Cough

• Definition of
Cough
• Impact
• Mechanism
• Approach to a
patient with
cough
• Complications
• Treatment
• Specific
What is
cough?
 What is
cough?
A forced
expulsive
maneuver,
usually against
a
closed glottis
and which is
associated with
a characteristic
 BTS Guidelines, Thorax 2006: 61 (Suppl 1):i1 –i24.
 Impact of Cough
• An important airway defense mechanism
• An explosive expiration
that provides a normal
protective mechanism
for clearing the tracheo-
bronchial tree of
secretions and foreign
material
• Coughing helps protect
the lungs against
aspiration Cough pellet

 Impact of Cough
• When excessive or bothersome, cough is
one of
the most common complaints motivating
patients to seek medical attention
throughout the world
• Heralds a disease or disorder
• Chronic cough is a common diagnostic and
therapeutic problem
 Impact of Cough
• Discomfort from the cough itself and its
complications
• Associated with a marked deterioration in
quality
of life and interference with normal lifestyle
• Psychosocial dysfunction returns to normal with
successful treatment


Chronic Cough is a
Disease
• it is inappropriate to minimize a
patient's complaint of chronic
cough and/or advise him/her to
"live with it" since chronic cough is
associated with adverse effects on
his/her quality of life and it can be
successfully treated in most
patients who adhere to treatment
Arch Intern Med. 1998;158:1657-1661 
 Magnitude of the Problem
• ? Cost of treating chronic cough
• IMS, 2004:
 Sales of expectorants P 2.5 B
 Sales of antitussives P 193.7 M
 Sales of nasal decongestants P 1.7 B
 Sales for Ascof P 38.2 M
• Population-Based Prevalence?
 Foreign studies: 3 to 40%
 Magnitude of the Problem
• 1989 Rural Survey (Victoria, Laguna): 10%
chronic bronchitis
• 1991 Urban Survey (Paco, Manila): 24.6% had
“cough which was chronic or present at time of
interview”
• 2002 3 Urban Cities, young patients: 13% had
cough persisting > 2 weeks
• Chronic cough is a common problem among
Filipinos
 Impact of Cough
• An important factor in
the
spread of infection


Mechanism
of Cough
One can voluntarily
inhibit himself from coughing.
C.True
D. False


Mechanism of Cough:
Initiation
• Voluntary
• Reflexive


 Mechanism of Cough: Reflex
Pathway
Cough phases
• Inspiratory
• Compressive
• Expulsive (Expiratory or
Explosive)- 1st cough sound heard
• Recovery


 Flow and Subglottic Pressures
During The Phases of Cough

 McCool, F. D. Chest 2006;129:48S-53S

 Which phase is not critical to
effective coughing?

C. Glottic closure
D. Compressive
E. Expiratory
McCool, F. D. Chest 2006;129:48S-53S
 Mechanism of Cough: Reflex
Pathway
Irritant Triggers
• Exogenous
Source
 Smoke, dust,
fumes, foreign
bodies
• Endogenous
Source
 upper airway
 mucus, gastric
Cough: involves a complex reflex arc
that begins with irritation of a
receptor
Afferent Limb Cough Center 
and Receptors (integrated in the 
(RARs, C fibers) Effectors
medulla oblongata)

/ Superior
Laryngeal

/ Recurrent
 Laryngeal
Approach to
the Patient
with Cough
 Duration of Cough
 Estimating the duration of cough is crucial
in
narrowing the list of etiologies
 ACCP/ ERS Consensus Guidelines (in
contrast to
Harrison’s)
• Acute Cough : < 3 weeks
• Sub-Acute Cough: lasting 3 – 8 wks
• Chronic Cough: > 8 wks

