13: 40-year-old man with a persistent cough

Question 1

Causes of Chronic Cough

Answer 1

Common causes of persistent cough include:
»upper airway cough syndrome (UACS - previously called postnasal drip)
»vocal cord dysfunction
»asthma
»gastroesophageal reflux disease (GERD)
»medications such as angiotensin-converting enzyme inhibitors (ACE-inhibitors)
»tobacco-related cough
»post-infectious cough
»chronic obstructive pulmonary disease (especially the chronic bronchitis type)
»non-asthmatic eosinophilic bronchitis.

Serious, less common causes of persistent cough include:
»pulmonary conditions such as bronchogenic carcinoma of the lung, sarcoidosis and tuberculosis.
»cardiac conditions such as congestive heart failure.

Question 2

Causes of Wheezing

Answer 2

Asthma is the most common cause of persistent cough and wheezing.

Other causes of wheezing to consider include:
Chronic obstructive pulmonary disease Congestive heart failure
Foreign body aspiration
Persistent bronchitis
Upper airway cough syndrome
Vocal cord dysfunction
PE

Question 3

Co-morbid Conditions of Asthma, Conditions that may require treatment to improve the control of asthma include:

Answer 3

gastroesophageal reflux disease (GERD) obesity or overweight
obstructive sleep apnea
rhinitis or sinusitis
stress and depression

Question 4

Symptoms of Acute Sinusitis

Answer 4

In acute sinusitis, the nasal discharge is opaque and mucopurulent, not clear. (Clear drainage may be associated with allergies).

Many viral upper respiratory infections will gradually worsen over the five days. To diagnose a patient with acute bacterial sinusitis, they should have symptoms for a minimum of seven to 10 days following a viral URI.

Nasal congestion or obstruction persisting for more than 12 weeks would be associated with chronic sinusitis, not acute sinusitis.

Question 5

Symptoms of Chronic Sinusitis

Answer 5

According to the AAO-HNS updated guidelines (2015), patients with chronic sinusitis have similar symptoms to patients with acute sinusitis, but they last at least 12 weeks. They must have two of the following symptoms:
»nasal obstruction or congestion
»mucopurulent drainage (anterior, posterior or both)
»facial pain, pressure or fullness
»decreased sense of smell

They must also have signs of inflammation on physical examination or radiological studies that will be discussed later.

However, according to the AAAAI/ACAAI Practice Parameter Update (2014), some patients with chronic sinusitis may have “subtle” symptoms such as only a mild increase in nasal congestion.

Question 6

Asthma and Aspirin

Answer 6

It is important to ask about about aspirin in particular, as 21% of adults who have asthma have aspirin-induced asthma and should avoid NSAIDs.

Question 7

Physical Exam - Persistent Cough

Answer 7

Nose examination may show swollen nasal turbinates and pallor of the nasal mucosa consistent Nose with allergic rhinitis. Clear, watery nasal drainage may also be present in patients with allergic rhinitis

Eyes
The eye examination may show signs of allergic conjunctivitis.

Ears
The examination of the ears should be performed as part of the examination of a patient with nasal symptoms, but may be normal.

Sinuses
Percussing the frontal and maxillary sinuses may be useful in assessing sinus tenderness that may indicate the possibility of an acute or chronic sinus infection.

Throat
Throat examination may reveal erythema or streaking, which may be a clue that the patient has upper airway cough syndrome.

Neck
Examining the neck for lymphadenopathy may show signs of infection.

Chest/Lungs
The lung examination may show wheezing. However, the absence of wheezing does not rule out asthma or other cardiac or pulmonary conditions. The lung examination may also show rales or other lung abnormalities that are suggestive of congestive heart failure or pneumonia.

Cardiovascular
The cardiac examination could show extra heart sounds (S3 or S4), which would suggest congestive heart failure.

Abdomen
Examination of the abdomen is unlikely to be helpful in this patient.

