Chronic Cough City and Hackney CCG  - PowerPoint Presentation

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Chronic Cough

City and Hackney CCG 

9th October 2020

Angshu Bhowmik, Consultant Respiratory Physician, Homerton Hospital

Chandra Sarkar, GP clinical lead, Spring Hill Practice

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Introduction

10% prevalence in adults

Common presentation in primary care, may become more so

Difficult to manage

No primary care guideline

Many possible causes

Treatments used as diagnostic aid

Patient expectations (often want a 'quick fix')

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Impact on patient

Physical

Chest pain

Hoarse voice

Stress incontinence

Sleep disturbanceHerniaRib fracture

Psychosocial

detrimental effect on a patient’s social life

cause embarrassment

partner sleeping in another

bedroom

 impact

can be similar to severe COPD in terms of depression and anxiety. 

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Definition

Acute cough(< 3 weeks)

Viral respiratory tract infection

Pneumonia

Exacerbation of underlying disease(

COPD,Asthma) 

Sub-acute(3-8 weeks)

Post infection cough (including TB)

Exacerbation of underlying chest condition

Upper Airway Cough Syndrome 

Chronic( > 8 weeks)

Asthma/Non-asthma eosinophilic bronchitis

Upper Airway Cough Syndrome

Gastro-oesophageal disease (Irwin RS et al CHEST 2018)

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Causes

Asthma/COPD

Upper Airway Cough Syndrome

Gastro-oesophageal reflux (acid and non-acid)

Drugs (e.g. ACE inhibitors, Sitagliptin)

Other lung disease (lung cancer, bronchiectasis, interstitial lung disease)Infection (TB, pertussis)

Post infectious cough (long covid?)

Cardiovascular problems (cardiac failure, recurrent P.E.) 

Cough hypersensitivity syndrome (refractory cough)

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Diagnostic prevalence for chronic cough

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History

The nature of the cough - is it dry/wet, intermittent/persistent, when did it start, is there vomiting or a whoop after coughing? 

Any associated symptoms and their impact, such as: wheeze, heartburn, post-nasal drip, nasal blockage and breathlessness.

It is really important to ask - how does it affect you?

Triggers cause by the patient’s occupation, their exposure to any pollutants such as smoking whether second-hand or direct, or from a main road, food, speech, lying down, allergens, medications, infections from recent travel (e.g. TB).

Past family history such as atopy or rhinitis

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Red Flags

Haemoptysis

Smoker

>45yrs new cough/ change in cough

Older smokers

HoarsenessDyspnoeaSystemic symptoms; fever, weight loss

Difficulty swallowing

Vomiting

Recurrent pneumonia

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Examination

Observations; HR, RR, BP, Sats

Generalised signs; anaemia, clubbing, lymphadenopathy, weight loss

chest – any localising signs, wheeze, basal crackles

upper airway (nose and throat)

Cardiovascularand if you suspect whooping cough, ask the patient to make a recording on their mobile phone. 

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Initial steps in primary care

Investigations:

CXR

Bloods – FBC (

eosinophilia

), CRP, ?Bordetella Pertussis serologySpirometrypeak flow monitoringRefer immediately if significant pathology suspected

Smoking Cessation

/ remove irritant

Stop

ACEi

/Sitagliptin

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Physical examination in acute cough

Rhinitis (inflamed nasal mucosa)

and pharyngitis

Otitis

Features of pneumoniaEffect of air pollution on “acute cough”??

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Treatment of acute cough

Usually benign – no prescription usually required

OTC preparations – patients report benefit, no objective evidence

Simplest and cheapest – honey and lemon

Central modulation of cough reflex – voluntary suppression works

Opiates – adverse effects

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Pharmacological agents 1

Dextromethorphan (Benylin cough and congestion, Benylin dry cough, Cavonia Bronchial Balsam, Night nurse etc)

60mg significant anti-tussive

OTC preparations often sub-therapeutic

Beware paracetamol e.g. Night nurse

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Pharmacological agents 2

Menthol – short lived effect

Sedative antihistamines – suitable for nocturnal cough

Codeine or pholcodine – same efficacy but probably more side-effects than dextromethorphan

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Chronic cough

Lots of questionnaires available

Simplest: Score the severity of your cough out of 10!

