CHRONIC COUGH

EVELYN VICTORIA E. RESIDE, MD., FPCP., FPCCP.Section of Pulmonary Medicine

The Medical City

ATENEO SCHOOL OF MEDICINEAND PUBLIC HEALTH

SESSION OUTLINE

• Definition of terms• Etiologies• Burden of illness• Diagnostic algorithm• Summary

DEFINITION OF TERMS

• ACUTE– < 3 weeks

• SUBACUTE– Between 3 and 8 weeks

• CHRONIC– > 8 weeks

DEFINITION OF TERMS

• COUGH– A rapid expulsion

of air from the lungs, typically in order to clear the lungs

ETIOLOGIES

• Bronchial Asthma, Cough Variant Asthma• GERD or LPR• Postnasal Drip Syndrome or Chronic Upper

Airway Cough Syndrome (UACS)• Pulmonary tuberculosis

DISEASE BURDEN

• Among 284 cases seen:– Asthma 33.3% – UACS in 30.4%– PTB in 20.3%– GERD in 3.8%

• May be due to – One condition 93% of the time– Two conditions 53% of the time– Three conditions 35% of the time– Four conditions 4% of the time

• Clinical profile of patients with chronic cough due to asthma, UACS, GERD:– Patients complain of coughing– Patients are immunocompetent – Patients have a normal or near-normal chest Xray– Patients are nonsmokers and without significant

environmental exposures– Patients are not taking an ace inhibitor

THE PHILIPPINE TASK FORCE ON CHRONIC COUGH

THE UNIFIED ALGORITHM:

Jennifer Mendoza-Wi, MD., FPCCP.Liza Llanes-Garcia, MD., FPCCP.

Camilo Roa, MD., FPCCP.Abundio Balgos, Jr., MD., FPCCP

Consuelo Obillo, MD., FPCCP.Rosauro Valenzuela, MD., FPCCP.

Evelyn Victoria Reside, MD., FPCCP.

With contributions from Dr. Richard Irwin(Immediate Past President, ACCP)

THE PHILIPPINE TASK FORCE ON CHRONIC COUGH

CHRONIC UPPER AIRWAY COUGH SYNDROME:

Zenaides Wi, MD., FPSO-HNS.Cesar Villafuerte, MD., FPSO-HNS.Joselito Acuin, MD., FPSO-HNS.

WilliamLim, MD., FPSO-HNS.Madeleine Sumpaico, MD., FPSAII.

Eileen Alikpala-Cuajunco, MD., FPSAII.

THE PHILIPPINE TASK FORCE ON CHRONIC COUGH

BRONCHIAL ASTHMA:

Liza Llanes-Garcia, MD., FPCCP.Dina Diaz, MD., FPCCP.

Camilo Roa, MD., FPCCP. 

THE PHILIPPINE TASK FORCE ON CHRONIC COUGH

GASTROESOPHAGEAL REFLUX (GERD):

Carla Sibulo, MD., FPSG.Gozaar Duque, MD., FPSG.Jaime Ignacio, MD., FPSG.

 

THE UNIFIED DIAGNOSTIC ALGORITHM

Cough ≥ 2 weeks Normal CXR

History and PE

History of ACE-inhibitor intake, smoking & exposure

to occupational irritants

Stop ACE-inhibitor for 4 wks Smoking cessation

Avoid exposure

Cough gone

Ace-Induced Cough Smokers’ cough Or Irritant cough

YESNO

Cough gone

NO

NO

Hx of TB exposure

PTB suspect

Initiate specific

treatment

3 sputum AFB smears

YES

Evaluate & treat for the Pathogenic Triad:

(1) Asthma, (2) UACS and/or (3)GERD

Response to treatment

UACS,Asthma

and/or GERD

YES

Cough gone

YESOptimize treatment

and consider overlapping etiologies

NO

NO

AFB smears (+)

Repeat Chest RadiographNO

Treat as TB

YES

Cough gone

YES

ON

PTB

Treatment Modification

Repeat Chest Radiograph Normal CXR

Order according to likely clinical

possibility

Sputum cytology, HRCT scans, Modified BaE, Bronchoscopy,

Cardiac Studies

Treat Specific Conditions

Accordingly

Post-infectious Cough or Psychogenic Cough

YES

LET’S PLAY A GAME!

WINNER: 10 POINTS2ND PLACE: 9 POINTS

3RD PLACE: 8.5 POINTS4TH PLACE: 8 POINTS

DIAGNOSTIC ALGORITHM FOR CHRONIC COUGH & GERD

Chronic Cough

GERD Symptoms

Empiric treatment with acid suppressants

Improved?Continue treatment

Refer to Gastroenterologist

Y

Y

N

Y

Alarm Symptoms?

N Y

FLOW IN THE DIAGNOSIS OF CHRONIC COUGH & CHRONIC UPPER AIRWAY COUGH SYNDROME

Allergic Rhinitis

Chronic Cough and Possible Chronic Upper

Airway Cough Syndrome

Non-Allergic Rhinitis

Rhinosinusitis Tonsillopharyngitis

Laryngopharyngeal Reflux

History Physical exam

Diagnostics: (+) Family history,

response to empiric treatment, allergy skin tests

Therapeutics: Environmental control,

antihistamines, nasal steroids, immunotherapy, surgery

Diagnostics: Sinus Xrays,

Sinus CT scan Therapeutics:

Antibiotics, decongestants,

mucolytics, surgery

Diagnostics: History and

Physical Exam Therapeutics: Antibiotics,

surgery

Diagnostics: Empiric therapy,

24-hr pH monitoring, Impedance

measurement Therapeutics: Proton pump

inhibitors

DIAGNOSTIC ALGORITHM FOR CHRONIC COUGH AND ASTHMA

SUMMARY

• History and PE !– ACE inhibitor treatment and cigarette smoking– When dealing with acute cough, rule out life-threatening

conditions, exacerbations of chronic illness or environmental/occupational exposure

• Non-infectious causes of subacute cough are managed in the same way as chronic cough

• Initial empiric treatment of chronic cough is a combination antihistamine + decongestant

SUMMARY

• Stepwise approach towards the diagnosis – More than one etiology of cough can be present

• If cough is due to ACE inhibitor intake, the drug should be stopped and replaced

• If cough continues to persist, refer to a specialist!

THANK YOU FOR YOUR ATTENTION!