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DRY COUGHCAUSES & MANAGEMENT

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Dr Jeetam singh rajputPG Dept of Internal MedicineMLN Medical college

COUGHOne of the most common symptoms for which patients seek medical attention.

Defensive reflex that enhance the clearance of secretions and particles from the airway.

Protects the lower airways from the aspiration of foreign materials.

Coughing may be initiated either voluntarily or reflexively.

Normal frequency of coughRate of 2.5 coughs/min has been quoted for a gathering.In a healthy people the frequency of cough over a 24-h period was found to be less than 16 coughs.Bursts of 11 cough per 24 h (range 134) in children.

COUGH REFLEX

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Different Types of Cough

Duration1,2Acute 8 weeks

Nature3ProductiveWet; with sputumNonproductive Dry with no sputum

Cause4Specific Associated with specific conditionNonspecific No specific disease association

RefractoryPersists after therapy1.Irwin RS, et al. Chest. 2006;129:1 23; 2. Shields MD, et al. Thorax. 2008;63(Suppl III):iii1iii15; 3. Schoor J. S Afr Pharm J. 2012;79(6):30 33; 4. Gibson PG, et al. MJA. 2010;192:265271. 10

Recurrent cough 2 episodes/yr each lasting for >7 14 days

Different types of cough have been recognized: Based on the duration there are three types of cough: Acute cough lasts less than 3 weeks, subacute or prolonged acute cough is cough lasting for 3 to 8 weeks and chronic cough is cough lasting for more than 8 weeks in both adults and children.1,2Based on nature, cough is classified into productive cough or wet cough with sputum, and nonproductive cough or dry cough without sputum.3Based on cause, cough can be associated with a specific condition or may not show any specific disease association. 4Refractory cough is the one that persists even after therapy4Recurrent cough in children is defined as more than 2 episodes of cough per year not associated with cold and each lasting for more than 7 to 14 days.2

ReferencesIrwin RS, Baumann MH, Bolser DC, et al. Diagnosis and Management of Cough Executive Summary: ACCP Evidence-Based Clinical Practice Guidelines. Chest. 2006;129;1 23.Shields MD, Bush A, Everard ML, et al. Recommendations for the assessment and management of cough in children. Thorax. 2008;63(Suppl III):iii1iii15.Schoor J. An approach to recommending cough mixtures in the pharmacy. S Afr Pharm J. 2012;79(6):30 33.Gibson PG, Chang AB, CICADA: Cough in Children and Adults: Diagnosis and Assessment. Australian Cough Guidelines summary statement. MJA. 2010;192:265271.10

ClassificationDe Blasio et al. Cough 2011, 7:7

Classification of cough based on symptom duration issomewhat arbitrary

Acute cough (8 weeks) In a smoker raises the possibilities of asthma, COPD or bronchogenic carcinoma, Eosinophilic Bronchitis , Esophageal Disease, Post Nasal Drip , ACEI , Smoking.

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ETIOLOGY

Dry Cough- Etiology Infections:- 1) Common cold: Rhinitis, Rhinusinusitis.2) Posterior nasal discharge/drip.3)Upperairwaydisease: : Epiglotitis, Laryngitis, tracheobronchitis.4) Viral respiratory infections.5) Tuberculosis( miliary)6) Whooping cough.7) Atypical pneumonia.8) Legionnaire disease.

Etiology continueEsophageal disease:- GERD, laryngopharyngeal reflux dis, tracheoesophageal fistula. Airway hyperresponsiveness:- AsthmaChronic obstructive airway disease:- Emphysema.Irritation to airway:- Dust, smoke, powder.Malignancy:- Endobronchial growth, Mediastinal tumor.Lung parenchymal disease:- ILD, Occupational lung dis.Drug induced: ACE inhibitors, Beta blocker.

Etiology cont.Other: 1) Pleurisy. 2) Foreign body inhalation. 3) Pneumothorax. 4) Aortic aneurysm. 5) Neurogenic & Psychogenic cough.

