Cough, Colds, Care Goals Flashcards
Your patient presents with 4-6 weeks of cough that started during an acute respiratory infection.
- There is no pre-existing asthma and she is a non-smoker with no known allergies.
- She had been seen previously and exam was indeed c/w a URI at the time.
- “I can’t get rid of the cough.”
- No longer has nasal congestion or sore throat.
- Does need to clear throat frequently.
- No fever since initial presentation.
- VS: Temp 99 degrees, RR 16, HR 78
- Your exam of the patient is not revealing for HEENT findings and her lungs are clear with normal respiration. What is the most likely diagnosis?
Postinfectious cough: Symptoms following an acute respiratory infection for at least 3 weeks but not > 8 weeks
Possible contributors:
- Airway inflammation
- Hyperresponsive airway
- Mucus hypersecretion and impaired mucociliary clearance
Must consider:
- UACS
- Asthma
- GERD
You make a diagnosis of postinfectious cough after other etiologies are excluded.
What is your plan for intervention:
- Macrolide antibiotics since this has been going on over 3 weeks
- Short acting bronchodilators
- Inhaled ipratropium
- Inhaled corticosteroids
- Inhaled ipratropium
- Antibiotics are NOT indicated in the absence of symptoms of pertussis
- SABA: No evidence of effectiveness in absence of wheezing
- Ipratropium may be effective in attenuating cough (Level B evidence)
- Consider ICS if coughing impacts quality of life and cough persists through ipratropium
Your patient, the 35 y/o female does not smoke and is not on an ACE-i.
- Her cough has been present for 7 weeks.
- 99% of people with cough with this scenario have one of 3 etiologies.
Name the “Big 3”.
- UACS: upper airway cough syndrome
- Asthma
- GERD
Your 35 y/o female patient presents with a cough that started 6 weeks ago.
This is known as :
- Acute cough
- Subacute cough
- Chronic cough
2. 3-8 weeks
- Acute cough is < 3 weeks
- Chronic cough is greater than 8 weeks
Your 40 y/o patient presents with a 10 day history of cough, congestion and low grade fever.
- The cough is interfering with rest and disrupts interactions at work.
- PMH is unremarkable and she is a non-smoker.
- She has tried OTC cough syrup and lemon with honey.
- You determine she has a common cold.
- She asks for a cough suppressant.
- You suggest:
- Fexofenadine 180 mg at bedtime
- Brompheniramine bromide/pseudoephedrine combination and naproxen
- Zinc supplements
- Albuterol inhaler
- Guaifenesin
- Grade A evidence for 1st generation antihistamine/decongestant combination. Naproxen 400-500 mg, then 200 -500 mg t.i.d for 5 days (A) Naproxen blocks inflammation that stimulates cough-provoking nerves and helps with headache, fever, myalgia.
- Non-sedating antihistamines: D
- Zinc supplements D
- Albuterol not indicated for patient w/o h/o asthma
- Guaifenesin unlikely to be effective expectorant or mucolytic (level B low quality RCT)
Ms. Tussive presents with a cough that began about 5 weeks ago when she was seen for a URI. Other symptoms have improved but the cough persists and she has noted mucus that seems continue to drain down the back of her throat.
- She does not have a history of asthma or GERD.
- She has tried Brompheniramine with pseudoephedrine which was in an OTC preparation along with Aleve.
- She can’t sleep and her colleagues are getting annoyed by her coughing.
What is your recommendation?
Diagnosis: Post-infectious cough
- Ipratropium inhaler has Grade B evidence for effectiveness in this scenario.
- Albuterol has not been shown to be effective in the absence of asthma.
- If unresponsive to ipratropium inhaled corticosteroids would be the next step.
Mr. Ace Tussive has a dry, persistent scratchy cough. He feels an annoying tingle in the back of his throat.
- He does not have asthma, no h/o GERD and has not had recent URI Symptoms.
- He does have a history of hypertension and started a new medicine about 4 months ago. He does not know the name of the medication and his is new to you with no access to his medical records.
