Clinical Practice Guidelines - Chronic Cough Flashcards
1
Q
acute cough
A
< 3 weeks
2
Q
chronic cough
A
≥ 3 weeks
3
Q
_____ should be done before any therapy is prescribed.
A
CXR
4
Q
Most Common Causes of Chronic Cough
A
Asthma
Postnasal Drip Syndrome (PNDS)
Gastroesophageal Reflux Disease (GERD)
5
Q
Most Common Causes of Chronic Cough in 0-18 mos.
A
Aberrant Innominate Artery
GERD
Cough-Variant Asthma
6
Q
Most Common Causes of Chronic Cough in 1.5-6 y.o.
A
Sinusitis
Cough-Variant Asthma
7
Q
Most Common Causes of Chronic Cough in 6-16 y.o.
A
Cough-Variant Asthma
Psychogenic Cough
Sinusitis
8
Q
A single cause for cough is found _____ of the time.
A
38-82%
9
Q
Multiple causes for cough are found _____ of the time.
A
18-62%
10
Q
Therapies should be initiated in the _____.
A
same sequence that the abnormalities were discovered
11
Q
Asthma with persistent cough without wheezing
A
Cough-Variant Asthma
12
Q
_____ of children with chronic cough have cough-variant asthma.
A
75%
13
Q
_____ of children with cough-variant asthma will develop into classical asthma.
A
54%
14
Q
_____ of children with chronic cough will eventually develop asthma.
A
45%
15
Q
When there is an identifiable trigger (exercise, nocturnal occurrence, seasonal and episodic attacks, personal or family history) a child is considered an _____.
A
asthma suspect
16
Q
_____ cough, wheeze, chest discomfort and shortness of breath can sometimes be the only feature of asthma.
A
Exercise-Induced
17
Q
Referral to an asthma specialist is done when:
A
- diagnosis needs to be confirmed by spirometry
- normal peak flow in an asthma suspect (> 80%)
- below normal peak flow and response to β2-agonist is equivocal (< 20% inc.)
- poor response to therapeutic trial
18
Q
_____ is the recommended initial test for asthma suspects and is feasible starting _____.
A
Spirometry, 5 y.o.
19
Q
If spirometry is not available, _____ may be used to measure Peak Expiratory Flow Rate (PEFR).
A
Peak Flow Meter
20
Q
PEFR correlates well with _____.
A
FEV1
21
Q
Predicted normal PEFR can be calculated for children _____.
A
6-17 y.o. at least 100 cm tall
22
Q
Predicted Normal PEFR for Males
A
(ht. in cm - 100)5 + 175
23
Q
Predicted Normal PEFR for Females
A
(ht. in cm - 100)5 + 170
24
Q
An increase of _____ in PEFR after β2-agonist supports the diagnosis of asthma.
A
> 20%
25
Further Work-Up for Asthma
Exercise Challenge Test
PEFR 2x/day (diurnal variation)
Steroid + Bronchodilator x 5 days
26
If a peak flow meter is not available, therapeutic trial of _____ may help diagnose asthma.
β2-agonist ± steroid
27
After giving inhaled or nebulized β2-agonist, relief of symptoms are seen in _____ and peaks in _____.
5 min., 60 min.
28
After giving oral β2-agonist, relief of symptoms are seen in _____ and peaks in _____.
30 min., 2-3 hrs.
29
A _____ course of systemic steroids may be given to relieve obstruction and restore response to β2-agonist.
5-day
30
Criteria for Persistent Asthma
```
> 1 attack/week
nocturnal symptoms > 2x/month
PEFR < 80%
PEFR Variability > 20%
FEV1 < 80%
```
31
Asthma Self-Management Behaviors
1. avoid triggers
2. peak-flow monitoring
3. asthma diary
4. proper use of medications
5. prompt management of exacerbations
6. asthma action plan
32
Stridor may be produced by _____ or by any _____ which can predispose to recurrent respiratory infection.
aspiration syndrome
| anatomic or dynamic problem of the airway
33
_____ is the congenital floppiness or weakness of the airway which can present as stridor.
Tracheomalacia
34
Tracheomalacia should resolve within _____.
18-24 mos.