Chronic cough is reported in nearly 10-20% of the general population.Most common causes of chronic coughAdult Cough: Epidemiology(IN INDIA)Acute cough is one of the most common presentations in general practice.PNDS: Postnasal drip syndrome; BA: Bronchial asthma; GERD: Gastro-esophageal reflux diseaseMahashur A. . Lung India. 2015;32(1):4449.Worrall G. Can Fam Physician. 2010;57:4851.Distribution of causes of acute cough among adults in typical general practice16

Acute cough is one of the most common presentations in general practice. The slide shows distribution of causes of acute cough among adults in typical general practice. Common cold is the most common cause of acute cough in clinical practice at 60% followed by acute bronchitis at 20% and asthma at 10%.1

Chronic cough is reported in nearly 1020% of the general population. Postnasal drip syndrome, bronchial asthma, and gastro-esophageal syndrome or GERD account for 67% of chronic cough. About 18% of coughs fall into the miscellaneous category or undiagnosed category. 2

ReferencesWorrall G. Acute cough in adults. Can Fam Physician. 2010;57:4851.Mahashur A. Chronic dry cough: Diagnostic and management approaches. Lung India. 2015;32(1):4449.

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Dry cough sometimes can have more than 1 cause

Smyrnios et al Arch Intern Med 1998 158:1222 3

Evaluation 0f Dry Cough A systematic, diagnostic approach has been validated in immunocompetent patients- 5 steps plan:

Step 1: Review history and examination focusing on the most common causes of cough.

Step 2: Order a CXR in all patients

Step 3: Do not order additional tests in present smokers or patients taking ACE inhibitors until the response to smoking cessation or drug discontinuation for at least 4 weeks can be assessed. - Cough due to smoking or ACE inhibitors should improve substantially or disappear during this time- frame of abstinence.

Step 4: Order additional diagnostic tests or embark on empiric treatment

Step 5: Determine the cause(s) of cough by observing which specific therapy eliminates cough If the evaluation suggests more than one possible cause, initiate treatment in the same sequence that the abnormalities were discovered Since cough can be simultaneously caused by more than one condition, do NOT stop therapy that appears to be partially successful; rather, sequentially add to it.

HistoryReasonsOnsetTo determine acute/subacute or chronic causes of coughFeverOngoing infectionSOB(shortness of breath)Respiratory distressNoisy breathingWheezing suggest asthmaLoss of appetite, loss of weight, hemoptysisSuggesting Tuberculosis, malignancyAllergy, nasal obstruction or congestion, rhinorrhoea, sneezing, facial pain, post-nasal drip or repetitive throat clearanceSuggesting RhinosinusitisAggravating factor, relieving factorCough due to GERD affected by postural changes, post mealCold induced or MDI relieved cough in asthma or COPDDyspepsia, heartburn, waterbrashGERD

History taking

Reflux: usually caused by transient relaxation of low esophageal sphincter. Thus, relaxation cough may occur after meal, during meal, supine, bending or stooping position : diminish at sleep (LOS closed) but recur on adopting an upright position : talking, laughing may precipitate reflux cough (diaphragm important component of LOS)

Dyspnoea, wheezing n chest tightness suggest asthma but can be absent in CVA-variability from day to day and nocturnal exacerbation suggestive

Pharyngeal sm: rhinosinusitis : many of these sm also occur in reflux disease. GERD may be suggested by presence of classic sm dyspepsia, heartburn, water brash

ACE-I :< 15% patient on ACE-I develop dry cough soon after commencement : usially disappear after cessation of tx but resolution may takes several months, may persists in small minority.

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HistoryReasonsMedication usedACE-inhibitorOccupationExposure to asbestos, chemical or cigarette smokeFamily historyAsthma, tuberculosis, lung cancer, cystic fibrosisSocial historyContact with PTB

Physical Examination

Physical examinationReasonsGeneral condition such as , accessory muscles usage, cyanosis, grunting, nasal flaring, clubbing, nicotine stainTo assess severity and to look for respiratory distressVital signsFever infectionTachycardia, tachypnoea respiratory distressPulsus paradoxus asthmaNasal polypsAllergy rhinitisPharynx: erythema, a cobblestone appearance of posterior pharyngeal mucosa or mucoid secretions dripping from the nasopharynxPost nasal dripChest:Hyperinflated

RecessionSilent chestCrepitations, wheezingSuggest air trapping due to chronic diseaseRespiratory distressSevere asthmaPneumonia, asthma, heart failure

Physical examinationReasonsEczema, transverse nasal crease, injected conjunctivaSigns of atopic diseaseLymphadenopathyTo suggest infection

Abnormal physical signs are rare in a chronic dry coughWheeze may be audible on examination but is usually absent in cough variant asthma

Relevance of Cough Quality Chang AB. Cough. 2005;1:7 .Chang AB, et al. MJA. 2006;184:398403.Croup, tracheomalacia, habit coughBarking or brassy cough