Patients up to age 30 with even 2 months of cough following respiratory infection do not usually warrant a CT scan (especially female)

Unless they have significant haemoptysis – but only after sputum tests

Or definite features of cancer e.g. lymphadenopathy, hepatomegaly etc

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Cough Hypersensitivity Syndrome

Exquisite sensitivity to environmental irritants

perfumes

bleaches

cold air

Sensations of tickling/irritation in the throat and an urge to cough

Features suggestive of heightened sensitivity of the neuronal pathways mediating cough

Epidemiology

Female:Male

= 2:1

peak prevalence in the fifties and sixties.

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Sinus imaging

Indications

Chronic cough with symptoms of rhinosinusitis after negative response to therapy and normal ENT examination

Procedure

CT better than plain radiographs

ConclusionsExperienced ENT surgeon prob better than imaging!

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Laryngopharyngeal reflux

Laryngeal oedema

Laryngeal cancer

Vocal cord nodule

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Treatments for cough 1

Usual principle: Treat the underlying cause

PPI for GORD

(but often doesn’t help cough!)

?Metoclopramide

?surgeryAvoidCCB, bisphosphonates, nitrates, ACEI, latanoprost eyedropsStop smoking – but cigarettes suppress cough reflex so cough may increase immediately after quitting

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Treatments for cough 2

Nasal steroids for rhinosinusitis

Corticosteroids (usually inhaled) for asthma

Appropriate inhaled treatment for COPD

Avoidance of occupational exposure (chemicals in spray paints,

moldy hay etc)

Treatment of pulmonary fibrosis with pirfenidone or sodium cromoglycate; or sarcoidosis with oral steroids etc.

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Treatments for cough 3

Idiopathic cough

Non-pharmacological therapy

Trial of asthma meds

Gabapentin

Low dose morphineDextromethorphanAzithromycin (limited evidence)P2X3 antagonists (experimental)

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1.

70 year old ex-smoker – cough 4 months, P

MH – pneumonia 2 years ago, previous bronchitis, hypertension, diet controlled DM. CXR normal.

What are the most likely differentials?

What would you do next?

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2. 42 year old lady with chronic cough; frequent “runny nose” but no known allergies. CXR, spirometry – normal.

What would you do next?

Refer for an ENT examination + fibreoptic laryngoscopy

Trial of nasal steroid

PEF diary and inhalersX-ray (or CT) of sinusesCT chest

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3. 35 year old man with a persistent cough, worse at night; 5 pack-yrs. Normal CXR, PEF and spirometry. PEF diary – no variability. Histamine provocation test leads to cough and fall in FEV

1

Most likely diagnosis:

Post nasal drip

Cough variant asthmaEosinophilic bronchitisEarly onset COPDChronic habitual cough

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4. 43 year old man eating peanuts while watching football on TV. H/O eczema and hayfever. Starts to cough and feels acutely breathless. Brought to A&E: a wheeze can be heard.

What would you do?

Request urgent CXR

IV hydrocortisone and piriton

Attempt PEF and prepare salbutamol nebulizerAdrenalineRequest urgent bronchoscopy

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5. 68 year old lady with chronic cough for 1 year. Never smoker, no h/o TB exposure or serious respiratory infections; no known allergy;

Spirometry – FEV

1

78%, FEV

1

/FVC ratio 69%; Bloods: Hb 11.9, WBC, Plt, U+E, LFT normalPlease see the CXRWhat is the most likely diagnosis?

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6. 46 year old stable manager presents with chronic cough for 4 months and exertional dyspnoea. Please review the CXR and CT.

What are the most likely diagnosis?

What management would you consider?

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Worked wearing a mask for 6 months

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7. A 48 year old man known to have chronic intractable cough, and no serious underlying disease, requests something for symptom relief. Which of the following are currently recommended treatments for chronic cough?

Codeine linctus

Lemon and honey

Proton pump inhibitors

Gabapentin

BaclofenSimple linctus

Morphine

Inhaled steroids

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