Clinical Practice Guideline on Chronic Cough

8/3/2019 Clinical Practice Guideline on Chronic Cough

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Clinical Practice Guideline on

CHRONIC COUGH

Ma. Quinna B. Boyles



COUGH

Is an explosive expiration that provides a

normal protective mechanism for clearing

the tracheobronchial tree of secretions

and foreign materials.



MECHANISM

Coughing

Intiated either voluntary or reflexively by both

Efferent and afferent pathways

Start with a deep inspiration, glottic closure,

relaxation diaphragm

Marked positive intrathoracic

pressure

Glottis open, there is a

rapid flow rates

Shearing force develop



• one of the most common complaints for w/c the

patient seek medical attention.

• Important factor in the spreading of infection, a

symptoms of underlying dse or a distressing

problem itself.



2 Categories

• 1. ACUTE – lasting less than 3 wks.

• 2. CHONIC – lasting 3 wks or more.



• Proper management is to identify the underlyingdisorder.

• Thorough history and physical examination to helpdetermine the most likely etiology.

Include:

Neonatal History

Feeding History

History of Foreign body aspiration

Family History of TB

Immunization Status (BCG, DPT)

Medication given, noting the dosage, durationof treatment, degree of compliance and

response.



Diagnostic Algorithm for

Chronic Cough

No

No

Yes

No

Chronic cough

(>3 wks)

Do Hx and PE

Signs and sx suggestive of

Pulmonary problems

Signs and sx

Suggestive of

PND

Signs and sx

Suggestive of

GERD

Request chest

X-ray

Is the chest x-ray

Normal?

Pneumonia,TB,CHF,

Bronchiectasis,

Recurrent Aspiration,

Foreign Body



Clinical Issues

1. Is the chest x-ray normal?

• If normal further work up for

possible etiology.• In children, asthma, PNDS and

GERD are the most common cause

of chronic cough.

• Two local studies showed that

asthma and PNDS from sinusitis or

allergic rhinitis were common

etiology of chronic cough



• In foreign studies, aberrant

innominate artery, GERD, and cough-variant asathma were common in

children 0-18 months old, sinusitis

and cva in 1.5 -6years old, and cva,

psychogenic cough and sinusitis inchildren 6 yrs – 16 yrs



Wheezing, or

Chest tightness

Breathlessness

Gurgly chest

Possible

asthma

Ass’d w/ any or all of the ff?

Exercise, nocturnal occurrence

Episodic/seasonal occurrence

Personal or family history of

Atopy, recognizable triggers

Expiratory

Stridor?

Consider

Other

Diagnosis

Probable

asthma

Peak flowMeter

Available/

Feasible?

Normal or

Dec. predicted values

w/ >20% inc

w/ inhaled SA B 2?

Refer to

Specialist for

Confirmatory

Test

TherapeuticTrial

Therapeutic trials w/

Inhaled/oral SA B 2 or

Inhaled/oral SA B 2 and

5 days oral steroids

Patient

Respond?

Treatasthma

Consider

Other

Diagnosis

No n

o

No

yes

N

o

n

o

Y

e

s



Clinical Issue

2. Is wheezing present?

• Asthma is the most common cause of

persistent cough in children.

• In one study, it turned out that the mostcommon cause of chronic cough on

children was cough – variant asthma, where

it presented w/ persistent cough but

without wheezing.

• 75%w/ chronic cough has c-v-asthma and

54% of these will develop into classical

asthma



Associated with trigger factor

• exercise

• Nocturnal occurence

• Seasonal and episodic attacts

• Personal and family hx of asthma

PROBABLE DIAGNOSIS OF ASTHMA



Is peak flow meter available and

feasible?

• Referral to an asthma specialist is

imperative in the ff. situations:

diagnosis of asthma needs to be confirmed

by spirometry

Peak flow measurements are normal in an

asthma suspect(>80%)

Peak flow measurements are below normal

and responds to B2 agonist is equivocal

(>20% inc. after B2 agonist)

There is poor response to therapeutic trial



SPIROMETRY

• Initial test for asthma suspects

• Is usually feasible in children from 5yrs old



PEAK FLOW METER

• Measure peak expiratory flow rate (PEFR)

which correlate well with FEV1 and offer

an acceptable alternative to assess

response to exercise challenge and peak

flow variability.

