9th October 2020 Angshu Bhowmik Consultant Respiratory Physician Homerton Hospital Chandra Sarkar GP clinical lead Spring Hill Practice Introduction 10 prevalence in adults Common presentation in primary care may become more so ID: 911688
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Slide1
Chronic Cough
City and Hackney CCG
9th October 2020
Angshu Bhowmik, Consultant Respiratory Physician, Homerton Hospital
Chandra Sarkar, GP clinical lead, Spring Hill Practice
Slide2Introduction
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')
Slide3Impact 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.
Slide4Definition
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)
Slide5Causes
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)
Slide6Diagnostic prevalence for chronic cough
Slide7History
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
Slide8Red Flags
Haemoptysis
Smoker
>45yrs new cough/ change in cough
Older smokers
HoarsenessDyspnoeaSystemic symptoms; fever, weight loss
Difficulty swallowing
Vomiting
Recurrent pneumonia
Slide9Examination
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.
Slide10Initial 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
Slide11Physical examination in acute cough
Rhinitis (inflamed nasal mucosa)
and pharyngitis
Otitis
Features of pneumoniaEffect of air pollution on “acute cough”??
Slide12Treatment 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
Slide13Pharmacological 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
Slide14Pharmacological agents 2
Menthol – short lived effect
Sedative antihistamines – suitable for nocturnal cough
Codeine or pholcodine – same efficacy but probably more side-effects than dextromethorphan
Slide15Chronic 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
Slide16Cough 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.
Slide17Sinus 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!
Slide18Laryngopharyngeal reflux
Laryngeal oedema
Laryngeal cancer
Vocal cord nodule
Slide19Treatments 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
Slide20Treatments 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.
Slide21Treatments for cough 3
Idiopathic cough
Non-pharmacological therapy
Trial of asthma meds
Gabapentin
Low dose morphineDextromethorphanAzithromycin (limited evidence)P2X3 antagonists (experimental)
Slide221.
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?
Slide232. 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
Slide243. 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
Slide254. 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
Slide265. 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?
Slide27Slide286. 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?
Slide29Slide30Slide31Worked wearing a mask for 6 months
Slide32Slide33Slide347. 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
Slide35