Chronic Cough2.ppt
Chronic CoughA Practical ApproachDefinitionnCough lasting more than 8 weeks in a nonsmoking,immunocompetent patient who has a normal chest radiograph,is not receiving therapy with an ACE inhibitor,and has not been exposed to an environmental irritant.ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Chronic Cough Practical Consideration.CHEST 1998;1213:639-660Textbook of Respiratory Disease.Murray-Nadel.Chapter 24.Chronic CoughnFifth most common symptom for which outpatient care is sought.n24,263,000 visits in the US in 1991nPrevalence among non-smoking:14 to 23%n38%outpatient pulmonary practicenCost exceeds$1 billion dollarsACCP consensus.CHEST 1998;114:133-181Evaluation of chronic cough.UPTODATE 2005Chronic Cough Practical Consideration.CHEST 1998;1213:639-660Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284The Cough ReflexComplications nIntrathoracic pressures of up to 300mmHGnExpiratory velocity:500 miles/hrTextbook of Respiratory Disease.Murray-Nadel.Chapter 24.ACCP consensus.CHEST 1998;114:133-181ComplicationsnMost common complaints:nSomething is wrong:98%nExhaustion:57%nFeeling self-conscious:55%nInsomnia:45%nLife style change:45%nMusculoskeletal pain:45%nHoarseness:45%nUrinary incontinence:39%Textbook of Respiratory Disease.Murray-Nadel.Chapter 24.ACCP consensus.CHEST 1998;114:133-181ComplicationsnLost of consciousnessnBrady and tachyarrhytmiasnSyncopenCerebral embolismnSeizuresnStroke due to vertebral arteries dissection.Evaluation of chronic cough.UPTODATE 2005ComplicationsnGERDnSplenic rupturenInguinal hernianIncrease CPKnPulmonary&subcutaneous emphysemanPneumothoraxnLung herniationEvaluation of chronic cough.UPTODATE 2005EtiologiesnPostnasal dripnAsthmanGERDnEosinophilic bronchitisnChronic bronchitisnBronchiectasisACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Chronic Cough Practical Consideration.CHEST 1998;1213:639-660Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284EtiologiesnPostinfectious coughnBronchogenic carcinomanACE inhibitorsnVocal cord dysfunctionnSingle cause:38 to 82%nMultiple cause:18 to 62%ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Chronic Cough Practical Consideration.CHEST 1998;1213:639-660Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284Evaluation of chronic cough.UPTODATE 2005Grading of EvidencenI-Properly randomized controlled trialsnII-Well-designed control trials.No randomization.nII-2 Prospective observationalnII-3 Retrospective observationalnIII-Experts opinion,clinical experience,descriptive studiesACCP consensus.CHEST 1998;114:133-181Postnasal Drip(PNDS)nSingle most common causenPrevalence:8 to 87%nPathogenesisnMechanical stimulation of the afferent limb in the upper airwaysACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284Evaluation of chronic cough.UPTODATE 2005Postnasal DripnClinical PresentationnDripping sensationnTickle in the throatnNasal congestionnMucus in the oropharynxnCobblestone appearance of oropharynxACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284Evaluation of chronic cough.UPTODATE 2005DiagnosisnSymptoms and signs are nonspecificn4 views sinus radiographs:nTiming and use not fully definednProductive cough,purulent nasal discharge,failure of empiric therapy for chronic rhinitis.(grade II-2)nChronic cough&excess sputum production.PPV&NPV:81&95%nChronic cough only:57&100%ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284Evaluation of chronic cough.UPTODATE 2005DiagnosisnImportant information:nPreceding URTInLegal or illegal nasal drugsnEnvironmental historynResponse to specific therapy&the absence of another cause of coughACCP consensus.CHEST 1998;114:133-181Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284Evaluation of chronic cough.UPTODATE 2005TherapynAllergic Rhinitis:nEnvironmental controlnNasal steroidsnFirst line of treatmentnConsider other therapies as possible alternatives.nConsider saline sprays to facilitate cleaningnNonsedating antihistaminesnCromolyn ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Management of allergic rhinitis.Uptodate.2005TherapynNasal decongestant not recommendednLeukotriene inhibitorsnNasal congestion and LTC4 levelsnLess effective than intranasal steroidsnPatients experiencing epistaxis with nasal sprays.nAllergen immunotherapyACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Management of allergic rhinitis.Uptodate.2005TherapynPerennial Non-Allergic RhinitisnOften difficult to control with traditional therapynIntranasal steroidsnTopical antihistamines with or without oral medications.nOlder generation antihistaminesACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Evaluation of chronic cough.UPTODATE 2