• The predictive normal PEFR for FilipinoChildren bet. 6 -17 yo w/ the height of at

least 100cm can be calculated using:

Males: (Ht in cm-100) 5+175

Female: (Ht in cm-100) 5+170

• When PEFR val. is abn or <80% of

predicted, the change or inc in PEFR val. Is

observed after B2 agonist.

• An inc of 20% will support a dx of asthma.



Is the PEFR normal or below

predicted val and is there a >20%

inc. in PEFR after inhaled B2

agonist ?

• In the asthma suspected whose

baseline PEFR is normal or

whose baseline is <80% of

predicted val., a >20% inc. in

PEFR after inhaled B2 agonist

supports the diagnosis of asthma.

Th ti t i l ith



Therapeutic trial with

B2 agonist with or

without oral steroids• Peak flow meter is not available

• After administration of short

acting inhaled or nebulized B2agonist, improvement of

expiratory airflow and relief of

the sx seen w/n 5 min andpeaks in 60 min.

• Oral form 30 min and peaks to

2-3hrs

F th ff t



Further ff-up meets

asthma specialist

consultation criteria?• Referral must be considered

once patient is diagnosed to

have persistent asthma.• Patient was labeled to have

such if:

> than 1 attact per wk

nocturnal sx of > than twice a

month



• PEFR of < than 80% of predicted

• PEFR variability of >than 20%• FEV1 of < than 80% of predicted



Emphasize asthma education

• Aviodance of asthma triggers

• Peak flow monitoring

• Keep a diary of sx

• Proper and prompt use of

medication

• Prompt management of acute

exacerbations at home or

school

• Using asthma action plan



Treat

asthma

On further ff-up

meets criteria for

Persistent

asthma

Emphasize

Asthma

education

Refer to

Asthma Specialist

N

o

yes



Consider other

diagnosis



Expiratory

Stridor?

Pulmonary

Consult for

Bronchoscopy

Collapsed

Trachea onExpiration?

Vascular ring

tracheomalacia

Refer to

Pediatric

cardiologist

yes

no

yes



Is there expiratory stridor?

• Stridor may be produced byaspiration symdrome or by any

anatomical or dynamic problem

of the airways

• Predisposition to recurrent

respiratory infections



Tracheomalacia

• A congenital conditioncharacterized by floppiness or

weakness of the wall of the

airway, presents as expiratory

stridor

• Noise produced during

expiration because most

trachea is intrathoracically

located

• Usually resolved w/n 18-24 mos



Refer to Pediatric

Cardiologist



Post nasal

Drainage/

Nasal

Obstruction?

Presence of

Mucopurulent

discharge

Consider

sinusitis

Therapeutic

Trial of

antibiotics

Patients

Responds?

Sinusitis

Consider other

Diagnosis/

Suspect

Complication/

Comorbid

condition

Refer to

Appropriate

specialist

yes

yes

yes

no

P t l D i



Postnasal Drip

Syndrome presenting as

Chronic Cough• Most common cause of chronic

cough in adult and children

• Considered when a patientcomplain of something dripping

down their throat

• Upon PE on nasopharynx andoropharynx reveals mucoid or

mucupurulent secretions



Consider Sinusitis

• Inflammation of perinasalsinuses with concomitant

inflammation of the nasal

passages

• Causes: allergies, non-allergic

rhinitis, bacterial and viral

infections, anatomic

abnormality

• Important to diagnose bacterial

sinusitis treatment lead to rapid

recovery



Therapeutic Trials with

Antibiotics• Bacterial sinusitis most

common pathogens are S.

pneumonia , H. influenza and M. catarrhalis

• Choice of antibiotics should be

considered with these organismsusceptability



Nasal pruritus

Or sneezing

Or family hx

Consider Allergic

rhinitis

Therapeutic trial w/ antihistamines,

Steroids, decongestants singly or

In combination based on px

classification

Patient

responds?

