PROBLEMS IN ETIOLOGY AND DIAGNOSIS OF COUGH AND CHRONIC COUGH

Muhammad Fachri
FKK UMJ RSIJ Sukapura, RSIJ Pondok Kopi

Introduction

The impact of cough on health is substantial. It can : (1) be important defens mechanism that helps clear excessive secretions and foreign material from airways (2) be important factor in the spread of infection (3) present as one the common symptoms for which patient seek medical attention.
2

How Common is Cough

Cough is one of the most common complaints for which patients seek medical attention 29,5 million US population visit for cough (1998) 3,6% of all physician visit Chronic cough being reported by 340% of the population (Europe) One of most common reasons for new visit to pulmonologist and respirologists

Chronic Cough Physiology

Each cough occurs through the stimulation of a complex reflex arc. Cough receptors exist : 1. In the epithelium of the upper and lower respiratory tracts 2. Pericardium 3. Esophagus 4. Diaphragm 5. Stomach.

Chronic Cough Physiology

Mechanical cough receptors Can be stimulated by triggers such as touch or displacement. Chemical receptors Sensitive to noxious gases or fumes. Laryngeal and tracheobronchial receptors Respond to both mechanical and chemical stimuli.

Chronic Cough Physiology

An effective cough have been classified as inspiratory, compressive, and expiratory.

Cough - History

Some controversy over definitions Arguably the best

Acute Sub acute Chronic

: less than 3 weeks : 3 to 8 weeks : more than 8 weeks

ACCP Evidence-Based Clinical Practice Guidelines CHEST 2006

Etiology of Cough
I.

Common Causes a. Chronic Upper airways cough syndrome b. Cough and common cold c. Asthma d. GERD e. Bronchitis f. Bronchiectasis g. Post Infection cough h. Lung Tumors
Cough in the immunocompromised Uncommon causes Unresolved cough (Idiopathic cough)

i. Cough and aspiration

j. ACE inhibitor induced k. Psychogenic cough l. ILD m. Occupational and enviroment causes n. Tuberculosis and other infection o. Peritoneal dialysis and cough

I. II.

III.

ACCP Evidence-Based Clinical Practice Guidelines CHEST 2006

Etiology of chronic cough

Eur Respir J 2004; 24: 481-492

Etiology of Chronic Cough

The most common etiology of chronic cough are : 1. Upper airway cough syndrome (UACS) due to a variety of rhinosinus conditions 2. Asthma 3. Nonasthmatic eosinophilic bronchitis (NAEB) 4. Gastroesophageal reflux disease (GERD)
ACCP Evidence-Based Clinical Practice Guidelines CHEST 2006; 129:1S23S

ACCP Evidence-Based Clinical Practice Guidelines CHEST 2006

ACCP Evidence-Based Clinical Practice Guidelines

In patients with chronic cough and a normal chest roentgenogram finding who are nonsmokers and are not receiving therapy with an angiotensin-converting enzyme (ACE) inhibitor, the diagnostic approach should focus on the detection and treatment of UACS (formerly called PNDS), asthma, NAEB, or GERD, alone or in combination. This approach is most likely to result in a high rate of success in achieving cough resolution. (Level Evidence B)

CHEST 2006; 129:1S23S

ACCP Evidence-Based Clinical Practice Guidelines

In all patients with chronic cough, regardless of clinical signs or symptoms, because UACS (formerly called PNDS), asthma, and GERD each may present only as cough with no other associated clinical findings (ie, silent PNDS, cough variant asthma, and silent GERD), each of these diagnoses must be considered. (Level Evidence : B)
CHEST 2006; 129:1S23S

Evaluation of Chronic Cough

History
Physical
Oropharyngeal mucous or cobblestone appearance suggests postnasal-drip syndrome silent postnasal-drip syndrome