Extremities
In examining the extremities, one can look for clubbing, cyanosis or edema. Clubbing is not a finding in patients with asthma, but if present, may be a sign of other pulmonary or cardiac conditions. Cyanosis is unlikely to be present in patients seen in the office setting, but if present, may indicate a hypoxic pulmonary or cardiac condition. If edema is present, it may be a sign of congestive heart failure.

Skin
The skin examination may show eczema, since eczema and asthma may coincide.

Mental status
Mood and affect may help you determine if there is underlying depression.

Question 8

Establishing a Diagnosis of Asthma

Answer 8

1. Episodic symptoms of airflow obstruction or hyperresponsiveness are present.
2. This obstructive airflow is at least partially reversible.
3. Alternative diagnoses are excluded.

Question 9

Classifying Asthma Severity

Answer 9

frequency of symptoms
frequency of nighttime awakenings
frequency of short-acting beta2 agonist use for symptom control interference with normal activity
FEV1 value
FEV1/FVC ratio

Question 10

Asthma Pathophysiology and Treatment

Answer 10

Pathophysiology
Asthma is a chronic inflammatory disease of the airways that involves many cells, in particular: mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells. This chronic inflammation leads to airway hyperresponsiveness and limitation of airway flow (obstruction). The persistence of inflammation can lead to airway edema. Long-term inflammation can lead to airway remodeling and permanent loss of lung function.

Treatment
Since inflammation is the primary pathologic mechanism in asthma, maintenance medication that reduces inflammation is first-line therapy.
If a patient is acutely wheezing, he or she may need quick-acting rescue medications that focus on bronchodilation and opening up the airways.

Question 11

Long-Term Effects of Uncontrolled Asthma

Answer 11

>Airway remodelling
>Inflammation
>Mucous hypersecretion
>Airway smooth muscle hypertrophy >Angiogenesis
>Subepithelial fibrosis

The most concerning long-term effect is less reversibility of the airway obstruction with medication so it will be more difficult to control the patient’s asthma. This is why we want to treat patients early on with appropriate medication to control symptoms and prevent all of the long-term complications.

Question 12

Suspected Asthma Management

Answer 12

For patients with chronic cough thought to be due to asthma, the American College of Chest Physicians (ACCP) recommends offering an inhaled bronchodilator and an inhaled corticosteroid.

Question 13

Allergic Rhinitis Management

Answer 13

Oral antihistamine + Nasal corticosteroid

Question 14

According to the National Asthma Education and Prevention Program Expert Panel Report 3 (2007), there are four key tasks in an initial evaluation of asthma including:

Answer 14

1. Classify asthma severity.
2. Assess the patient’s knowledge and skills for self-management.
3. Identify and control environmental factors and comorbid conditions that may aggravate asthma.
4. Offer appropriate medications.

Question 15

Maintenance Medication for Moderate Persistent Asthma

Answer 15

High dose inhaled corticosteroids are reserved for severe asthma as the risk of adverse effects increase with dose. Inhaled corticosteroids are well-tolerated and safe at the recommended doses. To reduce the potential adverse effects of inhaled corticosteroids: spacers are recommended to reduce local side effects, patients are advised to rinse their mouths and spit after inhalation, and consider adding a long-acting beta agonist to a low- or medium-dose of inhaled corticosteroid rather than using a higher dose of corticosteroid.

Oral corticosteroids suppress, control, and reverse airway inflammation. However, side effects with chronic administration include among other things: osteoporosis, adrenal suppression, growth suppression, dermal thinning, hypertension, Cushing’s syndrome, cataracts, increased emotional lability, psychosis, peptic ulcer disease, atherosclerosis, aseptic necrosis of the bone, diabetes mellitus, and myopathy. Every effort, then, is given to minimizing systemic corticosteroid use and maximizing other modes of therapy. When oral corticosteroids are resorted to (for quick relief of symptoms in a moderate or severe asthma exacerbation), they are given for a short duration, and side effects are monitored. Multiple courses of oral systemic corticosteroids (more than three courses annually) should prompt re-evaluation of asthma management for the patient.