Classically recognizable cough PsychogenicDry honking cough disappearing when engaged in activity or during sleep

Pertussis and parapertussisParoxysmal (with/without inspiratory whoop)

Chlamydia in infantsStaccato

Plastic bronchitis/asthma (rare)Cough productive of casts

Suppurative lung diseaseChronic wet cough in mornings only

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Cough characteristics are of little diagnostic value in adults.1 However, in children , certain cough characteristics can point towards a specific etiology. Barking or brassy cough points towards croup, tracheomalacia or habit cough, dry honking cough disappearing when engaged in activity or during sleep may suggest a psychogenic origin. Paraoxysmal cough with or without inspiratory whoop may suggest a pertussis or parapertussis. Staccato in infants points towards Chlamydia and cough productive of casts can suggest plastic bronchitis or asthma. Chronic wet cough in the mornings in children suggests suppurative lung disease. 2

ReferencesChang AB. Cough: are children really different to adults? Cough. 2005;1:7 .Chang AB, Landau LI, Asperen PPV, et al. Cough in children: definitions and clinical evaluation Position statement of the Thoracic Society of Australia and New Zealand. MJA. 2006;184:398403.

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Relevance of Cough Quality SinusitisCough at the time of going to bed & after getting up in the morning

Classically recognizable cough AsthmaCough especially early in the morning (2-3 AM)

GERDCough that starts as soon as you lie down in bed

URTIHacking cough

Bacterial tracheitisBarking cough

CroupBarking seal-like cough

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GERD: Gastro-esophageal reflux disease

Cough at the time of going to bed & after getting up in the morning may suggest sinusitis and cough especially early in the early morning around 2-3 am is suggestive of asthma. Cough that starts as soon as you lie down in bed may indicate gastro-esophageal reflux disease (GERD) and hacking cough may suggest an upper respiratory tract infection (URTI). While barking cough is suggestive of croup and barking seal-like cough is suggestive of croup.

Inputs by Dr Nagaraju 26

ManagementInvestigationTreatment

InvestigationsCXR mandatory a early stage as is significant abnormality will alter the diagnostic algorithm and avoid unnecessary Ix. Spirometry: -demonstrate significant airway reversibility (asthma) -unavailable or normal and history suggestive: serial measurement of PEF (diurnal variability).Plain sinus radiography: low specificity but improves with history and findings.

Cxr mandatory a early stage as is significant abnormality will alter the diagnostic algorithm and avoid unnecessary Ix. Spirometry : before and after inhaled bronchodilator Bronchoscopy: Suspected FB, CXR showing mass, pulmonary, lobar or segmental collapse, hemoptysis, recurrent pneumonia in the same areaFibreoptic bronchoscopy biopsyHigh Resolution CT scan: lung parenchymal disease or bronchiectasis (not appreciated from hx and CXR)

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Bronchoprovocation test : - negative: rules out asthma but does not rules out steroid- responsive coughBronchoscopy: Suspected FB, CXR showing mass, pulmonary, lobar or segmental collapse, hemoptysis, recurrent pneumonia in the same areaFibreoptic bronchoscopy biopsyHigh Resolution CT scan: lung parenchymal disease or bronchiectasis (not appreciated from hx and CXR)

Treatment:

Treat the cause.Detail about some specific condition :1) Upper airway cough syndrome.2) Cough variant asthma.3) GERD.4) ACE Inhibitor induced cough.

Causes of Upper Airway Cough SyndromeDisorder FrequencySinusitis40%Perenial non allergic rhinitis37%Allergic rhinitis26%Post infectious rhinitis6%Environmental rhinitis4%Vasomotor rhinitis 2%

Upper Airway Cough SyndromeAlso called Post-nasal drip syndrome (PNDS)Common cause of cough in all age groups Second most common cause in children Most common cause in adults and the elderly

In addition to cough, UACS can also cause - Wheeze - Dyspnea

Upper Airway Cough SyndromeClues to UACS History of Need to frequently clear their throat Friend/relative notices that the patient frequently clears their throat Sensation of dripping into throat Nasal symptoms Physical Exam demonstrating Secretions in nose or oropharynx Cobblestone appearance of mucosa

Upper Airway Cough SyndromeDiagnosis of UACS as a cause of cough is established when: frequent throat clearing is elicited from the history b) cobblestoning and phlegm are present on physical examination of the posterior pharynx c) cough responds favourably to specific therapy aimed at eliminating the drip

