Chronic Cough

Sep 16, 2019 admin HÔ HẤP 0

Chronic Cough

Aka: Chronic Cough

II. Definitions: Adults

  1. Chronic Cough
    1. Cough duration longer than 8 weeks (less than 4 weeks in children under age 15 years)
  2. Subacute Cough
    1. Cough duration from 3-8 weeks
  3. Acute Cough
    1. Cough duration shorter than 3 weeks

III. Causes

  1. See Chronic Cough Causes
  2. Pertussis is responsible for 20% of severe cough in adults and teens >2 weeks presenting to emergency departments
    1. Senzilet (2001) Clin Infect Dis 32:1691-7
  3. Most common causes of adult cough
    1. Upper Airway Cough Syndrome (UACS)
    2. Asthma
    3. Nonasthmatic eoisnophilic Bronchitis
    4. Gastroesophageal Reflux or laryngopharygeal reflux disease

IV. History: General

  1. Tobacco Smoking
    1. Packs per day
    2. Morning cough
  2. Post-nasal drainage (typically presents with Globus sensation)
    1. Allergic Rhinitis
    2. Sinusitis
  3. Asthma
    1. Night cough
    2. Environmental irritants
    3. Atopic Family History
  4. Gastroesophageal Reflux
    1. Cough Worse supine (exception in Reflux Laryngitis which is worse in upright position)
    2. Cough relieved with Antacids?
    3. Frequent throat clearing
  5. Chronic Bronchitis or COPD
    1. Productive cough
    2. Tobacco Smoker
  6. Medications
    1. ACE Inhibitors
    2. Beta Blocker
  7. Airway Hyperresponsive
    1. Non-productive cough
    2. Recent Upper Respiratory Infection or Bronchitis
      1. Bordatella Pertussis
      2. Chlamydia pneumoniae
      3. Mycoplasma pneumoniae
      4. Influenza
      5. RSV
      6. Parainfluenza

V. History: Red Flags (Cancer, Tuberculosis)

  1. Night Sweats
  2. Weight loss
  3. Hemoptysis
  4. Hoarseness
  5. Recurrent Pneumonia (e.g. atypical infection, congenital lung abnormality, Immunodeficiency, aspiration)
  6. Tobacco history 20 pack years or smoker over age 45 years

VI. Exam: Red flags or acute findings

  1. General
    1. Unintentional Weight Loss or Failure to Thrive
  2. Head and neck exam
    1. Supraclavicular Lymphadenopathy
  3. Lung Exam
    1. Dyspnea
    2. Tachypnea
    3. Hypoxia
    4. Wheezing
      1. Asthma
      2. Chronic Obstructive Pulmonary Disease (COPD)
      3. Tracheomalacia
    5. Rhonchi
      1. Upper airway secretions
      2. Interstitial Lung Disease
  4. Skin Exam
    1. Digital Clubbing
    2. Cyanosis

VII. Imaging

  1. Chest XRay
    1. Indicated in most cases of Chronic Cough (productive vs non-productive does not direct imaging)
    2. Conditions resulting in abnormal findings
      1. Bronchiectasis
      2. Bronchogenic Carcinoma
      3. Tuberculosis
      4. Sarcoidosis
      5. Peristant Pneumonia
  2. Chest CT Indications
    1. Elucidate abnormal Chest XRay

VIII. Management: Initial Interventions

  1. General
    1. Consider Chest XRay unless cause is obvious
    2. Algorithm applies to non-urgent cough evaluation
    3. Red flags (see above) or Chronic Cough in Immunocompromised patients require urgent evaluation
    4. Focus on most common causes of Chronic Cough in adults first (see above)
  2. Avoid Lung toxins
    1. Tobacco Cessation
    2. See Occupational Asthma
  3. Discontinue ACE Inhibitor if using
    1. Convert to Angiotensin Receptor Blocker
    2. Reassess after 4 weeks (cough resolution occurs within 1 to 12 weeks)
  4. If suspect post-Bronchitis airway hyper-responsiveness
    1. Consider Pertussis
    2. Consider Inhaled Corticosteroids
    3. Consider inhaled Ipratropium Bromide (Atrovent)
  5. If suspect Asthma
    1. Eliminate Asthma triggers
    2. Inhaled Bronchodilator
    3. Inhaled Corticosteroid
    4. Consider Leukotriene Receptor Antagonist (e.g. Singulair)
  6. If suspect Chronic Bronchitis (or COPD)
    1. Tobacco Cessation
    2. Inhaled Bronchodilator
    3. Inhaled Anticholinergics
    4. Consider oral Corticosteroid (with or without antibiotic)
      1. See Acute Exacerbation of Chronic Bronchitis
  7. If suspect Gastroesophageal Reflux
    1. GERD precautions (lifestyle changes)
    2. Empiric Proton Pump Inhibitor for 8 weeks
    3. Consider added H2 Blocker (e.g. Ranitidine), especially for the first week of Proton Pump Inhibitor
    4. Consider Baclofen 20 mg daily for refractory Chronic Cough due to GERD
    5. Xu (2016) J Thoracic Dis 8(1): 178-85 [PubMed]
  8. Consider infectious cause evaluation
    1. Purified Protein Derivative (PPD) for Tuberculosis
    2. Nasopharyngeal swab PCR for Bordetella pertussis

