THE OTOLARYNGOLOGIST AND CHRONIC COUGH
Joshua Schindler, MD
Medical DirectorNorthwest Clinic for Voice and Swallowing
Assistant ProfessorDepartment of Otolaryngology
Oregon Health & Science University
SCOPE OF THE PROBLEM
Estimated 28 million outpatient visits annually (2002)
- Most common condition for which patients seek medical treatment
CDC: National Ambulatory Medical Care Survey: 2002 Summary (2004)
US Retail sales of OTC medications was $15.1 billion in 2004 (excluding Wal-
Mart)- $3.6 billion in cough and cold medication
Consumer Health Care Products Assn (2004)
SCOPE OF THE PROBLEM
CDC: National Ambulatory Medical Care Survey: 2002 Summary (2004)
WHY WE COUGH
Adaptive- Defensive mechanism
• Protection from aspiration• Clearance of particulate debris
Maladaptive- Upper Airway Digestive Tract (UADT)
irritation• Inflammation• Hyperreflexia
- Habit?
COMPLICATED WEB
TARGETS FOR COUGH MANAGEMENT
OTOLARYNGOLOGY EVALUATION AND MANAGEMENT OF CHRONIC COUGH
DEFINITIONS OF COUGH
Acute Cough< 3weeks
Subacute Cough3 – 8 weeks
Chronic Cough> 8 weeks
NOMENCLATUREPost Nasal Drip Syndrome (PNDS)
= Upper Airway Cough Syndrome (UACS)
Idiopathic Cough= Unexplained Cough
Gastroesophageal reflux disease (GERD)= Reflux disease
Laryngopharyngeal reflux (LPR)
VANILLOID RECEPTORS IN CHRONIC COUGH
Groneberg, DA, et al.; Am J Respir Crit Care Med (2004); 170: 1276-1280
Control Chronic Cough
Laryngeal Epithelium Laryngeal Epithelium
COUGH FREEBIES• Smoking• ACE (angiotensin converting enzyme)
inhibitor therapy for hypertension- Incidence 5 - 35%- Timing: hours - months after 1st dose- Resolution with cessation:
• Typical 1 - 4 weeks• Range to 3 months
“In a patient with chronic cough, ACE inhibitors should be considered as wholly or
partially causative, regardless of the temporal relation between initiation of ACE inhibitor therapy and the start of cough.”
Dicpinigaitis, PV. Chest. 2006. 129(1), 169S-173S
“THE TRIFECTA”
• Asthma
• UACS (PND)
• GERD
These 3 causes are said to cause 90% of all chronic cough
Diagnosis and Management of Cough Executive Summary. Chest. 2006, 129(1) suppl.
ALGORITHM FOR MANAGEMENT OF CHRONIC COUGH
COUGH AND ASTHMA
Roughly 30% of all cough
Pavord, ID. Pulm Pharm Ther. 2004, 17, 399-402
Distinguished by treatment
Several variants:
– Classical asthma– Cough-variant– Eosinophilic
bronchitis– Atopic cough
COUGH AND ASTHMA
Pavord, I.D. Pulm Pharm Ther. 2004, 17, 399-402.
Airway Hyper –
Responsiveness
Eosinophilic Airway
Inflammation
BAL Eosinophili
a
Response to Bronchodilat
or
Response to Inhaled Steroids
Atopy
Classical Asthma + + / - + + + + / -
Cough Variant Asthma + + / - + + + + / -
Eosinophilic
Bronchitis - + + - + + / -
Atopic Cough - + / - - - + +
COUGH AND ASTHMAEvaluation
- CXR- Spirometry +/- bronchodilator- Methacholine challenge- Allergy testing
Management- Bronchodilator / inhaled steroid/ leukotriene
inhibitor therapy- Antihistamine / desensitization
UACS (PND) AND COUGH
- Sensation something running down the back of the throat
- Poor definition of syndrome• Usually no physical
findings
What is post nasal drip?
UACS (PND) AND COUGH
What is post nasal drip?- 2 liters secretions/day
• 500 cc nasal secretions- Ability to localize
symptoms to OP/NP is poor• Throat clearing• Globus sensation
- Association with cough is 8 - 56%
UACS (PND) AND COUGHUACS is a US
perceptionProctor & Gamble:
• US telephone interviews (892)
50% in US suffer from “PND”• UK telephone interviews
(1000) < 25% in UK suffer from “PND”
Difference felt to be labeling /marketing
UACS (PND) AND COUGH
“In patients with chronic cough, the diagnosis of upper airway cough syndrome should be determined by considering a combination of
criteria, including symptoms, physical examination findings, radiographic findings,
and, ultimately, the response to specific therapy. Because it is a syndrome, no
pathognomonic findings exist.”
Diagnosis and Management of Cough Executive Summary. Chest. 2006, 129, 1 suppl.
GERD AND COUGH
GERD- Prevalence as cause of cough 5 - 41%
• Trend toward increasing association- Common GI symptoms
• Heartburn• Regurgitation• Dysphagia
- Wide spectrum of clinical manifestations• ? Distal acid exposure can cause cough
Ing, A. Am J Respir Crit Care Med. 1994, 149, 160-7.
GERD vs. LPR
Koufman 1991 – “reflux laryngitis” and “laryngopharyngeal reflux”
Belafsky, PC, et al. Laryngoscope, 2001, 111, 1313-317
PROFILE OF GERD / LPR
•Chronic cough•Not exposed to chemical irritants• No ACE-I use• Normal chest radiograph• Failure of asthma therapy / Normal methacholine • Failure of antihistamine• Normal / stable sinus imaging• No eosinophilia of induced sputum / failure to respond to inhaled corticosteroids
Irwin, R.S. Chest. 2006, 129(1), 80S-94S.