Leukotriene receptor antagonists may be used in conjunction with low-dose inhaled corticosteroids, but they are expensive. (There is a generic version of montelukast, but it can still be expensive.) A Cochrane review also revealed as additions to patients already on inhaled corticosteroids, a long-acting beta2 agonist inhaler improves symptoms and lung function, while preventing exacerbations, more effectively than leukotriene receptor antagonists. A recent study suggests the efficacy of using a leukotriene-receptor antagonist as monotherapy in the treatment of asthma, however, at this time, clinical guidelines for the management of asthma have not changed.

Theophylline may also be used in conjunction with low-dose inhaled corticosteroids, but is not used that often due to the difficulty in titrating the theophylline dose to the correct level. A meta-analysis demonstrated that salmeterol (a long-acting beta2 agonist) inhaler led to improved lung function and more symptom-free days and nights compared to theophylline.

Question 16

Environmental Modifications – Reducing Exposure to Allergens and Irritants

Answer 16

Allergens - Pets, molds, seasonal pollens.

Irritants - Environmental tobacco smoke and industrial pollutants (sulfur dioxide and ozone).

Question 17

Pharmaceutical Therapy for Allergic Rhinitis

Answer 17

Nasal corticosteroids are the most effective medications for patients with allergic rhinitis. In one systematic review, nasal corticosteroids improved symptoms of nasal blockage, nasal discharge, sneezing, nasal itch and post nasal drip compared to antihistamines.

Similarly, a Cochrane review demonstrated that allergen immunotherapy (allergy shots) assists in controlling symptoms and decreasing medication use in patients with seasonal allergic rhinitis. A third Cochrane review demonstrated that allergen immunotherapy is effective in improving asthma symptoms and decrease asthma medication usage.

Question 18

Tetanus, Diphtheria, and Acellular Pertussis (Td/Tdap) Vaccination In Adults

Answer 18

Persons aged 11 years or older who have not received Tdap vaccine or for whom vaccine status is unknown should receive a dose of Tdap followed by tetanus and diphtheria toxoids (Td) booster doses every 10 years thereafter. Tdap can be administered regardless of interval since the most recent tetanus or diphtheria-toxoid containing vaccine.

Adults with an unknown or incomplete history of completing a 3-dose primary vaccination series with Td- containing vaccines should begin or complete a primary vaccination series including a Tdap dose.

For unvaccinated adults, administer the first 2 doses at least 4 weeks apart and the third dose 6 to 12 months after the second.

For incompletely vaccinated (i.e., less than 3 doses) adults, administer remaining doses.

Question 19

Influenza Vaccination

Answer 19

Annual vaccination against influenza is recommended for all persons aged 6 months or older.

Question 20

Pneumococcal 23-Valent Pneumococcal Polysaccharide Vaccine [PPSV23] Vaccination In Adults with Chronic Disease

Answer 20

Adults aged 19 through 64 years with chronic heart disease (including congestive heart failure and cardiomyopathies, excluding hypertension), chronic lung disease (including chronic obstructive lung disease, emphysema, and asthma), chronic liver disease (including cirrhosis), alcoholism, or diabetes mellitus: Administer PPSV23.

Question 21

Treatment for Chronic Sinusitis

Answer 21

All guidelines recommend maximizing treatment for allergic rhinitis, including regular use of nasal corticosteroids and, if indicated, allergen immunotherapy.

A Cochrane review found that regular nasal saline irrigation is a useful adjunct in treating chronic sinusitis, though not as effective as nasal corticosteroids.

There is no compelling evidence to support the use of antibiotics in patients with chronic sinusitis. The AAAAI/ACAAI Practice Parameter Update (2014) indicates that antibiotics can be used for acute exacerbations of chronic sinusitis. A Cochrane review concluded that there was “limited” evidence from one small study to support the use of antibiotics in patients with chronic sinusitis. A Canadian guideline recommended antibiotics for patients with chronic sinusitis only when there is pain or purulent discharge.

