Chronic Cough

1. Chronic Cough Barbara A. Cockrill, MD Massachusetts General Hospital Harvard Medical School

2. Cough • Vital protective mechanism • Four steps: • inspiratory gasp • Valsalva maneuver • expiratory blast as cords abduct • post-tussive prolonged inspiration

3. Chronic Cough • Common things are common • Patients who do not respond frequently have more than one cause • GERD causes cough. • Post-infectious cough is common

4. Causes of Cough ACCP Chest 2006 Irwin 1990

5. Number of causes of cough Patients % Number of Causes of Cough Smyrnios et al Arch Intern Med 1998 158:1222

6. Chronic Cough: D.A. • 55 yo school secretary • C/O cough for 3 years • Non-smoker • Cough: • Often productive, wax/wane • Better c abx, but comes back • “no better” with asthma meds • worst in AM

7. Chronic Cough: D.A. • Nasal voice, afebrile, looks well • Mild “cobblestoning” • No facial tenderness • normal heart and lungs • normal spirometry

9. Chronic Sinusitis • Often paucity of symptoms • Often improvement with antibiotics • Dx: Clinical & Sinus CT scan

10. Chronic Sinusitis • Evaluation • Allergies • Immunological • Rx: • Prolonged antibiotics (3-6 weeks) • Immunotherapy • Topical steroids • antihistamine/decongestants • Sinus irrigation • Consider surgical evaluation

12. Chronic Cough: The Computer Programmer • 35 yo woman • Yearly cough • starts only after a “cold” in fall or winter,lasts until mid-summer • Severe coughing FITS • goes away by itself • has happened last 4 years. • Tried “everything”

13. Chronic Cough: The Computer Programmer • Denies: wheezes, PND sx, allergies heartburn, aspiration • No: pets, exposures, current meds • Family hx negative • PMH: negative • Physical exam and CXR normal • Normal spirometry, no bronchdilator effect • “I can’t take it any longer!”

14. Methacholine Challenge Testing

15. Cough Variant Asthma • Cough is sole symptom • Spirometry is normal • Up to 25% of asthmatics • Diagnosis: • Positive methacholine challenge • Response to therapy • Mechanism

16. Non-asthmatic Eosinophilic Bronchitis • Eosinophilic airway inflammation WITHOUT variable airflow obstruction • Responds to inhaled corticosteroids • Dx = • sputum or BAL eosinphilia • Lack of variable airflow obstuction • Response to corticosteroids

17. Asthma vs. NAEB: Different localization Mast cells Brightling et. Al. NEJM 2002;346:1699

18. Chronic Cough: The Computer Programmer • Aggressive asthma regimen x 4 weeks • “I am only one iota better.......” • NOW WHAT?!

19. Reflux Esophagitis

21. Esophageal-tracheobronchial cough reflex & GERD • 22 pts with reflux & cough, 12 controls • Instilled acid into distal esophagus • Looked at effects of • Esophageal lidocaine • Esophageal ipratropium • Inhaled ipratropium Ing et al 1994

22. Ý cough in patients (p<.0001) Ing 1994

23. Cough blocked by esophageal lidocaine, not by esophageal ipratroprium

24. Cough blocked by esophageal lidocaine, not by esophageal ipratroprium Instillation of lidocaine before instillation of HCl Ing 1994

25. Cough was blocked by INHALED ipratropium Ing 1994

26. Cough blocked by INHALED ipratropium Ing 1994

27. Cough and Reflux Cough GERD causes cough & lowers cough threshold • abdominal pressure Ý Reflux

28. Stop smoking Avoid alcohol Lose weight Elevate HOB Small meals Avoid fatty/acidic foods High protein/low fat diet Avoid caffeine Avoid tight clothes eating < 4 hrs pre-bed Recumbency 3 hrs post Lifestyle Changes for GERD

29. Theophylline Progesterone Alpha-adrenergic antagonists Beta-adrenergic antagonists Calcium channel blockers Nitrates Medications that  LES tone

30. Cough & GERD: treatment • Conservative measures • Antacid therapy: • Proton pump inhibitor (high dose) • H2 blockers less effective • Motility therapy: • Metoclopromide (Cisapride) • Surgery is last resort

31. Cough & GERD • May be silent (up to 75%) • May complicate other causes • Diagnosis can be difficult • pH probe vs. therapeutic trial • Treatment must be aggressive • Bland reflux can still cause cough • Surgery effective in some patients

33. Chronic cough: J.B. • 46 yo woman • Secretary in College Infirmary • 3 wks severe cough • Followed mild “cold” • Cannot talk, sleep • Cough comes in “fits” • Otherwise very healthy

34. “The art of medicine is amusing the patient until Nature cures the disease.” -Voltaire

35. The Boston Globe Friday, June 8, 2007 Cape hospital hunts for whooping cough exposure By Stephen Smith, Globe staff Cape Cod Hospital embarked on a massive hunt to track down about 1,000 patients, relatives, and staff members who might have been exposed to whooping cough by workers in a cancer clinic.

36. B. pertussis“The hundred Day Cough” • Bordatella pertussis, parapertussis • Immunity wanes 12 yrs after vaccine • Phases: • catarrhal, paroxysmal, convalescent • Abx ß infectivity, no effect on cough • Prophylaxis

37. Trachea: effect of pertussis

38. Why diagnose pertussis? • Treatment: • does notß paroxysmal phase • does ß infectivity • Prophylaxis • To reassure patient • Minimize further work-up

39. New CDC Guideline Dec. 2006 • All adults should receive Tdap x 1 • Tetanus • Diphtheria • Pertussis

40. Post-infectious cough:Vagal neuropathy?? Jeyakumar et. al. Laryngoscope 116: 2108, 2006

41. Chronic Cough: Conclusions • Common things are STILL common • Many patients have > 1 cause • Most patients respond to therapy

43. Thank you