 Etiology of Cough

Any disorder
resulting in
inflammation,
constriction,
infiltration or
compression of the
upper or lower
airways and the
lung parenchyma
 Anatomic Diagnostic Protocol
• Systematic evaluation of
the afferent limb of the
cough reflex
• Detailed history to obtain
valuable clues, with
attention to associated
symptoms and includes
occupational Hx and
environmental exposure
• Thorough PE, including
ENT examination
• Targeted laboratory
examination; at least a
CXR for patients with 
 Anatomic Diagnostic Protocol
• Narrows DDX to specific
ENT, pulmonary and
extra-pulmonary causes
• Provides
recommendations for
targeted and successful
therapy
• Standard of evaluation
and management since
1981
• Adapted by ACCP
 Laboratory Work Up
of Cough

• Chest Radiograph
 Can identify the presence of chest wall,
pleural, lung parenchymal and
mediastinal lesions or abnormalities


 Chronic Cough
Nonsmoking Adults
Not on ACEI
Normal/ Near Normal CXR

Think PNDS, Asthma and/or GERD:

“The Pathogenic Triad of Chronic Cough”

Palombini, et. al., Chest 116: 279-84, 1999


 Laboratory Work Up of Cough
• Sputum Analysis
 gross and microscopic examination
 purulent: chronic bronchitis,
bronchiectasis,
pneumonia or lung abscess  do G/S,
C/S
 blood in the sputum: rule out
endobronchial
tumor
 eosinophilia: asthma or nonasthmatic
 eosinophilic bronchitis (NAEB)
 Specialized Laboratory Studies
To Work Up Cough
• Paranasal/Sinus X-Ray Series/ Screening
CT
Scan of the Sinuses
 Upper airway cough syndrome (UACS)
• 24-hour Esophageal pH monitoring
 Gastroesophageal Reflux Disease (GERD)
• Bronchoprovocation Test
 Cough-Variant Asthma
• Pulmonary Function Test/ Spirometry
 Differentiate Restrictive and Obstructive
DOs
 Detect Reversible versus Non-reversible
 Specialized Laboratory Studies
To Work Up Cough

•Fibreoptic Bronchoscopy
 Endobronchial tumors
• High-resolution CT Scan of the Chest
 Chest tumors, interstitial lung diseases
• 2-D Echocardiography with or without
Doppler
Studies
 Congestive heart failure
 Approach to Acute
Coughfirst step is to decide
• The most important
whether the acute cough is potentially a
reflection of a serious illness, or, as is usually
the case, a manifestation of a non-life-
threatening, transient condition
• Possible causes:
 URTI, including the Common Cold –
most common
 Lower respiratory tract infection/
Pneumonia
 Exacerbation of a pre-existing condition
e.g.,
COPD, bronchiectasis, allergic
 rhinitis Chest 2006; 129:222S–231S
 Approach to Sub-Acute Cough
• The first step is to determine whether or not
the
cough has followed an obvious preceding
respiratory infection
• If the subacute cough does not appear to be
postinfectious in nature, it should be
evaluated and managed as if it were a
chronic cough
• If post-infectious, consider:
 Post-Infectious Cough with BHR
 Atypical causes of RTI/ pneumonia
including
 Pertussis, PTB, atypicalChest pneumonia,
2006; 129:222S–231S.
 Chronic Cough Approach to Chronic
ACEI
Cough Stop ACEI
Cough gone

Hx / PE

Cough persists
Chest radiograph

Normal Abnormal
Abnormality
may not be Order accordingly to likely clinical
related to possibility
Avoid irritant cough Sputum cytology, HRCT scan, modified BaE,
bronchoscopy, cardiac studies

Cough gone Cough

persists
Treat accordingly
Evaluate for three most common conditions
singly in the following order, or in combination:
1. PNDS 2. Asthma 3. GERD
Cough Cough gone
persists
Cough gone Cough
persists Consider postinfectious cough

Evaluate for uncommon conditions

Sputum tests, HRCT scan, modified BaE,

bronchoscopy, cardiac studies

Cough gone Cough persists

Reconsider adequacy of treatment regimens before

considering habit or psychogenic cough
 Approach to Chronic Cough
• The starting point is the medical history,
physical examination, and CXR via the
anatomic diagnostic protocol
• Rule out ACEI-induced cough early on in the
work up
• Avoid identifiable irritants, when possible
• Evaluate and treat for the 3 most common
conditions, singly or in combination:
 Postnasal Drip Syndrome or UACS
 Cough-Variant Asthma
 GERD

 Chest 2006; 129:222S–231S.

