DR O ADEYOGPVTS ST2

16/04/13

COUGH – BTS guidelines

Cough

Acute cough

Chronic cough History Examination Investigation

Specific cough syndromes

Cough clinic referral

Questions/discussion

Acute cough

< 3 weeks

Mostly associated with viral URTI

In absence of significant co-morbidity, usually self-limiting

Little evidence for OTC preparations but patients report benefit

Impact on UK economy

£875 million to loss of productivity£104 million cost to the healthcare system and OTC

medication

Acute cough

Further investigate Haemoptysis Prominent systemic illness Suspicion of inhaled FB Suspicion of lung Ca

Chronic cough

> 8 weeks

10-20% of adults

Female and obese

10% of respiratory ref to 2◦ care

Decrement in QOL comparable with severe COPD

Most have dry or minimally productive cough

Significant sputum - 1◦ lung pathology

Heightened cough reflex is the 1◦ abnormality

History

Age + sex

Smoking

Characteristic Onset

Duration

Relation to infection

Sputum

Diurnal variation

Severe coughing spasms/paroxysms

Incontinence

Origin of sensation

Cough triggers + aggravants

Food

Cough on phonation

History

Medication

Occupation/hobbies/pets

PMH

FH May be familial (inherited anatomical abnormality,

neurological condition)

Physical examination

Signs of respiratory disease or cardiac failure

More often examination reveals less specific findings

ENT exam

If FH - neuro exam of legs to look for signs of familial neuropathy.

Baseline investigations in 1◦ care

CXR All chronic cough Acute cough with atypical sx

Assessment of pulmonary function Spirometry – all chronic cough

Helpful in identifying cough caused by chronic airway obstruction

Normal does not exclude asthma Avoid using single PEF or PEF to assess

bronchodilator response in diagnosis of airflow obstruction as cause of cough

Specific cough syndromes

Specific cough syndromes

Cough variant asthma

Eosinophilic bronchitis

GORD

Upper airway disease and cough

Undiagnosed or idiopathic cough

Cough due to other common respiratory disease

Cough variant asthma

Chronic cough is the main (if not the sole) symptom present

it is considered to be a variant type of asthma as well as a precursor to the development of classical asthma

Clinical indicators include Nocturnal, post-exercise, post-allergen exposure

Progresses to typical asthma in 17–37% of patients

Hyperresponsiveness is present

Cough variant asthma

In these patients eosinophils in sputum, bronchoalveolar lavage (BAL) fluid, and in bronchial biopsy specimens is characteristic

Measurement of airway hyperesponsiveness

Inhalation of methacoline If negative excludes asthma but does not rule out steroid

responsive cough.

Management Follow guidelines for asthma except no evidence for LABA Evidence exists for use of Leukotriene receptor agonist Responds to treatment with inhaled steroids

Eosinophilic bronchitis

Patients have cough and eosinophils in sputum but spirometric tests and airway hyperresponsiveness is normal

50% of patients with CVA have associated EB

Management Responds to inhaled steroids Use BTS asthma guidelines for guidance on dose,

preparation and duration

GORD

Pt’s have increased cough reflex sensitivity which improves with antireflux therapy

Microaspiration of gastric content into larynx and tracheobronchial tree

Vagally mediated oesophageal reflex stimulated by acid or non-acid volume reflux

Oesophageal motor dysfunction and reduced oesophageal clearance

GORD

Management PPI – omeprazole 20 -40 BD before meals – at least 8 weeks

Prokinetic agents – metoclopramide 10mg TDS may be required in some

Consider stopping medication that can potentially worsen GORD ( biphosphonates, nitrates, ca channel blockers, theophylline, progesterones)

Antireflux surgery in carefully selected cases

Upper airway disease and cough

Cough commonly accompanied by Nasal stuffiness Sinusitis Post-nasal drip

In presence of prominent upper airway sx 1 month trial of topical steroid recommended Can be a diagnostic approach

Undiagnosed or idiopathic cough

Chronic cough should only be considered idiopathic following thorough assessment at a specialist cough clinic

Clinical hx of reflux is usually present

A typical lymphocytic airways inflammation is seem

Middle aged women Present with chronic dry cough which starts at time of

menopause Often appears to follow a viral respiratory tract infection

Undiagnosed or idiopathic cough

Organ specific autoimmune disease is present in up to 30% - autoimmune hypothyroidism is particularly common

Treatment is disappointing and is largely limited to non-specific antitussive therapy such as dextromethorphan and drugs with weak evidence of benefit such as baclofen and nebulised local anaesthetics (lidocaine, mepivicaine)

Low dose morphine recently shown to be helpful

Cough due to other common respiratory diseases

Cough suppression undesirable in certain conditions

LRTI (acute tracheobronchitis + pneumonia)COPD

Control of sx and reduction of exacebations No studies on effectiveness of any particular treatment on

the cough itselfLung Ca

Radiotherapy Opiod and non-opiod antitussives recommended

Diffuse parenchymal lung disease Mostly breathlessness though frequently reported Limited information on treatment

Referral to cough clinic

Lack of availability of relevant diagnostic testing in 1◦ or 2◦ care

Failed trial of empirical treatment directed at asthma, GORD or rhinosinusitis

History suggestive of serious cough complication such as syncope or chest wall trauma

Patient preference

Recruitment and participation in clinical trials of antitussive therapy

References

BTS Guideline. Recommendations for the management of cough in adults. A H Morice, L McGarvey, I Pavord, on behalf of the British Thoracic Society Cough Guideline Group

Gp Practice Notebook – a UK medical reference

Cough

Thanks for listeningAny questions?