Probable

Allergic

rhinitis

Further ff up

Meets allergy

Consultation

criteria

Consider severe

AR & other Rhinitidis

Otitis media,

adenoidal hypertropy

Refer to

Appropriate

specialist

Px family multidiscipli

Nary health care

Provider ff up

Refer to allergologistimmunologist

Consider

Non-allergic

rhinitis

Refer tootorhino-

laryngologist

no

yes

no

yes

no

yes



Consider Allergic

Rhinitis• Symptomatic disorder of the

nose induced by IgE mediated

inflammation after allergenexposure of the membrane

lining of the nose.



• Criteria:

• Positive identification of allergen

• Establishment of a causalrelationship between exposure to

the antigen and occurrence of the

symptoms

• Positive identification of

immunologic mechanism



• PE patient had:

• Facial pallor and mouth breathing

• Pale bluish gray edematous nasalmucosa

• Watery nasal secretions

• Clear to mucoid post-nasal drip• Cobblestoning of posterior

pharyngeal wall



• Classifications

• Intermittent Symptoms

• < 4 days per week or • < 4 weeks

• Persistent Symptoms

• > 4 days per week and

• > 4 weeks



• Mild

• Normal Sleep

• Normal daily activities

• Normal work and school

• No troublesome symptoms



• Moderate to Severe

• Abnormal sleep

• Impairment of daily activities• Problems caused at work

• Troublesome symptoms



Therapeutic Trial based

on Patient Classification

• Oral antihistamines – dec.

symptoms of allergy

• Nasal antihistamines – decreasecongestion but cause sedation

• Nasal corticosteroids – anti-

inflam agent w/ effects onsneezing, pruritus rhinorrhea

and nasal blockage



• Nasal Chromones – mast cell

stabilizer

• Oral decongestants andantihistamines

• Antileukotrienes – anti-inflam

acting on the lipooxygenasepathway



Consultation with an

allergist/immunologist

• Prolonged duration of rhinitis

symptoms

• Identification of allergic or other triggering factors

• Possible immunotherapy

• Patient requiring systemiccorticosteroids

• Patient quality of life is

significantly affected



Consider non-allergic

rhinitis

• Condition with prominent nasal

congestion but lacks the

criteria for diagnosis for allergicrhinitis

• Infectios rhinitis

• Idiopathic rhinitis• Food induced

• Mucosal Abnormalities



Vomiting/

Regurgitaion/

Dyspeptic sx?

Consider

GERD

Therapeutic trial

w/ H2 RA/PPI

Lifestyle/dietary

Modification

(2 wks course)

Patient

Responds?

Probable

GERD

Continue treatment

Co-manage w/

Gastroenterologist

Consider

Psychogenic

cough

Refer for

counseling

Refer to

Pediatric

Gastroenterologist

no

no

yes



Consider GERD

• 10% - 20% of patient with

chronic cough have GERD

• 40% - 50% of patient withchronic cough have a silent GER

Signs and Symptoms of



Signs and Symptoms of

GERD

• Recurrent vomiting in an infant• Recurrent vomiting with poor

weight gain

• Recurrent vomiting andirritability

• Heartburn

• Esophagitis• Dysphagia

• Recurrent pneumonia

• Upper airway symptoms



Therapeutic Trial with

Acid Suppressant

• Omeprazole



GI referral for diagnosis

and monitoring

• Endoscopy and biopsy

• Direct visualization of esophageal

mucosa and biopsy of esophagealepithelium

• 24 hr Esophageal pH monitoring

• Helps confirm presents of GERDwithout evidence of mucosal

damage on endoscopy



Psychogenic Cough

• Diagnosis of exclusion

• Manifestation of more severe

psychological problem• Relatively common in pediatric

age group

• Diagnosis 3-10% in childrenwith cough of unknown etiology

• Refer for councelling

Clinical Practice Guideline on Chronic Cough

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