Approach to Chronic Cough

Approach to Chronic Cough 2018-01-30T16:36:57+08:00

Differential diagnosis

  • Respiratory
    • Lung cancer
    • Asthma
    • COPD
    • Tuberculosis
    • Pulmonary fibrosis
    • Bronchiectasis
    • Pneumonia
    • Pulmonary embolism
  • Ear, nose and throat
    • Post nasal drip
    • Upper respiratory tract infection
  • Cardiac
    • Mitral stenosis
    • Congestive cardiac failure
  • Gastro-oesophageal reflux disease
  • Neurology (aspiration)
    • Myasthenia gravis
    • Myotonic dystrophy
    • Multiple system atrophy
    • Parkinson’s disease
    • Miller-Fisher syndrome
  • Malignancy
    • Mediastinal mass
    • Carcinoid syndrome
  • Drugs
    • ACE inhibitor
  • Psychogenic cough

Relevant points in the history

  • Cough
    • When did it start?
      • Acute < 3 weeks
      • Sub-acute 3-8 weeks
      • Chronic > 8 weeks
    • How often do you cough?
    • Does it come on predictably at a certain time of the day or year?
    • Does anything bring on the cough?
    • Does anything make it better?
    • Does anything make it worse?
    • Do you have phlegm with the cough?
    • What colour is the phlegm?
    • Is there ever any blood?
    • Do you have chest pain?
    • Do you feel breathless when you cough?
    • Have you noticed any other breathing noises?
    • How has this been affecting your life?
  • Respiratory
    • Lung cancer & tuberculosis
      • Do you, or have you ever smoked?
      • Have you lost any weight?
      • Do you feel like you have no appetite?
      • Have you ever coughed up blood?
      • Do you feel breathless?
      • Have you noticed any change in your voice?
      • Have you had any fever?
      • Have you noticed any sweating at night?
    • Obstructive airways disease
      • Have you ever noticed a cough at night?
      • Have you noticed that this breathlessness is brought on by specific triggers?
      • Have you ever noticed a wheezing noise when you feel breathless?
      • Do you notice that your chest feels tight?
      • Have you ever tried an inhaler?
        • What inhalers have you tried?
        • Has the dose or number of puffs changed recently?
        • How do you use the inhaler?
        • Do you take your inhaler every day as prescribed?
      • Do you have eczema?
      • Have you noticed intermittent episodes of a runny nose?
      • Does anyone in the family have eczema, asthma or a runny nose?
      • Do you keep any pets at home?
      • Do you, or have you ever smoked?
    • Pulmonary fibrosis
      • (If breathless): has your breathlessness been getting worse?
      • Occupational lung disease
        • What is your job?
        • Have you ever worked in an industry which exposed you to dusts such as asbestos?
      • Connective tissue disease
        • Have you noticed that the skin of your hands or face is unusually tight?
        • Have you noticed any rashes anywhere on your body?
        • Do you find any difficulty in swallowing?
        • Have you noticed any whitish bumps on your fingertips?
        • Do your hands go white or blue in the cold?
        • Do you have any mouth ulcers?
        • Have you noticed your hair dropping moreso than usual?
        • When you wake up in the morning, do you notice hair on your pillow?
        • Have you noticed any joint pains?
        • Do you feel stiff early in the morning?
        • Have you noticed that your eyes or mouth are unusually dry?
      • Iatrogenic
        • Do you take any medicines?
        • Have you ever had chemotherapy?
        • Have you ever taken a medicine called amiodarone, methotrexate or nitrofurantoin?
        • Have you ever received radiation to the chest?
      • Post-infectious
        • Have you ever had tuberculosis?
        • Have you had any other chest infections before?
    • Bronchiectasis / pneumonia
      • Have you had any fever?
      • Do you feel you are bringing up a lot of phlegm?
    • Pulmonary embolism
      • Do you get chest pain that gets worse when you breathe in?
      • Have you noticed that one leg has been swollen or painful?
      • Have you been on any long flights recently?
      • Have you had any recent operations?
      • Do you use the oral contraceptive pill?
      • Have you ever had a clot in your leg or your lung?
      • Have you ever been pregnant?
      • How many times have you been pregnant?
      • How many children do you have?
  • Upper respiratory tract
    • Have you had a sore or runny nose recently?
    • Do you find you need to clear your throat often?
    • Do you ever get a sensation of liquid dripping into the back of your throat?
    • Do you have problems with a runny nose?
  • Cardiac
    • Do you ever get chest pain on walking?
    • How many pillows do you sleep on at night?
    • Do you ever wake up in the middle of the night feeling breathless?
    • Have you noticed any leg swelling?
    • Have you ever noticed a red flushing in your face?
    • Have you ever had rheumatic fever?
  • Gastro-intestinal reflux disease
    • Does the cough get worse after meals?
    • Do you ever get a burning sensation in your chest?
    • Is this worse on lying down or on an empty stomach?
  • Neurological
    • Have you ever noticed your eyelids drooping?
    • Do you feel weak?
    • Do you find that your eyes get tired after reading?
    • Have you ever had double vision?
    • Does this get worse throughout the day?
    • Do you ever choke on your food?
    • Have you noticed any tingling in your hands and feet?
    • Aside from the breathlessness, have you been ill recently?
    • Have you had any diarrhoea?
  • Drugs
    • Do you take any medication?
    • Have you ever taken a medicine called an ACE inhibitor, for example enalapril?
    • Have you ever taken NSAIDs or a beta blocker (asthma triggers)?

