Chronic Cough

1. Chronic Cough

2. The Size of the Problem Prevalence of 10% in the community Approximately 30 million physician visits annually (US) 5th most common symptom for outpatient care Up to 40 percent of an outpatient chest clinics Cost of treating exceeds �500 million annually, excluding cost of diagnostic tests and medications Multiple effects on patients: exhaustion, self-consciousness, insomnia, headache, dizziness, musculoskeletal pain, hoarseness, excessive perspiration, urinary incontinence, "something is wrong"

3. Complications

4. MEDULLARY COUGH CENTRE

13. Symptoms of GORD in Asthma Oesophageal symptoms Heartburn, Regurgitation, Dysphagia Extra-Oesophageal symptoms Coughing Sore-throat, Choking Hoarseness Chest Pain Odour Worsened Asthma symptoms with Eating, Alcohol, Supine position, Theophyllines, Systemic b2 agonists Anti-cholinergic drugs Clinically Silent

15. Pulmonary Indications for 24hr Oesophageal pH monitoring Unexplained Persistent Cough Cough associated with other symptoms of GORD, not responding to anti-reflux therapy Chronic Cough with proven aetiology not responding to specific therapy Difficult to control asthma despite maximal therapy Poor response in confirmed GORD, monitoring while ON anti-reflux Rx to determine persistent acid reflux (2-3% may require reflux surgery)

20. GORD Therapy for Difficult Asthma High-protein, low-fat anti-reflux diet Weight loss Eat only 3 meals per day Do not eat or drink 2-3 hours before lying down except for medications Elevate head of bed H2 antagonists: cimetidine, ranitidine, PPIs: (es)omeprazole, lansoprazole, Pro-kinetic agents MST Surgery

21. Specific Therapy for Common Causes of Chronic Cough Postnasal Drip Rhinitis - allergic, - perennial non-allergic, - post-infectious, environmental irritant - vasomotor Avoidance of environmental irritants Intranasal steroid spray Antihistamine-decongestant combination Intranasal ipratropium bromide (Atrovent), for non-responsive vasomotor rhinitis Sinusitis Antibiotics Decongestant nasal spray Antihistamine-decongestant combination

22. Specific Therapy for Common Causes of Chronic Cough Asthma Bronchodilators Inhaled corticosteroids Other asthma therapy COPD Local Guidelines Gastroesophageal reflux disease High-protein, low-fat anti-reflux diet eat 3 meals per day Do not eat or drink 2-3 hours before lying down except for medications elevate head of bed Histamine H2-receptor antagonists: cimetidine, ranitidine, famotidine, Acid (proton) pump inhibitors: omeprazole, lansoprazole, Pro-kinetic agents

25. 10 mins for a Chronic Cougher History 42 yrs female, 8 month cough, good health, embarrassed, prolapse What issues you should cover Take a brief history Ask about symptoms of asthma Ask about post nasal drip - repeated throat clearing - nasal discharge - excessive phlegm Ask about heartburn and regurgitation Smoker? Quality of Life? ACE Inhibitor? Explain that several consultations needed ! WARNING symptoms

26. 10 mins for a Chronic Cougher What you should do Examine the patient: URT and LRT - examine for signs of asthma (lung sounds!) and PNDS - remember examination usually normal Arrange CXR if WARNING symptoms; smokers, wt. loss, haemoptysis etc. Perform spirometry - treat for asthma or COPD if obstruction - Treat with nasal corticosteroids Treat with acid suppressants Ask the patient to make another appointment to assess response

27. Case Studies � first presentation Case 1 35 yr old male from Congo, cough for 6 weeks, wt. loss half stone Case 2 42 yr old female, cough for 8 weeks, recurrent ear infections, phlegm in the morning, chest clear, spirometry normal Case 3 16 yr old female, cough for 8 weeks, poor concentration at school, night sweats, phlegm in the morning, chest �clear�, spirometry normal Case 4 65 yr old male, cough for 2 months, pain in left shoulder, spirometry 1.0/2.8

28. Case Studies � further visits Case 5 32 yr old female, recurrent childhood infections, phlegm most mornings, blocked nose, face-aches, wheezy when exerting, better with bronchodilators, spirometry 1.7/2.9 Case 6 79 yr old male, cough for 3 months, breathless when exerting, waking at night with cough and breathlessness, phlegm in the morning, chest clear, spirometry 0.9/3.2, partially better with bronchodilators Case 7 42 yr old female, cough for 8 years, smoker, CXR normal, phlegm in the morning, chest wheezy, spirometry 1.7/2.8, inhalers �useless�, coughed ++ after VV surgery, anaesthetist comments �alright in op�, worse in recovery Case 8 38 yr old female, cough for 6 months, allergic to cats, breathless and wheezy, PEFs variable, watery and itchy eyes