American College of Chest Physicians CPG
LPR EVALUATION AND MANAGEMENT• Empiric treatment before testing
- Omeprazole (Prilosec) 40 mg BID or equivalent- Treatment should continue for 3-6 months- No benefit expected for 3 months- Revisit diagnosis if no improvement at 6 months
LPR EVALUATION AND MANAGEMENT• Empiric treatment before testing
- Omeprazole 40 mg BID or equivalent- Treatment should continue for 3-6 months- No benefit expected for 3 months- Revisit diagnosis if no improvement at 6 months
• Esophagoscopy can be normal• 24-hour pH probe is “gold standard”
- Conventional indices (DeMeester score)- Reflux induced coughs
• Barium esophagography or impedance testing for non-acid reflux determination
• Oropharyngeal acid studies
PROBLEMS WITH LPR / GERD DIAGNOSIS• Definitions are unclear• Symptoms are poorly defined• Physical findings are vague• Poor “gold standard”• Poor correlation with histologic
findings• High treatment failure rate• Remarkably poor studies
LPR EVALUATION
• Oropharyngeal pH montoring- Restech probe- Volatile acid- 24-48
monitoring
OROPHARYNGEAL PH PROBE
SENSORY NEUROPAHYLee & Woo (2005)
- 28 patients “cryptogenic” cough- Average duration of cough = 7 mo (range 2 wk –
20 yr)- 2/3 had “previous work-up”- 20/28 felt to have RLN/SLN neuropathy
Lee, B.; Woo, P. Ann Otol Rhinol Laryngol. 2005, 114, 253-257.
SENSORY NEUROPAHY
“Cryptogenic Cough” Lee & Woo (2005)- Treated with gabapentin (Neurontin)
• Started 100 mg/qd– increased to ~900 mg/qd• Dose titrated to effect/side effects
- Results:• 68% overall improvement• 80% of those with L-EMG neuropathy
Lee, B.; Woo, P. Ann Otol Rhinol Laryngol. 2005, 114, 253-257
BEHAVIOR MODIFICATION• Cortical control is evident
- Voluntary cough- Placebo-mediated cough suppression
Eccles R; Pulm Pharmacol Ther. 2002, 15, 303 – 8.
BEHAVIOR MODIFICATION
• Cortical control is evident- Voluntary cough- Placebo-mediated cough suppression- Cough depressed / absent in:
• Coma• Left cortical stroke• Sleep / anesthesia
• Cough Suppression- Capsaicin-induced cough can be
suppressed in humans
Hutchings, et al. Respir Med. 1993, 87, 379 - 382.
UNCOMMON CAUSES OF COUGH
Wegner’s Granulomatosis
Pulmonary Disorders:TracheobronchomalaciaAirway stenosis / stricturesTracheobronchopathia osteoplasticaMounier-Kuhn Syndrome
(Tracheobronchomegaly)Tracheobroncial amyloidosisAirway foreign bodiesBroncholithiasisLymphangioleiomyomatosisPulmonary Langerhans cell histiocytosisPulmonary alveolar proteinosisPulmonary alveolar microlithiasisHigh AltitudeTonsillar hypertrophyMediastinal massesPulmonary edemaPulmonary embolismOthers (vocal cord dysfunction,
surgical sutures in airway)Nonpulmonary Disorders:
Connective tissue disordersVasculitides (WG, GCA and RPC)Esophageal disorders (tracheoesophageal and
bronchoesophageal fistula)Inflammatory bowel diseases (Crohn disease and
ulcerative colitis)Thyroid disorders (goiter, thyroiditis)Others (Tourette Syndrome)
OHSU AND CHRONIC COUGH
• Retrospective chart review• 132 patients (2005-2010)
- Cough greater than 10 weeks- Evaluate work up and interventions- Response to therapy
• None• Partial response (therapy continued)• Complete response (>85% improved by report)
OHSU AND CHRONIC COUGH
DIAGNOSIS AND CHRONIC COUGH
LUNG SOURCES AND CHRONIC COUGH
GI PROBLEMS AND CHRONIC COUGH
UACS AND CHRONIC COUGH
LARYNX AND CHRONIC COUGH
NERVOUS SYSTEM AND CHRONIC COUGH
OTHER DIAGNOSES AND CHRONIC COUGH
MANAGEMENT OF CHRONIC COUGH
Patients with:Favorable response to Rx 77%
Partial Response to Rx 31%Complete Response to Rx 46%
CAUSE-DIRECTED THERAPIES
Selection bias likely a strong contributor to results
CAUSE-INDEPENDENT THERAPIES
Selection bias likely a strong contributor to results
CHRONIC COUGH ALGORITHM
TAKE HOME POINTS
• The causes of cough are as myriad as the nerves that meditate them
• Asthma and atopic/eosinophilic bronchitis probably account for the majority of chronic cough
• Post-nasal drip / UACS is probably “Voodoo”
• GERD / LPR is difficult to diagnose and expensive to treat
• An otolaryngologist may be helpful in evaluating and managing chronic cough
KNOWLEDGE PEARLS
• Chronic cough is almost always multifactorial- Listen to patient’s symptoms
• Optimize therapy and testing for each suspected diagnosis– use high yield definitive studies
• Eliminate OTC medications / cough drops• Patience is critical• Behavioral cough suppression can be
tremendously useful