Examination

  • General
    • Cachexia, general posture
    • Respiratory rate / signs of respiratory distress
    • Cyanosis
    • Pallor
  • Hands and wrist
    • Clubbing
    • Pulse – rate and rhythm
    • CO2 retention flap
  • Cardiovascular
    • Jugular venous pulsation
    • Apex beat – displaced suggests cardiac failure
    • Right ventricular heave (pulmonary hypertension secondary to underlying lung disease)
    • Auscultate for any murmurs (particularly MDM of mitral stenosis)
      • Re-enforcement manoeuvre for MS
    • Listen for loud P2 (pulmonary hypertension)
  • Respiratory
    • Fine end-inspiratory crepitations (pulmonary fibrosis – apical or basal)
    • Coarse crepitations (pneumonia, bronchiectasis)
    • Wheeze (obstructive airways disease)
    • Cervical lymphadenopathy (underlying malignancy)
    • Pleural effusion (malignancy)
  • Neurology
    • Ptosis
    • Proximal weakness
    • Fatigability
    • Count to 20 while looking upwards
    • Grip myotonia
    • Percussion myotonia

Investigations

  • Full blood count looking for eosinophilia
  • Renal function test if suspecting Churg-Strauss
  • Chest radiograph to look for left atrial enlargement, pneumonia, fibrotic change, bronchiectasis, pneumonia
  • Sputum culture and stain for acid-fast bacilli, together with nucleic acid amplification test
  • ECG to look for AF (associated with mitral stenosis)
  • Spirometry
    • Obstructive defect suggesting obstructive airways disease (FEV1/FVC < 0.7)
      • Methacholine challenge if normal to rule out underlying asthma
    • Restrictive defect (TLC, FVC, DLCO low, FEV1/FEV normal or high)
  • Consider oesophagogastroduodenoscopy or oesophageal manometry if trial of omeprazole fails
  • Consider HRCT for fibrosis / bronchiectasis
  • Consider CT thorax if index of suspicion for malignancy high
  • Consider trans-thoracic echocardiogram to look at mitral valve

Management

  • Patient education, multi-disciplinary team approach
  • Anti-tussives
  • Treat the underlying cause (see wheeze above)
  • RHEZ if proven TB
  • Referral to oncology if malignancy detected
  • Trial of omeprazole to see if cough improves

This Is A Custom Widget

This Sliding Bar can be switched on or off in theme options, and can take any widget you throw at it or even fill it with your custom HTML Code. Its perfect for grabbing the attention of your viewers. Choose between 1, 2, 3 or 4 columns, set the background color, widget divider color, activate transparency, a top border or fully disable it on desktop and mobile.

This Is A Custom Widget

This Sliding Bar can be switched on or off in theme options, and can take any widget you throw at it or even fill it with your custom HTML Code. Its perfect for grabbing the attention of your viewers. Choose between 1, 2, 3 or 4 columns, set the background color, widget divider color, activate transparency, a top border or fully disable it on desktop and mobile.