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1、Chronic CoughA Practical Approach,Miguel E Pellerano,MDPulmonary&Critical Care FellowUniversity of New Mexico,Definition,Cough lasting more than 8 weeks in a nonsmoking,immunocompetent patient who has a normal chest radiograph,is not receiving therapy with an ACE inhibitor,and has not been exposed t
2、o an environmental irritant.ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Chronic Cough Practical Consideration.CHEST 1998;1213:639-660Textbook of Respiratory Disease.Murray-Nadel.Chapter 24.,Chronic Cough,Fifth most common symptom for which outpatient care is sought.24,2
3、63,000 visits in the US in 1991Prevalence among non-smoking:14 to 23%38%outpatient pulmonary practiceCost exceeds$1 billion dollarsACCP consensus.CHEST 1998;114:133-181Evaluation of chronic cough.UPTODATE 2005Chronic Cough Practical Consideration.CHEST 1998;1213:639-660Pathogenic Triad in Chronic Co
4、ugh.CHEST 1999;116:279-284,The Cough Reflex,Complications,Intrathoracic pressures of up to 300mmHGExpiratory velocity:500 miles/hrTextbook of Respiratory Disease.Murray-Nadel.Chapter 24.ACCP consensus.CHEST 1998;114:133-181,Complications,Most common complaints:Something is wrong:98%Exhaustion:57%Fee
5、ling self-conscious:55%Insomnia:45%Life style change:45%Musculoskeletal pain:45%Hoarseness:45%Urinary incontinence:39%Textbook of Respiratory Disease.Murray-Nadel.Chapter 24.ACCP consensus.CHEST 1998;114:133-181,Complications,Lost of consciousnessBrady and tachyarrhytmiasSyncopeCerebral embolismSeiz
6、uresStroke due to vertebral arteries dissection.Evaluation of chronic cough.UPTODATE 2005,Complications,GERDSplenic ruptureInguinal herniaIncrease CPKPulmonary&subcutaneous emphysemaPneumothoraxLung herniationEvaluation of chronic cough.UPTODATE 2005,Etiologies,Postnasal dripAsthmaGERDEosinophilic b
7、ronchitisChronic bronchitisBronchiectasisACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Chronic Cough Practical Consideration.CHEST 1998;1213:639-660Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284,Etiologies,Postinfectious coughBronchogenic carcinomaACE inhibitors
8、Vocal cord dysfunctionSingle cause:38 to 82%Multiple cause:18 to 62%ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Chronic Cough Practical Consideration.CHEST 1998;1213:639-660Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284Evaluation of chronic cough.UPTODATE 2005
9、,Grading of Evidence,I-Properly randomized controlled trialsII-Well-designed control trials.No randomization.II-2 Prospective observationalII-3 Retrospective observationalIII-Experts opinion,clinical experience,descriptive studiesACCP consensus.CHEST 1998;114:133-181,Postnasal Drip(PNDS),Single most
10、 common causePrevalence:8 to 87%PathogenesisMechanical stimulation of the afferent limb in the upper airwaysACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284Evaluation of chronic cough.UPTODATE 2005,Postnasal Drip,Clini
11、cal PresentationDripping sensationTickle in the throatNasal congestionMucus in the oropharynxCobblestone appearance of oropharynxACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284Evaluation of chronic cough.UPTODATE 2005
12、,Diagnosis,Symptoms and signs are nonspecific4 views sinus radiographs:Timing and use not fully definedProductive cough,purulent nasal discharge,failure of empiric therapy for chronic rhinitis.(grade II-2)Chronic cough 116:279-284Evaluation of chronic cough.UPTODATE 2005,Diagnosis,Important informat
13、ion:Preceding URTILegal or illegal nasal drugsEnvironmental historyResponse to specific therapy 116:279-284Evaluation of chronic cough.UPTODATE 2005,Therapy,Allergic Rhinitis:Environmental controlNasal steroidsFirst line of treatmentConsider other therapies as possible alternatives.Consider saline s
14、prays to facilitate cleaningNonsedating antihistaminesCromolyn ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Management of allergic rhinitis.Uptodate.2005,Therapy,Nasal decongestant not recommendedLeukotriene inhibitorsNasal congestion and LTC4 levelsLess effective than i
15、ntranasal steroidsPatients experiencing epistaxis with nasal sprays.Allergen immunotherapyACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Management of allergic rhinitis.Uptodate.2005,Therapy,Perennial Non-Allergic RhinitisOften difficult to control with traditional therapy
