Essential work-up of chronic cough...COPD/bronchitis Bronchiectasis Eosinophilic bronchitis...

UCSF Voice and Swallowing CenterUniversity of California, San Francisco

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Essential work-up of chronic coughVyVy N. Young, MDAssociate Professor, Dept of Otolaryngology –Head and Neck Surgery

UCSF Voice and Swallowing Center

Disclosure

None personally

Spouse: - Olympus America Inc. (consultant) - Instrumentarium (royalties/holder of intellectual property rights)- Freundenberg (consultant) - Reflux Gourmet LLC (stock shareholder)


Objective

Review essential workup of chronic coughNOT treatment of chronic cough


Chronic CoughOne of the most common reasons that patients seek ambulatory medical treatment1

Prevalence: 9-33% worldwideAnnual US spendings on cough: $3.6B2

1Irwin RS, et al. Chest. 1998 Aug;114(2 Suppl):133S-181S2Altman KW, Irwin RS. Otolaryngol Head Neck Surg. 2011 Mar;144(3):348-52


Chronic Cough

Duration = 8 weeks- 3-8 weeks may be still

infectious/inflammatory PertussisAtypical PNA Viral Bronchitis

Spectrum of laryngeal hyperfunction/hypersensitivity- Throat clearing- Chronic cough- Cough paroxysms with post-

tussive emesis.


Reflux

Asthma

Allergies

“Roundabout” illness


Etiology of Chronic Cough

Irwin RS. Chest, 2006; 129:80S-94SIrwin RS et al. Chest 1998; 114(suppl 2):133S-181S

Pulmonary Cough variant asthmaCOPD/bronchitisBronchiectasisEosinophilic bronchitisPertussis, TBLung cancerPulm fibrosis

RhinologicChronic sinusitisAllergic rhinitis/PND

EsophagealGERD/LPREsophageal abn/dysphagia

Systemic/environmentalMeds: ACE inhibitors, ARBs, AdvairSmokingCF, sarcoidosis, GPADehydration

Laryngeal/neurologicNeurogenic cough“Hypersensitivity” syndromesGlottic insufficiencyLesionParadoxical vocal fold motionPost viral vagal neuropathy

Habitual


Etiology of Chronic Cough

Irwin RS. Chest, 2006; 129:80S-94SIrwin RS et al. Chest 1998; 114(suppl 2):133S-181S

Pulmonary Asthma (cough variant) COPD/bronchitisBronchiectasisEosinophilic bronchitisPertussis, TBLung cancerPulm fibrosis

Rhinologic/AllergicChronic sinusitisAllergic rhinitis/PND

EsophagealGERD/LPREsophageal abn/dysphagia

Systemic/environmentalMeds: ACE inhibitors, ARBs, AdvairSmokingCF, sarcoidosis, GPADehydration

Laryngeal/neurologicNeurogenic cough“Hypersensitivity” syndromesGlottic insufficiencyLesionParadoxical vocal fold motionPost viral vagal neuropathy

Habitual


Rational approach to evaluation/treatment

Many algorithms proposedUse one that makes sense to you

LPR

Asthma Sinusitis

Allergic rhinitis

Post URI


Algorithm for chronic cough – option 1

Courtesy of Dr. JP Giliberto(UWash) and

Dr. Lyndsay Madden (Wake Forest)



Courtesy of Dr. Tom Carroll (Brigham&Women’s



Altman KW et al. Otolaryngol Head Neck Surg. 2011;144(3):348-52



Gibson P, et al. Chest. 2016;149(1):27-44




What’s your first step(s)?

So many options… Make sure common problems have been addressed first


Essential work-upFirst visit

D/C ACE-inhibitorsD/C laryngeal irritants- Tobacco, caffeine, EtOHHydration

Order CXR if not done previously

Laryngoscopy (+/- stroboscopy)

- Look for glottic insufficiency- Look for paradoxical VF motionSpeech language pathologist (SLP) - Cough suppression/

management therapy- Vocal hygiene


If you’re really lucky…You will see something cool AND it may be the cause of the cough

Glottic insufficiency- Vocal fold atrophy- Vocal fold hypomobility

Paradoxical VF motion

Thickened mucus

Or something else… Video courtesy of Dr. JP Giliberto


Essential work-upFirst visit

If allergy/sinus symptoms: - Maximal medical tx x 4 weeks- Saline rinse, nasal steroids,

antihistamines, possible abx

Consider empiric acid suppression- At least 12 weeks- PPI 40mg daily, H2RB qhs,

alginate after meals & qhs

Then reassess 3 mos later- Cough gone:

Wean treatments

- Cough persists: Move on to other possibilities


Next stepsDepends on associated symptoms and your suspicion for underlying etiology

Potential additional workup:

Pulm referral- PFTs, chest CT, bronchoscopy, eval for Pertussis?Allergy testingSinus CT without contrastReflux testing- pH/impedance, manometry- TNE/EGD- Eval for anti-reflux surgery


Next steps

“Neurogenic cough” can be hard to diagnosis – treatment may be diagnostic and therapeutic

Superior laryngeal nerve blockNeuromodulators- Neurontin, pregabalin, TCA’s- Tramadol, baclofen


The Cough Wheel

From Ch 9 Chronic Cough, Plural Publishing 2019, TL Carroll Ed

Where to start?

How long to try?

One at a time? All at once?


Summary: essential workup of chronic coughHow to know which way to go?

Don’t forget the obvious- ACE inhibitors- Hydration- CXR- TobaccoHave a logical approach- Checklist- AlgorithmBe guided by pt’s symptomsBe willing to think outside the box


Patient SLP RTENT GISurg

Neuro GIAllergy Gen SurgPulm

Multi-disciplinary team = IDEAL Working as a team

to take care of our patients!


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Essential work-up of chronic cough...COPD/bronchitis Bronchiectasis Eosinophilic bronchitis...

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