy If severe, PO steroids followed by inhaled steroids for 6-8 weeks with ß2 agonist If mild, inhaled steroids with ß2 agonists

    21. Chronic Cough Asthma Response to asthma therapy does not make the diagnosis of asthma since allergic rhinitis will respond to anti-inflammatory therapy also Consider methacholine challenge testing Negative predictive value is 100% Positive predictive value is 60-88%

    25. Chronic Cough -- GERD Etiology Gross aspiration including pulmonary aspiration syndromes, abscess, chronic bronchitis, bronchiectasis, and pulmonary fibrosis Laryngeal inflammation Vagally mediated distal esophageal-tracheobronchial reflex

    26. Chronic Cough -- GERD When GERD is cause of chronic cough, up to 75% of patients have no GI symptoms 24-h esophageal pH monitoring is best Negative predictive value is less than 100% Positive predictive value is 89 Inconvenient for the patient Non consensus about the best way to interpret the results

    27. Chronic Cough GERD 24-hour esophageal monitoring is not routinely recommended Empiric therapy can if tried if GI complaints compatible with GERD or No GI complaints with normal CXR, no ACEI, who do not smoke and in whom PND and asthma have been eliminated.

    28. Chronic Cough -- GERD Therapy should include: H2 blockers, dietary (high-protein, low fat diet) and life style changes (weight reduction, no caffeine or smoking) Improvement may take 2-3 months to begin and the MEAN TIME TO RECOVERY IS 161-179 DAYS.

    30. Chronic Cough -- ACEI Class effect of drug; not drug related Incidence of 0.2 to 33%; true incidence ˜ 10% Cough may appear within a few hours up to months after taking the first dose Pathogenesis seems be an accumulation of inflammatory mediators: bradykinin, substance P and/or prostaglandins

    31. Chronic Cough

    32. Chronic Cough -- ACEI Therapy STOP ACEI Other therapies include oral sulindac, indomethacin, ASA and even oral iron

    33. Chronic Cough -- ACEI

    34. Chronic Cough

    35. Chronic Cough

    36. Chronic Cough

    37. Chronic Cough

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