16、Intranasal steroidsTopical antihistamines with or without oral medications.Older generation antihistaminesACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Evaluation of chronic cough.UPTODATE 2005,Therapy,Vasomotor RhinitisIpatropium bromideStudies are limited to few patient
17、s prospective study.SinusitisAcute:Antibiotics for 10 days intranasal steroids.Chronic:Antibiotics for 3 weeks,nasal decongestants for 3 days,oral antihistamines/decongestant.Intranasal steroids for 3 months after cough disappears.ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:55
18、3-566Management of allergic rhinitis.Uptodate.2005,Cough-Variant Asthma,Presence of cough as the only symptom of asthma in patients with demonstrable airway hyperresponsiveness.PrevalenceDifficult to estimate24 to 59%ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566The Journ
19、al of Respiratory Disease;25;310-315Which investigation are most useful in the diagnosis of chronic cough.THORAX 59;342-346,Cough-Variant Asthma,DiagnosisClinical diagnosisSuggested by the presence of:Episodic symptomsExposure to cold,dry air,fumes:PPV 56%Presence of reversibilityFalse positive in 3
20、3%PEF monitoringFamily historyBronchoprovocation testACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566The Journal of Respiratory Disease;25;310-315Which investigation are most useful in the diagnosis of chronic cough.THORAX 59;342-346,Cough-Variant Asthma,GERD,Vagally mediat
21、ed esophageal-tracheal-bronchial reflex.Pathogenesis:Transient lower esophageal sphincter relaxation(TLESR)Chronic absence of LES pressureCough:Stimulation of TLESR or swallow-induced LES relaxation.Non-acid refluxate Chronic Cough and GERD.CHEST 2003;123:679-684ACCP consensus.CHEST 1998;114:133-181
22、ERS Task Force.ERS Journal;24:553-566Which investigation are most useful in the diagnosis of chronic cough.THORAX 59;342-346,GERD,Prevalence:21%cause of chronic cough10 to 20%associated respiratory symptoms.6 to 10%prominent GI symptoms75%cough as the only manifestation805 of asthmatic with positive
23、 24hr esophageal pH monitoring.Chronic Cough and GERD.CHEST 2003;123:679-684ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Which investigation are most useful in the diagnosis of chronic cough.THORAX 59;342-346,GERD,Clinical Presentation:Macroaspiration:1 to 4 ml/Kg or 25m
24、l in adultsCough,wheeze,purulent sputum,dyspnea,chest pain,night sweats.Microapiration:10ml.GI symptoms may predate coughLaryngeal symptoms:Dysphonia,hoarseness,sore throat,vocal cord inflammation.BronchoconstrictionEsophageal dysmotility:Dysphagia,choking while eating,prominent GI symptoms.Chronic
25、Cough and GERD.CHEST 2003;123:679-684ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Which investigation are most useful in the diagnosis of chronic cough.THORAX 59;342-346,GERD,DiagnosisEmpirical antireflux therapy4 to 6 weeks of PPIs considered practical and cost effectiv
26、e.24hr esophageal monitoringTypical GI symptoms96%sensitivity and specificity(grade II-2)Cough onlyPPV 89 to 100%and NPV 100%Chronic Cough and GERD.CHEST 2003;123:679-684GERD.Experience with specific therapy and diagnosis.CHEST 2003;1123:679-684ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS
27、 Journal;24:553-566Which investigation are most useful in the diagnosis of chronic cough.THORAX 59;342-346,GERD,Therapy:Histamine type-2 blockersMost widely studiedNo longer standard of careAntireflux measures and/or prokinetic agentsResolution in 70 to 100%Mean time for recovery:161 to 179 days(gra
28、de II-2)Chronic Cough and GERD.CHEST 2003;123:679-684GERD.Experience with specific therapy and diagnosis.CHEST 2003;1123:679-684ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Which investigation are most useful in the diagnosis of chronic cough.THORAX 59;342-346,GERD,Thera
29、py:Prokinetic agentsBethanecol,cisapride and metoclopramideEsophageal motility disordersIncrease LES toneFacilitates gastric emptyingOne study found no evidence of delayed gastric emptying.Side effects:Cholinergic,bronchospasm,arrythmiaChronic Cough and GERD.CHEST 2003;123:679-684GERD.Experience wit
30、h specific therapy and diagnosis.CHEST 2003;1123:679-684ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Which investigation are most useful in the diagnosis of chronic cough.THORAX 59;342-346,GERD,Therapy:Proton pump inhibitorsBest diagnostic and therapeutic approachRespons