Treatment Antibiotics sinusitisOral antihistamine/decongestant x 3 weeksIntranasal decongestant for maximum of 5 days: e.g. oxymetazoline 2 sprays each nostril bid x 3 days only

AsthmaSecond most common cause of cough in adults Clues that chronic cough is due to asthma: Episodic wheezing, dyspnea , cold or exercise induced Reversible airflow obstruction Bronchial hyperresponsiveness Confirmed by resolution of cough with asthma treatment

Cough Variant Asthma 30-60% of patients presenting with chronic cough that was due to asthma had cough as their ONLY symptomClues: - nocturnal cough, exercise induced, after allergen exposureBronchoprovocation test: positiveNegative test exclude asthma but does not rule out steroid responsive cough

ASTHMA/Cough Variant Asthma Treatment Inhaled corticosteroid ICS/LABA combination > 8 weeksLeukotrine receptor antagonist

-Confirmed by resolution of cough with asthma treatment

GERD

Suspect GERD when Symptoms of heartburn or sour taste in mouth Reflux demonstrated by 24-hour pH-impedance monitoring Barium x-ray Cough is the only symptom of GERD in 40-75% of patients with chronic dry cough due to GERD

GERDCough due to GERD occurs most commonly while patients are awake, stooping posture, meal related, and usually does not occur during the night

Diagnosis of GERD as cause of chronic cough requires resolution of cough with GERD treatment

GERD - TreatmentLife-style changesStop smoking Avoid alcohol Lose weight Elevate Head end of bedSmall meals Avoid fatty/acidic foods /low fat dietAvoid caffeine Avoid tight clothes, eating < 4 hrs pre-bed, recumbency 3 hrs post meal

TreatmentConservative measures : Antacid therapy 2 months : Proton pump inhibitor (high dose) H2 blockers less effective Motility therapy: Metoclopromide

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ACE-inhibitor therapyAngiotensin converting enzyme (ACE) inhibitors (enalapril, captopril, lisinopril, ramipril, etc.)Dry cough in 3-30% patientsBegins 1 week to 6 months after drug startedUsually resolves 1-7 days after stopping therapy, but can take 4 weeksDiagnosis is confirmed when cough disappears after drug in discontinued

Minority of patient will have persistent cough even after the medication was off43

ANTITUSSIVE

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MucolyticsBromhexine/Ambroxol:Derivatives of the alkaloid vasicine obtained from Adhantoda vasica.Potent mucolytic and mucokinetic, capable of inducing thin copious bronchial secretion.Dissolve hard phelgum/mucus plugSide effect: Rhinorrhoea, lacrymation, gastric irritation, hypersecrition.Dose: Bromhexine 8mg tab tds

Acetylcysteine:Derivatives of cysteine.Reduces/open the disulfide bridge in mucoprotein present in sputum.These drug also act as antioxidant and may therfore reduces airway inflammation.Route of administration: oral, parentral, inhalationMost effective route is inhalational.Brand name and dose: Tab mucinac 600mg tds, inj mucomix for iv use and for nebulisation.

ANTITUSSIVE :These drug act in the CNS, to raise the threshold of cough centre(main MOA ) or act peripherally in respiratory tract to reduce cough impulse.OPIOIDS:- Suppress the cough reflex by acting on the cough centre in the medulla.NON-OPIODS:- Suppress the cough reflex by numbing the stretch receptors in the respiratory tract and preventing the cough reflex from being stimulated.

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ANTITUSSIVE INDICATIONUsed to stop the cough reflex when the cough is non-productive i.e dry cough.51

ANTITUSSIVE CONTRAINDICATIONS

AsthmaCOPDHypersensitivityHead injuryPregnancy

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OPOIDS:CODEINE:An opium alkaloid: less potent than morphine.It decreases senstivity of central cough centre to peripheral stimuli and decreases mucosal secretions.Suppresses cough centre for 6 hrs.The antitussive action blocked by naloxone.Abuse liability is low but at present constipation is the chief drawback.Higher doses respiratory depression and drowsiness can occurs.53

Brand NamesCodifos,Corex ,Codokuff ,Cufex,Tossex in the form of syp.Dose: 10-30mg per dayCodeine 15 mg tablets are also available.Side EffectsShortness of breathSedationEuphoriaAllergic reactionsConstipation

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HYDROCODONE: Antitussive agent,Analgesic agentMore potent than codeine.5mg of hydrocodone is equivalent to 30 mg of codeine when administered orally.Is combined anticholinergic drug(homatropine).Side effects:Light-headedness,Sedation,Constipation

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PHOLCODEINE:Similar in efficacy as antitussive to codeine.Long acting than codeine(12hrs).Dose:10-15mg/day(syp; ethinine 5 mg/5ml)

MORPHINE:(2-4mg i.m.):It is antitussive in subanalgesic doses but is seldom used for this purpose because of high abusive potential.