Evaluation of Chronic Cough

Heartburn and regurgitation suggest Gastroesophageal reflux disease

silentGERD in up to 75% of patients

Wheezing suggests asthma

silentasthma (cough variant asthma) in up to 57% of cases

Evaluation of Chronic Cough

Where to start
CXR: normal is consistent with PND, GERD, asthma, chronic bronchitis. Unlikely : bronchogenic carcinoma, sarcoid, TB and bronchiectasis Since PND syndromes are most common---start there

Sinusitis or rhinitis of the following varieties: nonallergic, allergic, postinfectious, vasomotor, drug-induced and environmental-irritant induced

DIAGNOSIS OF CHRONIC COUGH

DIAGNOSIS OF CHRONIC COUGH

Cough and Post Nasal Drip (UACS)

UACS (Upper Airway Cough Syndrome) Secondary to a variety of rhinosinus condition Underlying reasons for postnasal drip include allergic, perennial nonallergic, and vasomotor rhinitis; acute nasopharyngitis; and sinusitis Symptoms of postnasal drip include frequent nasal discharge, a sensation of liquid dripping into the back of the throat, and frequent throat clearing Diagnosis of UACS is determined by considering a combination of symptoms, physical finding, sinus imaging and respons to therapy

Cough and asthma

Cough and (Cough Variant) Asthma

Suggested when the patient is atopic or has a family history of asthma Cough may be seasonal, may follow an upper respiratory tract infection, or may worsen upon exposure to triggers Airways hyperreactivity can be demonstrated by bronchoprovocation testing. However, in a patient with persistent cough, the presence of reversible airflow obstruction or a positive bronchoprovocation test does not necessarily prove that the cough is secondary to asthma the best way to confirm asthma as a cause of cough is to demonstrate improvement in the cough with appropriate therapy for asthma

Chronic Cough -- GERD

Etiology
Gross aspiration including pulmonary aspiration syndromes, abscess, chronic bronchitis, bronchiectasis, and pulmonary fibrosis Laryngeal inflammation Vagally mediated distal esophageal-tracheobronchial reflex

When GERD is cause of chronic cough, up to 75% of patients have no GI symptoms

Chronic Cough -- GERD

24-h esophageal pH monitoring is best

Esophageal pH monitoring, ideally performed with event markers to allow correlation of cough with esophageal pH, is generally considered the optimal diagnostic study, with a sensitivity exceeding 90 percent

Cough and Non Asthmatic Eosinophilic Bronchitis

Chronic cough due to ACE Inhibitors

A nonproductive cough is a complication of treatment with angiotensin converting enzyme (ACE) inhibitors, Oocuring in 3 to 20 percent of patients treated with these agents Pathogenesis seems be an accumulation of inflammatory mediators: bradykinin, substance P and/or prostaglandins

Chronic cough due to ACE Inhibitors

ACE inhibitor-induced cough has the following general features usually begins within one week of instituting therapy, but the onset can be delayed up to six months It typically resolves within one to four days of discontinuing therapy, but can take up to four weeks It generally recurs with rechallenge, either with the same or a different ACE inhibitor It is generally not accompanied by airflow obstruction

DONT FORGET

Tuberculosis Bronchiectasis Chronic Bronchitis Lung tumor Occ and Env exposure ILD others

CONCLUSION

The most common etiology of chronic cough are UACS, Asthma, GERD and NAEB In patients with chronic cough and a normal chest roentgenogram finding who are nonsmokers and are not receiving therapy with an angiotensin-converting enzyme (ACE) inhibitor, the diagnostic approach should focus on the detection and treatment of UACS (formerly called PNDS), asthma, NAEB, or GERD, alone or in combination

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Cough and Non Asthmatic Eosinophilic Bronchitis

Patients with this disorder demonstrate atopic tendencies, with elevated sputum eosinophils and active airway inflammation in the absence of airway hyperresponsiveness bronchial mucosal biopsies are required to definitively diagnose eosinophilic bronchitis a trial of therapy is usually performed without biopsy, since most patients respond well to inhaled corticosteroids One year follow-up of 367 patients with normal lung function and eosinophilic inflammation noted that:

55 percent remained symptomatic with normal lung function, 32 percent were free of symptoms 13 percent developed asthma