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Chronic Cough. Barbara A. Cockrill, MD Massachusetts General Hospital Harvard Medical School. Cough. Vital protective mechanism Four steps: inspiratory gasp Valsalva maneuver expiratory blast as cords abduct post-tussive prolonged inspiration. Chronic Cough. Common things are common

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chronic cough

Chronic Cough

Barbara A. Cockrill, MD

Massachusetts General Hospital

Harvard Medical School

  • Vital protective mechanism
  • Four steps:
    • inspiratory gasp
    • Valsalva maneuver
    • expiratory blast as cords abduct
    • post-tussive prolonged inspiration
chronic cough3
Chronic Cough
  • Common things are common
  • Patients who do not respond frequently have more than one cause
  • GERD causes cough.
  • Post-infectious cough is common
causes of cough
Causes of Cough

ACCP Chest 2006

Irwin 1990

number of causes of cough
Number of causes of cough

Patients %

Number of Causes of Cough

Smyrnios et al Arch Intern Med 1998 158:1222

chronic cough d a
Chronic Cough: D.A.
  • 55 yo school secretary
  • C/O cough for 3 years
  • Non-smoker
  • Cough:
    • Often productive, wax/wane
    • Better c abx, but comes back
    • “no better” with asthma meds
    • worst in AM
chronic cough d a7
Chronic Cough: D.A.
  • Nasal voice, afebrile, looks well
  • Mild “cobblestoning”
  • No facial tenderness
  • normal heart and lungs
  • normal spirometry
chronic sinusitis
Chronic Sinusitis
  • Often paucity of symptoms
  • Often improvement with antibiotics
  • Dx: Clinical & Sinus CT scan
chronic sinusitis10
Chronic Sinusitis
  • Evaluation
    • Allergies
    • Immunological
  • Rx:
      • Prolonged antibiotics (3-6 weeks)
      • Immunotherapy
      • Topical steroids
      • antihistamine/decongestants
      • Sinus irrigation
      • Consider surgical evaluation
chronic cough the computer programmer
Chronic Cough: The Computer Programmer
  • 35 yo woman
  • Yearly cough
    • starts only after a “cold” in fall or winter,lasts until mid-summer
    • Severe coughing FITS
    • goes away by itself
    • has happened last 4 years.
  • Tried “everything”
chronic cough the computer programmer13
Chronic Cough: The Computer Programmer
  • Denies: wheezes, PND sx, allergies

heartburn, aspiration

  • No: pets, exposures, current meds
  • Family hx negative
  • PMH: negative
  • Physical exam and CXR normal
  • Normal spirometry, no bronchdilator effect
  • “I can’t take it any longer!”
cough variant asthma
Cough Variant Asthma
  • Cough is sole symptom
  • Spirometry is normal
  • Up to 25% of asthmatics
  • Diagnosis:
    • Positive methacholine challenge
    • Response to therapy
  • Mechanism
non asthmatic eosinophilic bronchitis
Non-asthmatic Eosinophilic Bronchitis
  • Eosinophilic airway inflammation WITHOUT variable airflow obstruction
  • Responds to inhaled corticosteroids
  • Dx =
    • sputum or BAL eosinphilia
    • Lack of variable airflow obstuction
    • Response to corticosteroids

Asthma vs. NAEB:

Different localization

Mast cells

Brightling et. Al. NEJM 2002;346:1699

chronic cough the computer programmer18
Chronic Cough: The Computer Programmer
  • Aggressive asthma regimen x 4 weeks
  • “I am only one iota better.......”
  • NOW WHAT?!
esophageal tracheobronchial cough reflex gerd
Esophageal-tracheobronchial cough reflex & GERD
  • 22 pts with reflux & cough, 12 controls
  • Instilled acid into distal esophagus
  • Looked at effects of
    • Esophageal lidocaine
    • Esophageal ipratropium
    • Inhaled ipratropium

Ing et al 1994


Cough blocked by esophageal lidocaine,

not by esophageal ipratroprium


Cough blocked by esophageal lidocaine,

not by esophageal ipratroprium

Instillation of lidocaine before instillation of HCl

Ing 1994

cough and reflux
Cough and Reflux


GERD causes cough

& lowers cough threshold

  • abdominal


Ý Reflux

lifestyle changes for gerd
Stop smoking

Avoid alcohol

Lose weight

Elevate HOB

Small meals

Avoid fatty/acidic foods

High protein/low fat diet

Avoid caffeine


tight clothes

eating < 4 hrs pre-bed

Recumbency 3 hrs post

Lifestyle Changes for GERD
medications that les tone


Alpha-adrenergic antagonists

Beta-adrenergic antagonists

Calcium channel blockers


Medications that  LES tone
cough gerd treatment
Cough & GERD: treatment
  • Conservative measures
  • Antacid therapy:
    • Proton pump inhibitor (high dose)
    • H2 blockers less effective
  • Motility therapy:
    • Metoclopromide (Cisapride)
  • Surgery is last resort
cough gerd
Cough & GERD
  • May be silent (up to 75%)
  • May complicate other causes
  • Diagnosis can be difficult
    • pH probe vs. therapeutic trial
  • Treatment must be aggressive
  • Bland reflux can still cause cough
  • Surgery effective in some patients
chronic cough j b
Chronic cough: J.B.
  • 46 yo woman
  • Secretary in College Infirmary
  • 3 wks severe cough
  • Followed mild “cold”
  • Cannot talk, sleep
  • Cough comes in “fits”
  • Otherwise very healthy
The Boston Globe

Friday, June 8, 2007

Cape hospital hunts for whooping cough exposure

By Stephen Smith, Globe staff

Cape Cod Hospital embarked on a massive hunt to track down about 1,000 patients, relatives, and staff members who might have been exposed to whooping cough by workers in a cancer clinic.

b pertussis the hundred day cough
B. pertussis“The hundred Day Cough”
  • Bordatella pertussis, parapertussis
  • Immunity wanes 12 yrs after vaccine
  • Phases:
    • catarrhal, paroxysmal, convalescent
  • Abx ß infectivity, no effect on cough
  • Prophylaxis
why diagnose pertussis
Why diagnose pertussis?
  • Treatment:
    • does notß paroxysmal phase
    • does ß infectivity
  • Prophylaxis
  • To reassure patient
  • Minimize further work-up
new cdc guideline dec 2006
New CDC Guideline Dec. 2006
  • All adults should receive Tdap x 1
    • Tetanus
    • Diphtheria
    • Pertussis
post infectious cough vagal neuropathy
Post-infectious cough:Vagal neuropathy??

Jeyakumar et. al. Laryngoscope 116: 2108, 2006

chronic cough conclusions
Chronic Cough: Conclusions
  • Common things are STILL common
  • Many patients have > 1 cause
  • Most patients respond to therapy