Chronic Cough & Hemoptysis Flashcards
Definition of a Chronic Cough:
Defined as a cough persisting for three weeks or longer.
- Fifth most common outpatient symptom
- Over 1 billion dollars per year
What is the physiology of chronic cough?
- During cough, intrathoracic pressures may reach 300 mmHg
- Expiratory velocities approach 500 mph
- Complex reflex arc: mechanical and chemical receptors
What nerves are involved in the cough reflex?
Trigeminal, Glossopharyngeal, Phrenic, Vagus, Spinal motor
What feeds into the medullary cough center?
- Nose and sinuses through —> Trigeminal nerve
- Posterior pharynx through —> Glossopharyngeal nerve
- Pericardium, diaphragm through —> Phrenic nerve
- Ear canals and ear drums, Trachea, Bronchi, Esophagus, Stomach, Pleura through —> Vagus nerve
What are the outputs of the medullary cough center?
- Spinal motor nerve —> Expiratory muscles
- Phrenic nerve —> Diaphragm
- Vagus nerve —> Larynx, Trachea, Bronchi
What etiologies are associated with chronic cough (3 most common!)?
Most common:
- Postnasal drip
- Asthma
- GI reflux
- Many patients have more than one cause
- Also consider URI’s, side effect of ACE inhibitors
- 25% of smokers have a chronic cough
Major causes of chronic cough:
- Postnasal drip
- Asthma
- Gastroesophageal reflux
- Chronic bronchitis
- Bronchieotasis
- Miscellaneous
- Angiotensin-converting enzyme inhibitors
Less common causes of chronic cough:
- Bronchiectasis
- Eosinophilic bronchitis
- Bronchogenic carcinoma
- Interstitial lung disease
- Occult pulmonary infection
- Occult congestive heart failure
- Occult aspiration
- Tracheobronchial foreign body or mass (other than bronchogenic carcinoma)
- Occupational asthma
- Nasal polyps
- Disorders of external auditory ear canals, pharynx, larynx, diaphragm, pleura pericardium, esophagus, stomach, or thyroid
- Psychogenic
What is the most common cause of chronic cough?
Post-nasal drip
- Can be allergic, vasomotor rhinitis, sinusitis
- May be “silent drip”
- No definite criteria for diagnosis
What treatment is recommended for post-nasal drip chronic coughs?
- Treatment may be empiric before large workup is done
- Ipratropium nasal spray, nasal corticosteroids, antibiotics (if sinusitis is present) (consider but try to stay away)
What is the second most common cause of chronic cough?
Asthma!
- Can be associated with wheezing but may have “cough variant type”
- Best way to confirm diagnosis is demonstrate improvement with one week of inhaled beta-agonist therapy
- Spirometry not always helpful
What is the best treatment for asthma?
Inhaled bronchodilators and/or inhaled corticosteroids. Consider short course of prednisone.
What is another common cause of chronic cough?
Gastroesophageal Reflux!
- Most common cause in recent study
- Many patients have reflux symptoms but 40% may not have symptoms
- Receptors stimulated in larynx, lower respiratory tract and distal esophagus
What workup should you do for Gastroesophageal Reflux?
24 hr. esophageal pH monitoring
What is the recommended treatment for Gastroesophageal Reflux?
Dietary changes (smaller meals, no evening snacks), elevation of head of bed, proton pump inhibitor. -May need 6-12 months of Rx
What are less likely causes of chronic cough?
- Lung cancer - less than 2% of chronic coughs. Neoplasms in large airways.
- Bronchiectasis - chronic purulent sputum
- Eosinophilic bronchitis - atopic tendencies, elevated serum eosinophils, respond to inhaled steroids
What are centrally acting cough medications?
- Codeine vs. Dextromethorphan
- One study indicated equal effectiveness
- Both superior to placebo
What is the overall treatment plan for chronic cough?
- Establish etiology
- If no cause found, try dextromethorphan and inhaled ipratopium or inhaled corticosteroid
Most Common Causes of Cough:
Asthma, GERD, post-nasal drip
Describe hemoptysis:
- Can be pure blood or mixed with sputum
- Rarely massive (over 300 cc in 6 hours)
What are vascular origins of hemoptysis?
- Bronchial arteries - supply airways, hilar lymph nodes, visceral pleura
- Are at systemic pressure unlike the pulmonary arteries]
- Can cause massive bleeding
What approaches should you use to evaluate hemoptysis?
H and P, CXR, CBC, UA, Creatinine, Coags (plts, INR, PTT), Bronchoscopy
In what patients should bronchoscopy used in?
Patients with hemoptysis and normal CXR.
- Tumor found in less than 5%
- Increased risk factors:
- -Male sex
- -Older than age 40
- -Smoking history over 40 pack years
- -Hemoptysis greater than one week
What should be used in assessing hemoptysis (Bronchoscopy or CT)?
- One study: In 91 patients with hemoptysis, CT found all the tumors seen by bronchoscopy plus several others
- However, CT can’t detect bronchitis and small mucosal lesions
- Therefore, they are complimentary
- Probably best to do bronchoscopy first