Question 22

Studies to Evaluate Upper Respiratory Symptoms With New Onset Wheeze

Answer 22

Spirometry findings will help us rule in or rule out several of the diagnoses on the differential.

Tests not indicated at this time: CXR, CT scan of chest, methacholine challenge, V-Q scan

Question 23

Spirometry

Answer 23

Spirometry measures how much air the patient can inhale and exhale, as well as how fast the patient can exhale. For this test, the patient breathes into a mouthpiece attached to a recording device called a spirometer. The information collected by the spirometer will be printed out on a chart called a spirogram. The test is repeated at least three times to make sure that it is reliable. First, a baseline sample is obtained. Then, the patient is given a bronchodilator. Once this is given, the patient will perform the same tests again to provide pre- and post- bronchodilation data.

Question 24

Definition of Spirometry Terms

Answer 24

FEV1 value = Volume of air exhaled during the first second of forced exhalation following maximal inhalation.
FVC value = Maximal volume of air forcibly exhaled from the point of maximal inhalation.

Question 25

Peak Flow Requirements

Answer 25

Green
Doing well
> 80%

Yellow
Getting worse
50-79%

Red
Medical alert
< 50%

Question 26

Distinguishing Viral Rhinosinusitis From Acute Bacterial Sinusitis

Answer 26

A patient is more likely to have viral rhinosinusitis if the duration of symptoms is fewer than 10 days and the
symptoms are not worsening. In this case, you can continue to observe the patient and reassure him or her that ABX arent necessary at this time

Question 27

Differential Upper Respiratory Symptoms With New Onset Wheezing

Answer 27

Asthma with uncontrolled allergic rhinitis and possible chronic sinusitis (E) is the most likely diagnosis as the patient presents with upper respiratory symptoms and a new onset of wheezing.

Other possible, though less likely, causes of his symptoms include chronic obstructive pulmonary disease (A) , nonasthmatic eosinophilic bronchitis (B), and vocal cord dysfunction (G), since all of these conditions can cause coughing and/or wheezing.

Another possible cause is gastroesophageal reflux. Asymptomatic gastroesophageal reflux (confirmed by esophageal pH studies) can occur and can be associated with asthma.

Question 28

asthma

Answer 28

The National Asthma Education and Prevention Program Expert Panel Report 3 (2007) states that an improvement in the FEV1 value by > 12% or an increase in the percent predicted FEV1 value by 10% after a bronchodilator is given is diagnostic for asthma.

Reversible obstructive findings on spirometry is the distinctive diagnostic abnormality in patients with asthma, especially early in the course. Patients with chronic, severe asthma may have less or no reversibility of their obstructive findings, very similar to patients with chronic obstructive pulmonary disease.

Question 29

Differential of Obstructive Lung Disease With Reversible Findings: Less Likely Diagnoses

Answer 29

Patients with nonasthmatic eosinophilic bronchitis will respond to inhaled corticosteroids like patients with asthma, but they will have a normal spirometry and normal chest x-ray. The diagnostic finding for this condition is sputum eosinophilia on induced sputum or bronchial wash obtained at bronchoscopy.

Patients with vocal cord dysfunction may have flattening of the inspiratory loop on spirometry, but do not typically have reversible obstructive findings on spirometry like patients with asthma. The diagnostic finding of this condition is visualizing abnormal vocal cord movement during an episode of wheezing.

Symptoms of chronic obstructive pulmonary disease, like those of asthma, should improve following treatment with bronchodilators and inhaled corticosteroids. Obstructive findings are seen on spirometry with this condition, however, should not be reversible.

Patients w/ GERD typically present with either heartburn symptoms or findings of esophagitis on upper endoscopy. Even if asymptomatic, reflux can trigger bronchoconstriction and serve as an exacerbating factor for patients with asthma. If a patient with asthma fails to improve with standard treatment, it is reasonable to consider whether gastroesophageal reflux is present.