Chronic CoughChronic Cough

Barbara A. Cockrill, MDBarbara A. Cockrill, MD

Massachusetts General HospitalMassachusetts General Hospital

Harvard Medical SchoolHarvard Medical School

CoughCough

• Vital protective mechanism• Four steps:

– inspiratory gasp– Valsalva maneuver– expiratory blast as cords abduct– post-tussive prolonged inspiration

Chronic CoughChronic Cough

• Common things are commonCommon things are common• Patients who do not respond frequently have Patients who do not respond frequently have

more than one causemore than one cause• GERD causes cough.GERD causes cough.• Post-infectious cough is commonPost-infectious cough is common

Causes of Cough

41

24

5 4 521

0

20

40

60

80

100

Irwin 1990Irwin 1990

0

10

20

30

40

50

60

70

80

ACCP Chest 2006ACCP Chest 2006

Number of causes of coughNumber of causes of cough

73

7

20

0

25

50

75

100

1 2 3

Patie

nts

%Pa

tient

s %

Number of Causes of CoughNumber of Causes of Cough

Smyrnios Smyrnios et alet al Arch Intern Med 1998 158:1222 Arch Intern Med 1998 158:1222

Chronic Cough: D.A.Chronic Cough: D.A.

• 55 yo school secretary55 yo school secretary• C/O cough for 3 yearsC/O cough for 3 years• Non-smokerNon-smoker• Cough:Cough:

– Often productive, wax/waneOften productive, wax/wane– Better c abx, but comes backBetter c abx, but comes back– ““no betterno better”” with asthma meds with asthma meds– worst in AMworst in AM

Chronic Cough: D.A.Chronic Cough: D.A.

• Nasal voice, afebrile, looks wellNasal voice, afebrile, looks well• Mild Mild ““cobblestoningcobblestoning””• No facial tendernessNo facial tenderness• normal heart and lungsnormal heart and lungs• normal spirometrynormal spirometry

Chronic SinusitisChronic Sinusitis

• Often paucity of symptomsOften paucity of symptoms• Often improvement with antibioticsOften improvement with antibiotics• Dx: Clinical & Sinus CT scanDx: Clinical & Sinus CT scan

Chronic SinusitisChronic Sinusitis

• EvaluationEvaluation– AllergiesAllergies– ImmunologicalImmunological

• Rx: Rx: • Prolonged antibiotics (3-6 weeks)Prolonged antibiotics (3-6 weeks)• ImmunotherapyImmunotherapy• Topical steroidsTopical steroids• antihistamine/decongestantsantihistamine/decongestants• Sinus irrigationSinus irrigation• Consider surgical evaluationConsider surgical evaluation

Chronic Cough: Chronic Cough: The Computer ProgrammerThe Computer Programmer• 35 yo woman35 yo woman• Yearly coughYearly cough

– starts only after a starts only after a ““coldcold”” in fall or in fall or winter,lasts until mid-summerwinter,lasts until mid-summer

– Severe coughing FITSSevere coughing FITS– goes away by itselfgoes away by itself– has happened last 4 years.has happened last 4 years.

• Tried Tried ““everythingeverything””

Chronic Cough: Chronic Cough: The Computer ProgrammerThe Computer Programmer

• Denies: wheezes, PND sx, allergiesDenies: wheezes, PND sx, allergiesheartburn, aspirationheartburn, aspiration

• No: pets, exposures, current medsNo: pets, exposures, current meds• Family hx negative Family hx negative • PMH: negativePMH: negative• Physical exam and CXR normalPhysical exam and CXR normal• Normal spirometry, no bronchdilator effectNormal spirometry, no bronchdilator effect• ““I canI can’’t take it any longer!t take it any longer!””

Methacholine Challenge Testing Methacholine Challenge Testing

Cough Variant AsthmaCough Variant Asthma

• Cough is sole symptomCough is sole symptom• Spirometry is normal Spirometry is normal • Up to 25% of asthmaticsUp to 25% of asthmatics• Diagnosis:Diagnosis:

– Positive methacholine challengePositive methacholine challenge– Response to therapyResponse to therapy

• MechanismMechanism

Non-asthmatic Eosinophilic BronchitisNon-asthmatic Eosinophilic Bronchitis

• Eosinophilic airway inflammation Eosinophilic airway inflammation WITHOUT variable airflow obstructionWITHOUT variable airflow obstruction

• Responds to inhaled corticosteroidsResponds to inhaled corticosteroids• Dx = Dx =

– sputum or BAL eosinphiliasputum or BAL eosinphilia– Lack of variable airflow obstuctionLack of variable airflow obstuction– Response to corticosteroidsResponse to corticosteroids

Asthma vs. NAEB:

Different localization

Mast cells

Brightling et. Al. NEJM 2002;346:1699

Chronic Cough: Chronic Cough: The Computer ProgrammerThe Computer Programmer

• Aggressive asthma regimen x 4 weeksAggressive asthma regimen x 4 weeks• ““I am only one I am only one iotaiota better....... better.......””

• NOW WHAT?!NOW WHAT?!