31、e to once a day dose in 1 to 12 weeks40mg omeprazole or 30mg lansoprazole before breakfastFailure only after 12 weeksOmeprazole 40mg bidChronic Cough and GERD.CHEST 2003;123:679-684GERD.Experience with specific therapy and diagnosis.CHEST 2003;1123:679-684ACCP consensus.CHEST 1998;114:133-181ERS Tas
32、k Force.ERS Journal;24:553-566Which investigation are most useful in the diagnosis of chronic cough.THORAX 59;342-346,GERD,Therapy:Antireflux measuresNot addressed by clinical trialsWeight reductionLow-fat dietElevation of the head of the beadNo meals or drink 3 hrs before lying downAvoid coffee,col
33、a,tea,mint,chocolate,citrus,onion,alcohol.Chronic Cough and GERD.CHEST 2003;123:679-684GERD.Experience with specific therapy and diagnosis.CHEST 2003;1123:679-684ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Which investigation are most useful in the diagnosis of chronic
34、cough.THORAX 59;342-346,GERD,TherapyAntireflux surgery:Treatment failureInadequate acid suppressionNon-acid refluxateWork up for other conditionsGI evaluationClinical improvement:45 to 84%,f/up periods of 3 to 18 months.Systematic review of 24 cases series and uncontrolled trialsImprove in asthma sy
35、mptoms and medication requirements.No pulmonary function test.ACCP consensus.CHEST 1998;114:133-181Effects of antrelux surgery in asthamatics.CHEST 1998;3:477Surgical management of GERD.UPTODATE.2005Refractory GERD.UPTODATE.2005,ACE Inhibitors,All ACEIs in clinical use(grade II-2)Frequency:0.2 to 33
36、%Not dose relatedCough is non-productive.Tickling sensation in the throatAppears within hours,weeks,monthsResolution;1 day to weeks.Median 26 days(grade I).ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Evaluation of chronic cough.UPTODATE 2005,ACE Inhibitors,ACE-Inhibitor
37、sPathogenesisUnknownBradykininSubstance PProstaglandinIncrease cough reflex sensitivityDoes not results in pulmonary dysfunctionACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Evaluation of chronic cough.UPTODATE 2005,ACE Inhibitors,DiagnosisConsidered in patients with coug
38、hConfirmed when cough disappearsAngiotensin receptors antagonistACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Evaluation of chronic cough.UPTODATE 2005,Postinfectious Cough,After a respiratory tract infection,associate with a normal chest radiograph,eventually resolves on
39、 its own.Frequency:11 to 25%C.trachomatis,mycoplasma.B.pertussiPathogenesis:Airway inflammation with or without airway hyperresponsivenessPNDSACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Evaluation of chronic cough.UPTODATE 2005,Postinfectious Cough,DiagnosisClinical and
40、 one of exclusionB.pertussiDifferent presentationSOB,tingling sensation in the throatCough;Spasmodic,absent whoopLast 4 to 6 weeksSerum acute IGA antibody ELISA Immunofluorescent visualization and/or nasopharyngeal culture.Usually negative in adults.ACCP consensus.CHEST 1998;114:133-181,Therapy,Anti
41、bioticMacrolides,doxy:Chlamydia,mycoplasma2 weeks of azithro,erythr,TMP/SMX:PertussisInhaled ipatropium(grade I)Decrease efferent limb of the cough reflexDecrease stimulation of cough receptorsPrednisone burst for 2 to 2 weeks in severe cough(grade II-3)Inhaled steroids(grade III)ACCP consensus.CHES
42、T 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Evaluation of chronic cough.UPTODATE 2005,Diagnostic Protocol,Diagnostic Protocol,Final diagnosis can be reach 90%Cost-effective7 prospective and 4 retrospective studies.Successful achieved in 84 to 98%ACCP consensus.CHEST 1998;114:133-181ERS Ta
43、sk Force.ERS Journal;24:553-566,Diagnostic Protocol,Limitation of a positive testHas not been able to consistently predict a good response to specific therapyNot diagnostic unless favorable response No systematic approach has been validated in immunocompromised patients.ACCP consensus.CHEST 1998;114
44、:133-181ERS Task Force.ERS Journal;24:553-566,Pharmacologic therapy,Antitussive therapyWhen cough performs no useful functionSpecific:Directed at the etiologySmoking in chronic bronchitisPNDS in allergic rhinitisNonspecific:Directed at the symptomUse only when specific therapy cannot be given,has no
45、t had a chance to work or will not work(grade II-2)CodeineDextromethorphanIpatropium bromideACCP consensus.CHEST 1998;114:133-181Treatment of chronic cough.UPTODATE.2005,Pharmacologic therapy,Protrussive therapyWhen cough performs a useful functionCF,post-op atelectasis,pneumonia,bronchiectasisGuaifenesinChest physiotherapyACCP consensus.CHEST 1998;114:133-181,