- All he knows is that it is a small white round pill.
- He does not have His BP is 120/78 today.
- His HEENT, lung and heart exam is normal.
- What medication is the possible cause?
- How will you manage the cough?
- What anticipatory guidance should you provide?
- ACE-inhibitor
- Stop the lisinopril and provide alternative anti-hypertensive such as an ARB.
- Cough usually resolves in 1-4 weeks but may persist up to 3 months.
Stopping ACE-i is the only 100% effective treatment.
May not occur with rechallenge. (30%)
Ms. Chester is a 52 y/o woman who is a non-smoker. She has a cough for over 6 weeks.
- OTC remedies have not helped.
- She denies URI symptoms prior to the cough.
- Cough is the only symptom.
- She does not have a h/o asthma.
- She denies GERD symptoms.
- PMH is positive for prior episodes over the past few years.
- She is not on any chronic medication. She wants help.
- You suspect UACS. Her exam is normal. What are the clinical criteria for UACS and how will you proceed?
- Hx and exam reveal no clear cause (pneumonia, smoking, COPD, use of ACE-I)
- No recent URI symptoms
- Normal spirometry
- Treat for UACS: formerly Postnasal drainage syndrome starting with antihistamine/decongestant combo
- Empirical therapy for most common causes of cough sequentially.
- R/O asthma, GERD if symptoms persist.
- Beware of “silent asthma or GERD”
- Consider NonAsthmatic eosinophilic bronchitis. NAEB.
Joanie is a 1st year family medicine resident who drags herself into the clinic.
- She is just completing her pediatric rotation.
- She has a cough, postnasal drainage and congestion and rhinorrhea.
- She had a low grade fever, sore throat the first couple of days.
- She has used a box of tissues today and her colleagues suggest that she go home.
- She is has no chronic health issues and does not smoke.
- She agrees to see her doctor and to follow her advice which should include…
- Rest, hydration
- First generation antihistamine/sustained released decongestant (grade A)
- Naproxen 400-500 mg initially, the 200-500 mg 3 times daily for 5 days (grade A)
- No clear evidence for guaifenesin as an expectorant or mucolytic.
Discussion:
What advice should she receive about work?
James 1
James is a 19 yo Freshman at Duke who presents after his holiday break with 2 days of symptoms including:
- Cough productive of yellow sputum and chest hurts when he coughs
- LGF with Tmax of 101
- Nasal congestion and runny nose
- Malaise, no myalgias
- Headache
He has at home contacts with similar symptoms over the break. He does not have allergies or h/o asthma. He is UTD on immunizations including his flu shot. His father in New Jersey, an orthopedist, told him to ask for some moxifloxin so he can get back to class and return to his team sports activity.
- Exam: VS T 99, RR 16, HR 80, BP 110/60.
- HEENT: boggy nasal mucosa with clear mucus.
- Ears/Eyes WNL. Heart: normal
- No frontal or maxillary tenderness
- Lungs: rhonchi which clear after cough, no wheezing.
Your diagnosis: acute bronchitis.
Which antibiotic would you recommend?
None: Grade A recommendation
Acute bronchitis is most often a viral infection.
- Rhinovirus, enterovirus, Influenza A and B, Parainfluenza, coronavirus, human metapneumovirus, RSV
- Bacterial 1-10%
- Atypical bacteria: Mycoplasma pneumoniae, Chlamydophila pneumoniae, Bordetella pertusis are rare causes
- M. pneumonaie < 1% of sputum samples in bronchitis of over 5 days
- B. pertussis: cough of at least 2 weeks: 10%, more often in children
- antibiotics to eradicate B. pertussis from nasopharynx but does not shorten course
- be aware of outbreaks in the community
- Be aware of red flags for pneumonia
- Lab testing not necessary in most cases as this is self-limited unless it would impact management
- Procalcitonin may help with decision but not readily available at POC outside ED
- Cough may last up to 18 days
James 2
James is not happy with your decision and says his dad will likely have something to say to you about this. He demands a CXR and pushes again for antibiotics.