IX. Management: Step 1 – Treat empirically for postnasal drip

  1. Diagnoses to consider
    1. Upper Airway Cough Syndrome (UACS)
    2. Acute Sinusitis or Chronic Sinusitis
    3. Allergic Rhinitis
    4. Vasomotor Rhinitis
  2. Medications to consider
    1. Consider Decongestant and Antihistamine combination
    2. Consider using First Generation Antihistamine
      1. Example: Chlorpheniramine
      2. Non-Sedating Antihistamine may not be potent enough
    3. Intranasal Corticosteroids
    4. Atrovent nasal Inhaler (Vasomotor Rhinitis)
    5. Nasal Saline irrigation
    6. Consider Acute Sinusitis Management
  3. Diagnostics to consider in refractory cases
    1. Sinus CT
    2. Nasolargyngoscopy

X. Management: Step 2 – Evaluate for Asthma

  1. Consider cough-variant Asthma empiric trial
    1. Trial Bronchodilator with or without Inhaled Corticosteroid (e.g. Albuterol, Advair)
    2. Trial Leukotriene Receptor Antagonist (e.g. Singulair)
    3. Consider Prednisone 40 mg orally daily for 7-10 days
  2. Perform Pulmonary Function Tests
    1. FEV1 before and after Bronchodilator
    2. Consider Methacholine Challenge test
      1. High False Positive Rate (25%)
      2. Near 100% Negative Predictive Value
  3. Treat Asthma if present
    1. See Allergen Control
    2. Inhaled Corticosteroids or Cromolyn Sodium
    3. Inhaled Beta Agonist

XI. Management: Step 3 – Evaluate Pulmonary and Sinus Disease

  1. Chest XRay (if not already done)
  2. CT Sinuses

XII. Management: Step 4 – Treat for Gastroesophageal Reflux

  1. High Dose Proton-Pump Inhibitor
    1. Omeprazole (Prilosec) 20 to 80 mg PO qd
    2. Requires 2-3 months of therapy to eliminate cough
  2. Anti-Reflux Esophagitis measures
  3. Consider diagnostic testing
    1. Upper GI
    2. Upper Endoscopy
    3. 24 hour esophageal pH monitoring

XIII. Management: Step 5 – Advanced lung diagnostics

  1. Consider Eosinophilic Bronchitis evaluation
    1. Obtain 3 induced Sputum samples
    2. Negative if Eosinophils <3% in Sputum
    3. Responds to inhaled or Systemic Corticosteroids (but not to Inhaled Bronchodilators)
  2. Pulmonology Consultation
    1. Bronchoscopy may be considered
  3. If pulmonary evaluation negative
    1. Repeat Asthma medications
    2. Repeat Antihistamine and Decongestant combinations
    3. Consider Gabapentin (1800 mg/day) or Pregabalin (300 mg/day)
      1. Improvement within 1 month
      2. Ryan (2012) Lancet 380(9853): 1583-9 [PubMed]
  4. Evaluate for less common etiologies
    1. See Chronic Cough Causes

XIV. References

  1. Benich (2011) Am Fam Physician 84(8): 887-92 [PubMed]
  2. Holmes (2004) Am Fam Physician 69(9):2159-66 [PubMed]
  3. Irwin (2000) N Engl J Med 343:1715-21 [PubMed]
  4. Michaudet (2017) Am Fam Physician 96(9): 575-80 [PubMed]
  5. Philip (1997) Am Fam Physician 56(5): 1395-1402 [PubMed]
  6. Smyrnios (1995) Chest 108:991-7 [PubMed]

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