35
Patients with vascular rings present with symptoms during _____.
infancy or early childhood
36
Most Common Types of Vascular Rings
R Aortic Arch w/ L Ligamentum Arteriosum (95%)
| Double Aortic Arch (85%)
37
Vascular rings can present as _____ cough.
high-pitched, brassy
38
Vascular Rings:
| CXR
ill-defined arch
compression of trachea
hyperinflation
atelectasis
39
Vascular Rings:
| Barium Esophagogram
posterior compression of the esophagus
*diagnostic in most cases
40
Vascular Rings:
| Therapy
surgery
41
_____ is the single most common cause of chronic cough in adults and in children.
Postnasal Drip Syndrome (PNDS)
42
Postnasal Drip Syndrome:
| Symptoms
something dripping down the throat
need to clear throat frequently
mucoid or mucopurulent secretions
cobblestone appearance of mucosa
43
Postnasal Drip Syndrome:
| Pathophysiology
chronic laryngeal irritation → mechanical stimmulation of the afferent limb of the cough reflex
44
Postnasal Drip Syndrome:
| Causes
```
sinusitis (39%)
allergic rhinitis (23%)
perennial non-allergic rhinitis (37%)
post-infectious rhinitis (6%)
vasomotor rhinitis (2%)
environmental irritant (2%)
```
45
_____ is the inflammation of the paranasal sinuses with concomitant inflammation of the nasal passages and surrounding bone.
Sinusitis
46
Bacterial sinusitis is associated with symptoms lasting _____.
≥ 10 days
47
Bacterial Sinusitis:
| Symptoms
```
purulent nasal/postnasal discharge (3-4 days)
daytime cough which may worsen at night
high fever (≥ 39° C)
```
48
Bacterial Sinusitis:
| Duration - Acute
> 10-14 days
| < 30 days
49
Bacterial Sinusitis:
| Duration - Subacute
30-90 days
50
Bacterial Sinusitis:
| Duration - Recurrent Acute
< 30 days
| ≥ 10 day intervals
51
Bacterial Sinusitis:
| Duration - Chronic
90 days
52
Bacterial Sinusitis:
| Pathogens
S. pneumoniae
H. influenzae
M. catarrhalis
53
Bacterial Sinusitis:
| Treatment
Beta-Lactam (Amoxicillin)
54
Bacterial Sinusitis:
| Treatment - S. pneumoniae
Penicillin
Co-Trimoxazole
Chloramphenicol
55
Bacterial Sinusitis:
| Treatment - H. influenzae
Ampicillin
Co-Trimoxazole
Chloramphenicol
56
Bacterial Sinusitis:
| Treatment - Duration
once the patient becomes symptom free then +7 days
57
Bacterial Sinusitis:
| Treatment - Antibiotic Response
48-72 hours
58
Bacterial Sinusitis:
| Complications
periorbital and intraorbital infections
59
_____ is the IgE-mediated inflammation of the nasal membranes after allergen exposure.
Allergic Rhinitis
60
Allergic Rhinitis:
| Criteria for Diagnosis
allergen
causal relationship
immunologic mechanism
history of atopy
61
Allergic Rhinitis:
| Symptoms
rhinorrhea
nasal obstruction
nasal itching
sneezing
62
Allergic Rhinitis:
| Symptoms - Nasal Congestion
```
postnasal drainage
chronic cough
frequent sore throats
dry mouth and oropharynx
nasal twang
snoring
sleep disturbance
```
63
Allergic Rhinitis:
| Physical Examination
```
facial pallor
mouth breathing
pale bluish gray edematous nasal mucosa
watery nasal secretions
cobblestoning of posterior pharyngeal wall
postnasal drip
injection of palpebral conjunctivae
watery eye discharge
puffy eyelids
```
64
Allergic Rhinitis:
| Classification - Intermittent
< 4 days/week
| < 4 weeks
65
Allergic Rhinitis:
| Classification - Persistent
> 4 days/week
| > 4 weeks
66
Allergic Rhinitis:
| Classification - Mild
does not interfere with daily living
67
Allergic Rhinitis:
| Classification - Moderate-Severe
abnormal sleep
impairment of activities
problems at work or school
troublesome symptoms
68
Oral Antihistamines decrease the symptoms of _____ but have less effect on _____.
allergy, nasal congestion
69
_____ are the mainstay treatment of allergies.
Oral Antihistamines
70
1st Generation Antihistamines may cause _____.
sedation
impair performance
anti-cholinergic effects
71
_____ may help smaller children due to their sedative effect.
1st Generation Antihistamines
72
2nd and 3rd Generation Antihistamines have a greater _____ ratio with less _____ and are shown to have _____ effects.
benefit:risk, sedation and side effects, anti-inflammatory
73
_____ are used as first-line therapy for allergic rhinitis.
Nasal Antihistamines
74
Nasal Antihistamines decreases _____ but causes _____.
nasal congestion, sedation
75
Nasal Antihistamines are comparable with _____ but are inferior to _____.
Oral Antihistamines
| Nasal Corticosteroids
76
The limitation of Nasal Antihistamines is the _____.
bitter taste
77
Nasal Antihistamines:
| Age
≥ 5 y.o.
