Chronic Cough in Adults - UT Southwestern Medical Center

CHRONIC COUGH IN ADULTS

Rahele Lameh, M.D. Department of Family & Community Medicine

Definition: chronic (more than eight weeks)

A. History/ salient points:

Description: Dry or productive, timing (day/night/posture), aggravating and relieving factors? History of allergies and or reflux? History of smoking, asthma? Medications ACE inhibitors, ARB, rennin inhibitors, NSAID`s. Associated symptoms: fever, night sweats or weight loss, wheeze, dyspnea. History of recent URI? (Post URI cough can persist for 3-4 weeks/gradual improvement) Possible exposure to noxious inhalants or environmental irritants?

Note: When a patient has a cough lasting for two weeks or more than two weeks without another apparent cause and it is accompanied by paroxysms of coughing, posttussive vomiting, and/or an inspiratory whooping sound, the diagnosis of a B. Pertussis infection should be made unless another diagnosis is proven. Note: Cough with eating in elderly: Chronic aspiration is common in the elderly patient, especially following stroke. Note: A nocturnal cough may be associated with asthma, post-nasal drip, congestive heart failure or gastroesophageal reflux disease (GERD).

Hoarseness or a problem with your voice Clearing your throat Excess mucus in the throat, or drip down the back of your nose Retching or vomiting when you cough Cough on first lying down or bending over Chest tightness or wheeze when coughing Heartburn, indigestion, stomach acid coming up (or do you take medications for this, if yes score 5) A tickle in your throat, or a lump in your throat Cough with eating (during or straight after meals) Cough with certain foods Cough when you get out of bed in the morning Cough brought on by singing or speaking (for example, on the telephone) Coughing during the day rather than night A strange taste in your mouth

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? 2009 The University of Texas Southwestern Medical Center at Dallas

Chronic Cough in Adults

The University of Texas Southwestern Medical Center at Dallas

B. Physical Examination to Include.

Examination of the upper airways: look for nasal mucous membrane swelling, post-nasal drip or nasal polyps.

Examination of the lower airways: wheezes, rhonchi or crackles. The finding of unilateral wheezing may be due to an endobronchial lesion or foreign body.

Masses in the neck, including thyroid enlargement, can compress the trachea and cause cough.

C. Diagnostic Studies

The work-up for chronic cough should begin with standard posterior- PA/Lat CXR. Spirometric studies before and after bronchodilator administration may reveal reversible airways obstruction (asthma). If indicated consider further work up for Asthma. CT scans of the thorax may reveal changes due to subtle lung pathology. Barium esophagograms and upper gastrointestinal endoscopy have a low sensitivity (48%) and specificity (76% ) for identifying GERD as the culprit in chronic cough; monitoring the esophageal pH for 24 hours is the gold standard.

CT imaging of the sinuses adds little to the routine evaluation of patients with chronic cough.

Note: For patients who diagnosis of upper airway cough syndrome and asthma have been eliminated, nonasthmatic eosinophilic bronchitis should be considered with a sputum test for eosinophils.

D. Treatment:

Tx specifically identified causes - asthma, GERD, Ace inhibitor`s, smoking etc. For no obvious cause - empiric treatment of the most common causes of cough (Upper airway cough

syndrome, asthma, nonasthmatic eosinophilic bronchitis, and GERD ) (Class B) Stepwise treatment for Chronic cough with no obvious underlying cause : (Class B)

1. Upper airway cough syndrome: Antihistamines and decongestant. 2. Asthma: Inhaled corticosteroid, bronchodilator, leukotriene receptor antagonist. 3. Non-asthmatic eosinophilic bronchitis: Inhaled bronchodilator. 4. GERD: PPI, diet,/ lifestyle

Note: Cough can be multifactorial.

E. When to Refer:

The patient remains symptomatic despite treatment for 6 to 8 weeks. Referral to GI for a work up of reflux (Endoscopy, pH monitor etc) Referral to an allergist for testing and treatment. Pulmonary medicine.

References further reading

1. Eur Respir J 2004; 24: 481?492 DOI: 10.1183/09031936.04.00027804, Copyright #ERS Journals Ltd 2004 European Respiratory Journal , ISSN 0903-1936

2. Mayo Clin Proc. 1997;72:957-959 ? 1997 Mayo Foundation for Medical Education and Research, Assessment of the Patient With Chronic Cough MARIETTE L. YU, M.D.*; JAY H. RYU, M.D. From the Division of Pulmonary and Critical Care Medicine and Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota.*Current address: San Diego, California. Address reprint requests to Dr. J. H. Ryu, Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905.

3. Diagnosis and Management of Cough Executive Summary ACCP Evidence-Based Clinical Practice Guidelines Chest - Volume 129, Issue 1 (January 2006) - Copyright ? 2006 The American College of Chest Physicians - About This Guideline

Rahele Lameh, M.D. Assistant Professor, Family & Community Medicine Last Reviewed: 3/2008

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