Chronic Cough2.ppt

chroniccoughapracticalapproach miguelepellerano mdpulmonary criticalcarefellowuniversityofnewmexico definition coughlastingmorethan8weeksinanonsmoking immunocompetentpatientwhohasanormalchestradiograph isnotreceivingtherapywithanaceinhibitor andhasnotbeenexposedtoanenvironmentalirritant accpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566chroniccoughpracticalconsideration chest1998 1213 639 660textbookofrespiratorydisease murray nadel chapter24 chroniccough fifthmostcommonsymptomforwhichoutpatientcareissought 24 263 000visitsintheusin1991prevalenceamongnon smoking 14to23 38 outpatientpulmonarypracticecostexceeds 1billiondollarsaccpconsensus chest1998 114 133 181evaluationofchroniccough uptodate2005chroniccoughpracticalconsideration chest1998 1213 639 660pathogenictriadinchroniccough chest1999 116 279 284 thecoughreflex complications intrathoracicpressuresofupto300mmhgexpiratoryvelocity 500miles hrtextbookofrespiratorydisease murray nadel chapter24 accpconsensus chest1998 114 133 181 complications mostcommoncomplaints somethingiswrong 98 exhaustion 57 feelingself conscious 55 insomnia 45 lifestylechange 45 musculoskeletalpain 45 hoarseness 45 urinaryincontinence 39 textbookofrespiratorydisease murray nadel chapter24 accpconsensus chest1998 114 133 181 complications lostofconsciousnessbradyandtachyarrhytmiassyncopecerebralembolismseizuresstrokeduetovertebralarteriesdissection evaluationofchroniccough uptodate2005 complications gerdsplenicruptureinguinalherniaincreasecpkpulmonary subcutaneousemphysemapneumothoraxlungherniationevaluationofchroniccough uptodate2005 etiologies postnasaldripasthmagerdeosinophilicbronchitischronicbronchitisbronchiectasisaccpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566chroniccoughpracticalconsideration chest1998 1213 639 660pathogenictriadinchroniccough chest1999 116 279 284 etiologies postinfectiouscoughbronchogeniccarcinomaaceinhibitorsvocalcorddysfunctionsinglecause 38to82 multiplecause 18to62 accpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566chroniccoughpracticalconsideration chest1998 1213 639 660pathogenictriadinchroniccough chest1999 116 279 284evaluationofchroniccough uptodate2005 gradingofevidence i properlyrandomizedcontrolledtrialsii well designedcontroltrials norandomization ii 2prospectiveobservationalii 3retrospectiveobservationaliii expertsopinion clinicalexperience descriptivestudiesaccpconsensus chest1998 114 133 181 postnasaldrip pnds singlemostcommoncauseprevalence 8to87 pathogenesismechanicalstimulationoftheafferentlimbintheupperairwaysaccpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566pathogenictriadinchroniccough chest1999 116 279 284evaluationofchroniccough uptodate2005 postnasaldrip clinicalpresentationdrippingsensationtickleinthethroatnasalcongestionmucusintheoropharynxcobblestoneappearanceoforopharynxaccpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566pathogenictriadinchroniccough chest1999 116 279 284evaluationofchroniccough uptodate2005 diagnosis symptomsandsignsarenonspecific4viewssinusradiographs timingandusenotfullydefinedproductivecough purulentnasaldischarge failureofempirictherapyforchronicrhinitis gradeii 2 chroniccough116 279 284evaluationofchroniccough uptodate2005 diagnosis importantinformation precedingurtilegalorillegalnasaldrugsenvironmentalhistoryresponsetospecifictherapy116 279 284evaluationofchroniccough uptodate2005 therapy allergicrhinitis environmentalcontrolnasalsteroidsfirstlineoftreatmentconsiderothertherapiesaspossiblealternatives considersalinespraystofacilitatecleaningnonsedatingantihistaminescromolynaccpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566managementofallergicrhinitis uptodate 2005 therapy nasaldecongestantnotrecommendedleukotrieneinhibitorsnasalcongestionandltc4levelslesseffectivethanintranasalsteroidspatientsexperiencingepistaxiswithnasalsprays allergenimmunotherapyaccpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566managementofallergicrhinitis uptodate 2005 therapy perennialnon allergicrhinitisoftendifficulttocontrolwithtraditionaltherapyintranasalsteroidstopicalantihistamineswithorwithoutoralmedications oldergenerationantihistaminesaccpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566evaluationofchroniccough uptodate2005 therapy vasomotorrhinitisipatropiumbromidestudiesarelimitedtofewpatientsprospectivestudy sinusitisacute antibioticsfor10daysintranasalsteroids chronic antibioticsfor3weeks nasaldecongestantsfor3days oralantihistamines decongestant intranasalsteroidsfor3monthsaftercoughdisappears accpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566managementofallergicrhinitis uptodate 2005 cough variantasthma presenceofcoughastheonlysymptomofasthmainpatientswithdemonstrableairwayhyperresponsiveness prevalencedifficulttoestimate24to59 accpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566thejournalofrespiratorydisease 25 310 315whichinvestigationaremostusefulinthediagnosisofchroniccough thorax59 342 346 cough variantasthma diagnosisclinicaldiagnosissuggestedbythepresenceof episodicsymptomsexposuretocold dryair fumes ppv56 presenceofreversibilityfalsepositivein33 pefmonitoringfamilyhistorybronchoprovocationtestaccpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566thejournalofrespiratorydisease 25 310 315whichinvestigationaremostusefulinthediagnosisofchroniccough thorax59 342 346 cough variantasthma gerd vagallymediatedesophageal tracheal bronchialreflex pathogenesis