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!
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