 International Validation of
Anatomic Diagnostic Protocol

• Cause successfully determined in 88-100%

• Successful therapy in 82 to 98%
• Asthma, PNDS, GERD in 85 to 94%
• Single cause in 38-82%; 2 or more in 18-62%
• 3 Asian studies
• Validated in the Philippines at the PGH
 Identification of the Causes of
Cough > 3 Weeks in Adult Filipinos
Figure 3. Frequency Distribution of the Causes of Chronic Cough
Among the Evaluable Patients.
35.0 33.3
30.4
30.0

25.0
20.3
20.0
15.2
15.0

10.1
10.0
6.8
5.1
5.0 3.8 3.8 3.0
1.7
0.8
0.0
Asthma

PNDS

PTB
COPD/ CB

PostInfx Cough

Bronchiectasis

Pneumonia

GERD

ACEI-induced

Pulmonary CA

CHF

Others
Causes of Chronic Cough

David-Wang AS, Balgos A, Roa Jr. CC, Dantes R, et.

al.,
 Identification of the Causes of
Cough > 3 Weeks in Adult Filipinos
Figure 4. Number of Causes Identified Per Patient

80.0

67.5
70.0

60.0

50.0

%
40.0
29.5

30.0

20.0

10.0 2.5

0.0

1 2 3
Number of Causes

• Most frequent 2 combination: Asthma and PNDS in 40%

• Most frequent 3 combination: Asthma, PNDS, GERD in 33%
David-Wang AS, Balgos A, Roa Jr. CC, Dantes R, et.
al.,
 Local Modifications to
the Chronic Cough
Algorithm
Sputum AFB smears must be ordered early on
esp. if the clinical probability of PTB is high
Chest radiographs can narrow the differentia
diagnosis and thus must also be ordered
earlier whenever possible
Empiric drug therapy for asthma, PNDS and
GERD can be tried if the clinical probability is
high
Health Seeking Behavior Among
TB Symptomatics (NPS 1997)

9.6%

6.5%

49.1%

24.3%

No action taken Self-medication Gov't Centers Private MDs

Treatment
of Cough
 Treatment of Cough
• Specific Therapy
• Symptomatic or
Nonspecific Therapy


 Specific Cough Therapy
• Definitive treatment: treat the
underlying cause!
• elimination of the inciting agent,
whenever possible


 Non-Specific Cough Therapy
• when the cause is unknown or
specific Rx is not possible
• the cough performs no useful
function or causes marked discomfort


 Non-Specific Cough Therapy

1. Antitussive or Cough
Suppressant
• drugs that increase the latency or
threshold
of the cough center, e.g., codeine,
dextromethorphan
• drugs that affect the afferent limb of
the

 Non-Specific Cough Therapy

2. Protussive
• enhance cough effectiveness by
promoting the clearance of airway
secretions and loosen mucus
• indicated in cystic fibrosis,
bronchiectasis,
pneumonia and postoperative
atelectasis
• pharmacologic agents e.g., nebulized
 saline solution, erdosteine
 Non-Specific Cough
Therapy

2. Protussive
• mechanical aids- for
patients with
neuromuscular or
neurologic diseases

Cough assist machine


• 35 y.o. businessman
• Indian origin
• Non-smoker
• 3 weeks of non-productive
cough
• No other associated Sx’s
• No co-morbidities
• Nasal, posterior pharyngeal,
chest, heart and lung
examination was unremarkable.
What will be your next step for this
patient?
2. Perform a more thorough physical
exam
3. Do a CXR
4. Treat empirically for PNDS
5. Treat empirically for asthma
6. Treat empirically for GERD
Cause of cough for this patient…