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NONOPOIDS:

1.NOSCAPINE:It is a benzylisoquinoline alkaloid from plants of the Papaveraceae family.It depresses cough but has no narcotic, analgesic or dependence inducing property & equipotent to codeine.It is non-addictive and has a low side-effect incidence.Side effect: headache , nausea, it can produce bronchoconstriction.Dose: 15-30mg/day(syp- coscopin 7mg/5ml).

2.Dextromethorphan(DXM)Effective as codeine ,doesnt depress mucociliary function.Antitussive action not blocked by nalaxone.Primary metabolite is a NMDA receptor antagonist ie has a CNS depressant effect and also sigma receptor agonist.Side effect: Dizziness, nausea, drowsiness, ataxia.Dose : 10-20mg/day(Suppressa, Corex-DX, Cotuss, Action DMR tablet).

3.OXELADIN:It is asynthetic centrally acting antitussive agent devoid of opoid side effect.Dose : 15-30mg(syp- Pectamol 15mg/5ml).

4. CHLOPHEDIANOL:It is similar to oxeladin in antitussive action but has longer duration of action.Dose: 20-40mg( syp- detigon, tussigon 20mg/5ml)

AntihistaminesThe antitussive activity of antihistamines are established from clinical trials (not enough research to establish MOA)Following effect has been linked to antitussive action of Antihistamines but no research is conclusive enoughSedative (study shows non-sedating Antihistamines are not antitussive)Anticholinergic (no rank based action)histamine H1 receptor binding strength (no rank based action)Example: Chlorpheniramine(2-5mg), Diphenhydramine, Promethazine(15-20mg Phenargan5mg/ml)Second generation antihistamines are ineffective.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3131005/ 60

Bronchodilators: SalbutamolIt is short-acting 2-adrenergic receptor agonist. Constriction of bronchioles caused by allergen, asthma or exercise induced leads to coughSalbutamol dilates bronchioles thus providing reliefIt is absorbed through the lungs and administered by an inhaler. (R)/Levo-salbutamol has a 100-fold greater binding affinity than (S)/Dextro-salbutamol for the 2-adrenergic receptor.

Take Home MessageIn patients with cough and a normal CXR finding who are nonsmokers and are not receiving therapy with an ACE inhibitor, the diagnostic approach should focus on the detection and treatment of UACS (formerly calledPNDS), asthma, GERD, alone or in combination. This approach is most likely to result in a high rate of success in achieving cough resolution.

THANK YOU

1.Most common cause of dry cough isLaryngo-tracheo-bronchitisILDAtypical pneumoniaBronchial asthma

2. Aspirin sensitive asthma associated with which of the following:ObesityUrticariaNasal polypExtrinsic asthma

ANS is CFeatures of intrinsic asthmaNegative f/h of allergyNegative skin test to common inhalant allergensNormal serum conc. of IgE.Concommitant nasal polypSenstivity to aspirin and related chemicalsLater onset of disease

3. Investigation of choice for GERDBa swallowEndoscopy and duodenal biopsy24 hrs Ph monitoring in esophagusUrea breath test

4. Most common cause upper airway cough syndromeAllergic rhinitisPostinfectious rhinitisPerenial nonallergic rhinitisVasomotor rhinitis

5. Safest antitussive agent during pregnancyCodeinePholcodeine2nd generation antihistaminicChlorpheniramine

6.True about Globus hystericus It is a hysterical aphoniaIt is a sensation of lump in throat.It is a sensation of lump in abdomenIt is abnormal sensation of large tongue

7. DOC for acute opoid poisoningNaltrexone NalaxoneAcamprosateNalmefene

8. Tolerance develop to all of the following action of opoid exceptAnalgesiaEuphoriaNausea & vomitingConstipation

9) Which of the following antitussive devoid of constipation side effectCodeineDextromethorphanNoscapinePholcodeine

10) Which of the following cranial nerve does not take part in cough reflexVagusGlossopharyngealPhrenic nerveNone of the above