Cough resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Haddadi, M.D.[2]

Cough Resident Survival Guide
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Cough is a defense mechanism for clearing excessive secretion or foreign body from the airway and also it may spread infection. Dependent on the duration of cough it can be categorized to three group including acute, subacute, chronic. cough is the symptom of involving organs such as upper airway tract, lung, heart, or gastrointestinal tract. Assessment of life threatening causes of cough such as pulmonary embolism or obstructive airway disease is of important.

Causes

Common Causes

• Allergic Rhinitis
• Asthma
• Bronchiectasis
• Gastroesophageal Reflux Disease (GERD)
• Post-nasal drip
• Medications' side effect
  • ACE inhibitors
• Bronchitis
• Laryngopharyngeal reflux
• Respiratory tract infection
• Lung cancer
• Non-asthmatic eosinophilic bronchitis

• Uncommon Causes of Cough:

• Non-acid reflux disease
• Swallowing disorder
• Congestive heart failure
• Habitual cough.

Diagnosis

Acute cough is considered cough that lasts less than three weeks. Shown below is an algorithm summarizing the evaluation of acute cough according to the American College of Chest Physicians guidelines.

Acute Cough < 3 weeks

History and physical examination, ask about environmental and occupational factors and travel exposures ± investigations

Life-threatening diagnosis

Non-life-threatening diagnosis

Pneumonia, severe exacerbation of asthma or COPD, pulmonary embolism, heart failure, other serious disease

Infections

Exacerbation of pre-existing condition

Lower respiratory tract infection

Upper respiratory tract infection

Asthma

Bronchiectasis

Upper airway cough syndrome

COPD

Evaluate and treat first

Acute Bronchitis

Pertussis

Consider tuberculosis (TB) in endemic areas or high risk

• Subacute cough is considered 3 to 8 weeks. Shown below is an algorithm describing the evaluation of subacute cough in adults according to the American College of Chest Physicians guidelines.

Subacute Cough ,(3-8 weeks)

History and Physical Exam, Ask about red flags, environmental and occupational factors, travel exposures

Postinfectious or life-threatening diagnosis

New onset or exacerbation of pre-existing condition

Not postinfectious

Pneumonia, severe exacerbation of asthma or COPD,pulmonary embolism, heart failure, other serious disease

Pertussis

COPD

Upper airway cough syndrome

Asthma

Bronchitis

Gastroesophageal reflux disease

Bronchiectasis

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Postinfectious

Tuberculosis

Non-asthmatic eosinophilic bronchitis

Acute exacerbation of chronic bronchitis/COPD

Abbreviations: TB: Tuberculosis; NAEB: Nonasthmatic eosinophilic bronchitis;; AECB: Acute exacerbation of chronic bronchitis; COPD Chronic obstructive pulmonary disease; GERDgastroesophageal reflux disease; UACSUpper airway cough syndrome.

• Not postinfectious: Work up same as chronic cough

• Chronic cough is defined as cough that lasts more than 8 weeks. Shown below is an algorithm describing the evaluation of chronic cough in adults according to the American College of Chest Physicians guidelines.

Chronic Cough> 8 weeks

History, Physical exam and CXR

Life-threatening condition

Consider four most common causes: 1) Upper Airway Cough Syndrome secondary to rhinosinus diseases, 2) Asthma, 3) Non-asthmatic Eosinophilic Bronchitis,4) Gastroesophageal Reflux Disease (GERD)

Smoking, ACEI, Sitagliptin

Treat based on the cause

Discontinue for at least four weeks

Follow up 4-6 weeks if inadequate response

Initial treatments for each condition

Further investigation if No response to treatment

Consider four most common causes of cough if No response at 4-6 weeks follow up

Follow up 4-6 weeks if inadequate response to optimal treatment

• Consider the following further investigations if no response to treatment:

• 24h esophageal pH / Impedance monitoring
• Endoscopic and/or videofluoroscopic swallow evaluation
• Barium esophagram / Modified barium swallow
• Sinus Imaging, HRCT
• Bronchoscopy
• Cardiac Work-up (ECG,Holter Monitoring, Echocardiography)
• Environmental / Occupational Assessment
• Consider uncommon causes

Treatment

Shown below is an algorithm summarizing the treatment of Cough according to the American College of Chest Physicians guidelines.