• Hair in the ear canal touching the

tympanic membrane
• Cough resolved with hair plucking
 Upper Airway Cough
Syndrome
• formerly Postnasal Drip Syndrome
• related to upper airway conditions
• unclear whether cough mechanism is due to
PND, direct irritation or inflammation of
cough receptors
• includes allergic/ perennial
nonallergic/vasomotor / postinfectious/
occupational rhinitis, allergic/ bacterial
sinusitis, etc.
• nasal congestion or discharge, PND, throat
 clearing/ itchiness, facial
Chestpain,
2006;hoarseness;
129:1S–23S.
 Upper Airway Cough
Syndrome
• In patients in whom the cause of the UACS-
induced cough is apparent, specific therapy
directed at this condition should be
instituted (Grade of Recommendation: B)
• Empiric therapy for UACS should be
instituted for patients with chronic cough
prior to extensive testing (Grade of
Recommendation: B) with a first-generation
antihistamine/ decongestant (Grade of
Recommendation: C) Chest 2006; 129:1S–23S.
 Cough Variant Asthma

• Cough is the main or predominant complaint

• = Mild Persistent Asthma (GINA Guidelines)
• Empiric therapy if clinical suspicion is high
(Grade A)
• Bronchoprovocation testing if PE and
spirometry are nondiagnostic and if it is
available (Grade A)
• Inhaled steroids and inhaled bronchodilators
(Gr. A) Chest 2006; 129:1S–23S.
•1-2 weeks short course systemic steroid for
Clinical Findings Suggestive
of Cough Variant Asthma

 intermittent/ episodic
 nocturnal cough
 identifiable triggers
 family history of asthma and/or atopy
 presence of wheezing
 relief with bronchodilators
 resolves with inhaled steroids


 GERD

• Heartburn, regurgitation, ‘acidic’

taste,
dysphagia, epigastric pain,
hoarseness
• Worsens when lying supine
• Aggravated by intake of coffee/
tea, carbonated drinks, citrus fruits
• Cough may be the only
manifestation Chest 2006; 129:1S–23S.
 GERD
• Empiric therapy if clinical suspicion is high
(Grade B)
• 24-hour esophageal pH-monitoring test is the
most sensitive and specific test and should be
done if cough does not improve with medical
therapy or to assist in determining if Rx needs
to be intensified (Grade B)
• Anti-reflux therapy: proton pump inhibitors (as
1st line or if H2-blockers are ineffective),
lifestyle modification; add prokinetic therapy if
PPIs alone are ineffective (Grade B)
Chest 2006; 129:1S–23S.
 Nonasthmatic Eosinophilic
Bronchitis
(NAEB)
• Airway eosinophilia but N spirometry, no
variable airflow obstruction and no BHR
• Consider occupation-related cause
• First line drug: Inhaled steroids or short-
course oral steroids


 Post-Infectious Cough
• Cough that has been present for at least
3 weeks following symptoms of an acute
respiratory infection
• Includes post viral BHR
• Trial of inhaled ipratropium (Grade B)
• Use of Inhaled ICS if inhaled ipratropium
ineffective (Grade E/B)
• Central acting antitussives such as
codeine or dextromethorphan should be
considered when other measures fail
(Grade E/B)
 Post-Infectious Cough

• Consider other diagnoses if cough > 8

weeks
• Consider Pertussis if cough > 2 weeks, in
paroxysms, with posttussive vomiting or
inspiratory whooping (even in adults);
treat with macrolide
 ACEI-Induced Cough
• Accumulation of protussive mediators such
as bradykinins and substance P in the resp.
tract with ACEI; bradykinins stimulate
production of prostaglandins
• Dry cough, scratchy throat
• In order to determine that ACEI is the cause,
therapy should be discontinued regardless of
the temporal relaton between the onset of
cough and the initiation of ACEI (Grade B)
• Cough usually resolves within 1 to 4 weeks of
cessation, up to 3 months

 Habit or Psychogenic
Cough
• A diagnosis of exclusion
• After an extensive evaluation has been
performed
that includes ruling out tic and neurologic
disorders (e.g., Tourette syndrome) and
other uncommon causes
• Improves with specific therapy such as
behavior
modification or psychiatric therapy