transientloweresophagealsphincterrelaxation tlesr chronicabsenceoflespressurecough stimulationoftlesrorswallow inducedlesrelaxation non acidrefluxatechroniccoughandgerd chest2003 123 679 684accpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566whichinvestigationaremostusefulinthediagnosisofchroniccough thorax59 342 346 gerd prevalence 21 causeofchroniccough10to20 associatedrespiratorysymptoms 6to10 prominentgisymptoms75 coughastheonlymanifestation805ofasthmaticwithpositive24hresophagealphmonitoring chroniccoughandgerd chest2003 123 679 684accpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566whichinvestigationaremostusefulinthediagnosisofchroniccough thorax59 342 346 gerd clinicalpresentation macroaspiration 1to4ml kgor25mlinadultscough wheeze purulentsputum dyspnea chestpain nightsweats microapiration 10ml gisymptomsmaypredatecoughlaryngealsymptoms dysphonia hoarseness sorethroat vocalcordinflammation bronchoconstrictionesophagealdysmotility dysphagia chokingwhileeating prominentgisymptoms chroniccoughandgerd chest2003 123 679 684accpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566whichinvestigationaremostusefulinthediagnosisofchroniccough thorax59 342 346 gerd diagnosisempiricalantirefluxtherapy4to6weeksofppisconsideredpracticalandcosteffective 24hresophagealmonitoringtypicalgisymptoms96 sensitivityandspecificity gradeii 2 coughonlyppv89to100 andnpv100 chroniccoughandgerd chest2003 123 679 684gerd experiencewithspecifictherapyanddiagnosis chest2003 1123 679 684accpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566whichinvestigationaremostusefulinthediagnosisofchroniccough thorax59 342 346 gerd therapy histaminetype 2blockersmostwidelystudiednolongerstandardofcareantirefluxmeasuresand orprokineticagentsresolutionin70to100 meantimeforrecovery 161to179days gradeii 2 chroniccoughandgerd chest2003 123 679 684gerd experiencewithspecifictherapyanddiagnosis chest2003 1123 679 684accpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566whichinvestigationaremostusefulinthediagnosisofchroniccough thorax59 342 346 gerd therapy prokineticagentsbethanecol cisaprideandmetoclopramideesophagealmotilitydisordersincreaselestonefacilitatesgastricemptyingonestudyfoundnoevidenceofdelayedgastricemptying sideeffects cholinergic bronchospasm arrythmiachroniccoughandgerd chest2003 123 679 684gerd experiencewithspecifictherapyanddiagnosis chest2003 1123 679 684accpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566whichinvestigationaremostusefulinthediagnosisofchroniccough thorax59 342 346 gerd therapy protonpumpinhibitorsbestdiagnosticandtherapeuticapproachresponsetoonceadaydosein1to12weeks40mgomeprazoleor30mglansoprazolebeforebreakfastfailureonlyafter12weeksomeprazole40mgbidchroniccoughandgerd chest2003 123 679 684gerd experiencewithspecifictherapyanddiagnosis chest2003 1123 679 684accpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566whichinvestigationaremostusefulinthediagnosisofchroniccough thorax59 342 346 gerd therapy antirefluxmeasuresnotaddressedbyclinicaltrialsweightreductionlow fatdietelevationoftheheadofthebeadnomealsordrink3hrsbeforelyingdownavoidcoffee cola tea mint chocolate citrus onion alcohol chroniccoughandgerd chest2003 123 679 684gerd experiencewithspecifictherapyanddiagnosis chest2003 1123 679 684accpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566whichinvestigationaremostusefulinthediagnosisofchroniccough thorax59 342 346 gerd therapyantirefluxsurgery treatmentfailureinadequateacidsuppressionnon acidrefluxateworkupforotherconditionsgievaluationclinicalimprovement 45to84 f upperiodsof3to18months systematicreviewof24casesseriesanduncontrolledtrialsimproveinasthmasymptomsandmedicationrequirements nopulmonaryfunctiontest accpconsensus chest1998 114 133 181effectsofantreluxsurgeryinasthamatics chest1998 3 477surgicalmanagementofgerd uptodate 2005refractorygerd uptodate 2005 aceinhibitors allaceisinclinicaluse gradeii 2 frequency 0 2to33 notdoserelatedcoughisnon productive ticklingsensationinthethroatappearswithinhours weeks monthsresolution 1daytoweeks median26days gradei accpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566evaluationofchroniccough uptodate2005 aceinhibitors ace inhibitorspathogenesisunknownbradykininsubstancepprostaglandinincreasecoughreflexsensitivitydoesnotresultsinpulmonarydysfunctionaccpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566evaluationofchroniccough uptodate2005 aceinhibitors diagnosisconsideredinpatientswithcoughconfirmedwhencoughdisappearsangiotensinreceptorsantagonistaccpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566evaluationofchroniccough uptodate2005 postinfectiouscough afterarespiratorytractinfection associatewithanormalchestradiograph eventuallyresolvesonitsown frequency 11to25 c trachomatis mycoplasma b pertussipathogenesis airwayinflammationwithorwithoutairwayhyperresponsivenesspndsaccpconsensus chest1998 114 133 181erstaskforce ersjournal 24 553 566evaluationofchroniccough uptodate2005 postinfectiouscough diagnosisclinicalandoneofexclusionb pertussidifferentpresentationsob tinglingsensationinthethroatcough spasmodic absentwhooplast4to6weeksserumacuteigaantibodyelisaimmunofluorescentvisualizationand ornasopharyngealculture usuallynegativeinadults accpconsensus chest1998 114 133 181 therapy antibioticmacrolides doxy chlamydia mycoplasma2weeksofazithro erythr tmp smx pertussisinhaledipatropium gradei decreaseefferentlimbofthecoughreflexdecreasestimulationofcoughreceptorspre