Acute Cough

❑Determine if the cause of the cough is one of the life-threatening conditions: ❑Pneumonia ❑Severe exacerbation of asthma or COPD ❑ Pulmonary embolism ❑Heart failure ❑ Other serious condittons

❑Cough due to the common cold: ❑ First-generation antihistamine plus a decongestant ❑ Naproxen (Naprosyn) favorably affects cough ❑ Newer-generation nonsedating antihistamines are not effective

Subacute Cough

confirmed whooping cough by culture positive nasopharyngeal swab: macrolide antibiotics plus isolation for 5 days

Cough not caused by bordetella pertussis: ❑ Inhaled ipratropium (Atrovent) ❑ If cough persists: inhaled corticosteroids ❑ Severe cough:30 to 40 mg of prednisone per day for a brief period) ❑ When other treatments fail: codeine or dextromethorphan (Delsym)

Chronic Cough

UPPER AIRWAY COUGH SYNDROME–INDUCED CHRONIC COUGH ❑First-generation antihistamine/decongestant ❑Partial or complete resolution of cough after one to two weeks shows upper airway cough syndrome as the cause ❑ Persistent symptoms: begin a topical nasal steroid ❑ Symptoms still persist: sinus imaging for sinusitis

ASTHMA-INDUCED CHRONIC COUGH ❑ Inhaled corticosteroids and beta agonists ❑ No response or cannot take inhaled medication:consider oral corticosteroids for 5-10 days ❑ Consider adding a leukotriene inhibitor before an oral corticosteroid

NON-ASTHMATIC EOSINOPHILIC BRONCHITIS-INDUCED CHRONIC COUGH ❑ Inhaled corticosteroids for 4 weeks

GERD-INDUCED CHRONIC COUGH ❑ Empirically treated for GERD if there is not response to therapy ❑ Anti-reflux diet, lifestyle modification, proton pump inhibitor ❑ Adding prokinetic therapy if there is NO response to treatment

If a complete workup fails to find a cause for the cough, the remaining diagnosis is an unexplained cough. and referral to cough specialist should be considered

Do's

• Always first determine if the cause of the cough is one of the life-threatening conditions especially in the management of acute cough such as pulmonary embolism or obstructive airway disease.
• Always ask about environmental and occupational factors and travel exposures for management of acute cough.
• Routinely assess quality of life or cough severity with a validated tool.
• Routinely follow up the patient with sub-acute cough within 4-6 weeks.
• Naproxen (Naprosyn) favorably affects the acute cough due to common cold.
• Leukotriene inhibitor is prefered to treat asthma induced chronic cough before begining of oral corticosteroid agents for prevention of the side effects of cotricosteroid.
• Three common causes of chronic cough include postnasal drip syndrome, asthma, and gastroesophageal reflux disease.
• Notify GERD in pediatric presented with cough, vomiting, poor weight gain, dysphagia, abdominal or substernal pain.
• The mechanism of cough in upper airway cough syndrome include postnatal drip, direct irritation, or inflammation of the cough receptors in the upper airway.

Don'ts

• Do not continue ACE inhibitors if cough was associated with the begining of ACEI.
• Do not miss the following red flags during an assessment of cough:
  • Hemoptysis
  • Changing in cough or initiating caugh in smoker > 45 years old
  • Coexisting voice disturbance
  • Hoarseness
  • Systemic symptoms including fever, weight loss, Peripheral edema with weight gain
  • Vomiting
  • Recurrent pneumonia
  • Abnormal chest radiographic findings
  • Adults aged 55-80 years with history of a 30 pack-year smoking
  • Currently smoking or history of quitting within the past 15 years
  • Dyspnea at rest, orthopnea
  • swallowing difficulty during eating or drinking

References