Reflux EsophagitisReflux Esophagitis

Esophageal-tracheobronchial cough Esophageal-tracheobronchial cough reflex & GERDreflex & GERD

• 22 pts with reflux & 22 pts with reflux & cough, 12 controlscough, 12 controls

• Instilled acid into distal Instilled acid into distal esophagusesophagus

• Looked at effects ofLooked at effects of– Esophageal lidocaineEsophageal lidocaine– Esophageal ipratropiumEsophageal ipratropium– Inhaled ipratropiumInhaled ipratropium

Ing et al 1994Ing et al 1994

Ing 1994Ing 1994

cough in patients (p<.0001)cough in patients (p<.0001)

Cough blocked by esophageal lidocaine,

not by esophageal ipratroprium

Cough blocked by esophageal lidocaine,

not by esophageal ipratroprium

Instillation of lidocaine before instillation of HClInstillation of lidocaine before instillation of HCl

Ing 1994Ing 1994

Ing 1994

Cough was blocked by INHALED ipratropium

Ing 1994

Cough blocked by INHALED ipratropium

Cough and RefluxCough and Reflux

CoughCough

abdominalabdominal

pressurepressureRefluxReflux

GERD causes cough GERD causes cough

& lowers cough threshold& lowers cough threshold

Lifestyle Changes for GERDLifestyle Changes for GERD

• Stop smokingStop smoking• Avoid alcoholAvoid alcohol• Lose weightLose weight

• Elevate HOBElevate HOB• Small mealsSmall meals

• Avoid fatty/acidic foods Avoid fatty/acidic foods • High protein/low fat dietHigh protein/low fat diet• Avoid caffeineAvoid caffeine• AvoidAvoid

– tight clothestight clothes– eating < 4 hrs pre-bedeating < 4 hrs pre-bed– Recumbency 3 hrs post Recumbency 3 hrs post

Medications that Medications that LES tone LES tone

• TheophyllineTheophylline• ProgesteroneProgesterone• Alpha-adrenergic antagonistsAlpha-adrenergic antagonists• Beta-adrenergic antagonistsBeta-adrenergic antagonists• Calcium channel blockersCalcium channel blockers• NitratesNitrates

Cough & GERD: treatmentCough & GERD: treatment

• Conservative measuresConservative measures• Antacid therapy: Antacid therapy:

– Proton pump inhibitor (Proton pump inhibitor (high dosehigh dose))

– HH22 blockers less effective blockers less effective

• Motility therapy: Motility therapy: – Metoclopromide (Cisapride)Metoclopromide (Cisapride)

• Surgery is last resortSurgery is last resort

Cough & GERDCough & GERD

• May be May be silent (up to 75%)silent (up to 75%)• May complicate other causesMay complicate other causes• Diagnosis can be difficultDiagnosis can be difficult

– pH probe vs. therapeutic trialpH probe vs. therapeutic trial

• Treatment must be aggressiveTreatment must be aggressive• Bland reflux can still cause coughBland reflux can still cause cough• Surgery effective in some patientsSurgery effective in some patients

Chronic cough: J.B.Chronic cough: J.B.

• 46 yo woman46 yo woman• Secretary in College InfirmarySecretary in College Infirmary• 3 wks severe cough3 wks severe cough• Followed mild Followed mild ““coldcold””• Cannot talk, sleepCannot talk, sleep• Cough comes in Cough comes in ““fitsfits””• Otherwise very healthyOtherwise very healthy

“The art of medicine is amusing the patient until Nature cures the disease.”

-Voltaire

The Boston Globe Friday, June 8, 2007

Cape hospital hunts for whooping cough exposure

By Stephen Smith, Globe staffCape Cod Hospital embarked on a massive hunt to

track down about 1,000 patients, relatives, and staff members who might have been exposed to whooping cough by workers in a cancer clinic.

B. pertussis“The hundred Day Cough”

• Bordatella pertussis, parapertussis• Immunity wanes 12 yrs after vaccine• Phases:

– catarrhal, paroxysmal, convalescent

• Abx infectivity, no effect on cough• Prophylaxis

Trachea: effect of pertussisTrachea: effect of pertussis

Why diagnose pertussis?Why diagnose pertussis?

• Treatment:Treatment:– does does notnot paroxysmal phaseparoxysmal phase– does does infectivity infectivity

• ProphylaxisProphylaxis• To reassure patientTo reassure patient• Minimize further work-upMinimize further work-up

New CDC Guideline New CDC Guideline Dec. 2006Dec. 2006

• All adults should receive Tdap x 1All adults should receive Tdap x 1 •Tetanus Tetanus •DiphtheriaDiphtheria•PertussisPertussis

Post-infectious cough:Post-infectious cough:Vagal neuropathy??Vagal neuropathy??

Jeyakumar et. al. Jeyakumar et. al. LaryngoscopeLaryngoscope 116: 2108, 2006 116: 2108, 2006

Chronic Cough: ConclusionsChronic Cough: Conclusions

• Common things are Common things are STILLSTILL common common • Many patients have > 1 causeMany patients have > 1 cause• MostMost patients respond to therapy patients respond to therapy

Thank youThank you