- He has no dyspnea or rusty or bloody sputum
- Pulse is normal
- RR is normal
- Temperature is < 100
- Chest exam is negative for signs of consolidation
- No sinus tenderness
- Symptoms < 5 days
How are you going to handle his demands?
- Positive treatment recommendations
- Viruses do not respond to antibiotics
- Antibiotic risks
- Nausea, vomiting diarrhea
- Vaginitis
- Nerve damage
- Torn tendons
- Life-threatening allergic reactions
- Antibiotic resistance
- Contingency plan
- Delayed antibiotic prescriptions
- 48 hour
- Worsening course
- Expiration date on script so script cannot be prescribed at a later date
- Anticipatory guidance
- Choosing Wisely poster
Sallie Chan is a 30 y/o who is a teller at Wells Fargo. She was seen about a two weeks ago for evaluation of a URI and was treated with symptom management after a benign exam. She states that she did improve but after a few days she was sick again and worse this time. She as a thick, greenish mucus nasal discharge, a headache and facial pain. She had a fever but did not actually measure it. “Even my teeth ache”. She does not smoke though her husband does. Chart review reveals a penicillin allergy.
Exam:
- VS: T 99.8 RR 15 HR 85 BP 120/80 Pain level 3
- Ill appearing
- Nasal mucosa is swollen with thick mucus that is gray
- Tender to palpation over right maxillary region and right frontal region
- Oropharynx and TMs normal
- Lungs are clear to auscultation
You correctly diagnose acute rhinosinusitis. Is she a candidate for antibiotics?
Yes.
She demonstrates a pattern of “double sickening” and a clinical exam c/w bacterial rhinosinusitis. Symptoms have been present for greater than 10 days. But, what antibiotic should she take? Her allergy was years ago and involved hives.
Ms. Chan’s description of. her allergy is convincing. Amoxacillin is the first-line choice for acute rhinosinusitis for most patients. Amoxicillin-Clavulanate covers beta-lactam producing H. flu and Moraxella catarrhalis. She has Duke Select insurance through her husband’s job.
So, what can you do for Ms. Chan?
She had a Type 1 allergic reaction to the penicillin which makes a cephalosporin contraindicated.
Doxycycline is 77-81% effective
- 100 mg bid or 200 mg daily for 5-10 days
- Duke Select 1st tier, generic
Levfloxacine is 90-92% effective
- 500 mg daily for 10-14 days or 750 mg daily for 5 days
- Duke Select tier 1, generic
Moxifloxin is 90-92% effective
- Moxifloxacin 400 mg daily for 10 days
- Duke Select tier 1
High rates of resistance to macrolides and trimethoprim/sulfamethhoxazole
Third generation cephalosporins plus clindamycin are an option
Remember Ms. Chester, the lady with the persistent cough? You treated her symptomatically with a 1st generation antihistamine/decongestant combination. She is back a year later and is still having issues with a cough. She does have some occasional heartburn symptoms that responds to Tums or a drink of water. She does not take any other medication including the antihistamine/decongestant. Her chronic cough is interfering with her quality of life. Her exam is normal except she has a couple of episodes of a dry cough during the exam. She has no risk factors for tuberculosis or cancer. Her weight is stable and her VS are normal. PO2 is 99%.
How do you proceed with her evaluation and management?
- Be sure to clarify exposure hx
- Work
- Home
- Secondhand smoke
- Spirometry
- Cough variant asthma may be without wheezing
- Trial of bronchodilator
- Still coughing
- GERD therapy trial
Patient who has history of chronic cough and a negative evaluation for asthma, GERD and response for UACS intervention, though initially useful, did not last. A spirometry was normal and she had a negative brochoprovocation test. She had a normal CXR.
You asked for a consult from pulmonology who obtained an induced sputum sample that revealed a 7% eosinophil count.
He recommended a trial of inhaled corticosteroids which was effective.
What is the likely diagnosis?
Nonasthmatic Eosinophilic Bronchitis
Be sure to remember to look for causal allergan or sensitizer.