78
Nasal Corticosteroids are anti-inflammatory agents which affects _____.
sneezing
pruritus
rhinorrhea
nasal blockage
*except ocular syptoms
79
Nasal Corticosteroids:
| Age
≥ 3 y.o.
80
Nasal Corticosteroids:
| Onset of Effect
2-4 hours
81
_____ are mast stabilizers which include sodium cromoglycate and nedocromil sodium.
Nasal Chromones
82
The limitation of Nasal Chromones is _____.
QID dosing
83
When decongestants are used alone, they may cause _____.
insomnia
anorexia
nervousness
84
When decongestants are used with _____ they may significantly improve symptoms of allergic rhinitis.
antihistamines
85
_____ are anti-inflammatory agents acting on the lipo-oxygenase pathway.
Antileukotrienes
| Montelukast, Zafirlukast
86
Allergic Rhinitis:
| Parameters of Response to Therapy
```
Nasal Symptoms
Physical Signs
Quality of Life
Concomitant Medical Conditions
Side Effects
```
87
Short Term Complications of Allergic Rhinitis
```
asthma exacerbation
acute sinusitis
eustachian tube dysfunction
serous otitis media with effusion
sleep-disordered breathing
chronic mouth breathing
decreased cognitive functioning
neuropsychiatric concerns
anosmia
aqeusia
```
88
Long Term Complications of Allergic Rhinitis
```
asthma
chronic sinusitis
acute and chronic otitis media
hearing and speech impairment
sleep apnea
craniofacial abmormalities
decrease in productivity
allergic irritability syndrome
anosmia
ageusia
```
89
Allergic Rhinitis:
| Follow-Up Checklist
control of symptoms
maintenance of improved quality of life
no impairment of activities
absence of side effects
90
Allergic Rhinitis:
| Indications Allergologist/Immunologist Consultation
```
prolonged duration
identification of triggers
implementation of avoidance of triggers
immunotherapy
decreasing cost of multiple medications
complications/co-morbidities
systemic corticosteroids
significantly affected quality of life
```
91
_____ are conditions with prominent nasal congestion but lack the criteria for the diagnosis of allergic rhinitis.
Non-Allergic Rhinitidis
92
Non-Allergic Rhinitidis
```
infectious
idiopathic/vasomotor
idiopathic neonatal (autonomic prematurity, GER)
non-allergic rhinitis with eosinophilia syndrome (NARES)
food-induced
mucosal abnormalities
hormonal
drug-induced
foreign bodies
structural abnormalities
tumors
```
93
GERD-related cough occurs predominantly during the _____ and in the _____ position.
day, upright
94
Cough due to GERD has a duration of _____.
13-58 mos.
95
GERD can cause _____.
heartburn
hoarseness
sore throat
dysphonia
96
_____ of patients with chronic cough have GERD.
10-20%
97
_____ of children with chronic respiratory symptoms have silent GER.
40-50%
98
GERD
| Symptoms
```
recurrent vomiting
poor weight gain
irritability
heartburn
esophagitis
dysphagia
feeding refusal
apnea
asthma
recurrent pneumonia
upper airway symptoms
```
99
A therapeutic trial with a _____ or a _____ is a common approach to the diagnosis of GERD.
Histamine-2 Receptor Antagonist (H2RA)
| Proton Pump Inhibitor (PPI)
100
Relief of symptoms with _____ had a sensitivity of 75% and a specificity of 55% in diagnosing GERD.
1 week of Omeprazole
101
Treatment with Omeprazole _____ showed resolution of GERD symptoms within _____.
40 mg BID
| 5-14 days
102
Lansoprazole has been shown to be effective in healing _____ due to GERD.
erosive esophagitis
103
GERD:
| Lifestyle Changes for Infants
changing/thickening formula
prone/lateral decubitus position
1-2 week trial of hypoallergenic formula
104
Thickening of formula should be done by adding _____.
1 tbsp. of rice cereal to 1 oz. of formula
105
GERD:
| Lifestyle Changes for Children and Adolescents
avoid caffeine, chocolate and spicy foods
106
GERD:
| Lifestyle Causes
obesity
alcohol intake
tobacco exposure
107
_____ is the gold standard for diagnosing GERD.
24 Hour Esophageal pH
108
Acid-induced cough occurs simultaneously with the pH drop _____ after an acid reflux episode.
5 min.
109
_____ is diagnosed in 3-10% of children with cough of unknown etiology that persists for more than 1 month.
Psychogenic Cough
110
Psychogenic Cough is more common in _____.
girls
111
Psychogenic Cough is described as _____.
barking or honking
112
Psychogenic Cough is managed with _____.
suggestion therapy
psychological counseling
psychiatric intervention
