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Transcript of Chronic Cough
Why should you care about a simple cough? The most common complaint leading patients to consult with primary care physicians in the United States
~ 829.3 million visits to office-based
physicians in the US.
of those, 3.6% (29.5million visits) were for cough Cough is classified into acute (<3wks), subacute (3-8wks) and chronic (>8wks)
Acute cough is most likely to be related to an upper respiratory infection, pneumonia, sometimes PE
Subacute coughs are most likely post infectious in nature and usually resolve on their own Cough Reflex In addition, health-care expenditures for treating cough are substantial (on the order of several billion/year)
And the presenting symptom of cough, specifically chronic cough, can be a herald of a more ominous illness such as cancer.
Therefore, it is important to be knowledgeable regarding the evidence-based clinical practice guidelines for diagnosing and treating cough. Chronic Cough
Most Common Causes: Upper Airway Cough Syndrome (the artist formerly known as Post Nasal Drip)
Interstitial lung disease
Neoplasm Cough is present in 65% of patients at the time lung cancer is diagnosed. However, lung cancer is diagnosed in <2% of those who present with chronic cough
Among other important points in a person’s medical history that lead to a higher index of suspicion for primary lung cancer are: passive cigarette smoke exposure; exposure to asbestos, radon, and selected other carcinogens; COPD; and a family history of lung cancer.
Any form of cancer involving the lungs may be associated with cough. However, cough is far more likely to indicate involvement of the airways than the lung parenchyma because of the location of cough receptors
Bronchoscopy is usually indicated when there is suspicion of airway involvement by a malignancy Evaluation and Diagnostic Approach First step ( in those who are non-smokers, not on an ACE, with a normal CXR) is to treat empirically for UACS with an antihistamine & decongestant combination.
Evaluate 2-3 weeks later When taking an H&P play close attention to clues such as:
purulent sputum production?
weight loss, constitutional symptoms
If the above points you to a particular cause treat accordingly
(Studies have revealed that patient's description (character, timing, nonproductive or not ) of cough has little to do with their underlying cause ) What if the H&P does not strongly suggest a cause? But Doc, I'm still coughing! Consider a pre/post bronchodilator spirometry --> if no reversible obstruction is found --> proceed to a methacholine challenge to assess for bronchial hyperresponsiveness
Treat empirically for asthma
Also check a sputum for eosinophils to evaluate for non-asthmatic eosinophilic bronchitis (this is treated with inhaled glucocorticoids as well) Cough, Cough >:( If a cough still persists despite all of the above start a PPI for GERD
If no/partial response, consider further studies (24 hour esophageal pH monitoring, bronchoscopy, PFTs)
**In a patient with cough who has risk factors for lung cancer or a known or suspected cancer in another site that may metastasize to the lungs, a chest radiograph should be obtained.
**In patients with a suspicion of airway involvement by a malignancy (eg, smokers with hemoptysis), even when the chest radiograph findings are normal, bronchoscopy is indicated. Chronic Cough & Lung Cancer References Uptodate
Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines.
Morice AH, Kastelik JA. Cough. 1: Chronic cough in adults. Thorax 2003; 58:901.
Irwin RS, Madison JM. The diagnosis and treatment of cough. N Engl J Med 2000; 343:1715. Pratter MR, Bartter T, Akers S, DuBois J.
An algorithmic approach to chronic cough. Ann Intern Med 1993; 119:977. Mello CJ, Irwin RS, Curley FJ.
Predictive values of the character, timing, and complications of chronic cough in diagnosing its cause. Arch Intern Med 1996; 156:997.