PULMO-COUGH, TB

Question 1

What is cough?

•

Answer 1

A complex reflex arc
Internal Laryngeal n and Recurrent in the piriform recess

• A defense mechanism
• A means of spreading infection
• A common symptom
• A means of providing CPR
• Results in 30mil clinician visits in the US annually, 40% of a pulmonologists practice

Question 2

Cough can be divided into 3 categories:

Answer 2

1. Acute (< 3 weeks)
2. Subacute (3-8 weeks)
3. Chronic (> 8 weeks)

Estimating the duration is the first step in narrowing the list of causes.

Question 3

MC causes of acute cough:

Answer 3

• URI’s (the common cold)- croup (kids)
• Acute bacterial sinusitis
• Bordetella pertussis infection (whoop)
• Exacerbation of COPD
• Allergic rhinitis
• Environmental irritant rhinitis

Question 4

MC subacute cough following URI:

Answer 4

Post-infectious cough
• Bordetella pertussis
• Bacterial sinusitis
• Asthma

Question 5

What do we know about the workup of cough?

Answer 5

systematic anatomic protocol, the cause can be determined 88-100%

leading to specific therapy with success rates between 84-98%.

diagnostic evaluation of cough:
more than 1 condition (18-93% of the time)
3 conditions up to 42% of the time
5 conditions 4%

Question 6

The 3 MC causes of cough in children > 1 year and adults

Answer 6

1. Post nasal drip (PND)
   • 2. Asthma
   • 3. Gastroesophageal reflux disease (GERD)

Question 7

Chronic cough in adults is almost always due to one or more of the following:

Answer 7

• PND (Upper airway cough syndrome)
• Asthma 57-75%
• GERD- 57-75%
• Chronic bronchitis
• Bronchiectasis
• Non-asthmatic eosinophilic bronchitis

Question 8

If the patient is a non-smoker, not taking an and has a normal chest x-ray, 92% of the time the cough is due to one of the following:

Answer 8

PND
• Asthma
• GERD
• Eosinophilic bronchitis

Don’t send to them if the our on an ACE-1
ACE-I (up to 10- 15% get a dry cough),

Question 9

Diagnostic testing Asthma

Answer 9

o Spirometry with bronchodilators

o Methacholine challenge – very high negative predictive value

Question 10

Diagnostic testing GERD

Answer 10

o Endoscopy
o 24-hour esophageal pH monitoring
 4% of time pH < 4
 Observing GER-induced cough

o May need a barium esophogram

Question 11

• Bronchoscopy

Answer 11

oChest x-ray is normal in 93% of patients with CHRONIC cough
o low yield (4%) in this group
o helpful if the x-ray suggests a cancer or inflammation

testing is to exclude suspected possibilities.
limitation is that a positive test does not consistently predict a favorable response to specific therapy.

Question 12

Treat Acute cough from URI

Answer 12

o Can last 3-4 weeks

o ?Tincture of time is the best therapy

o Atrovent inhaler may help 20% of the time

o Narcotic-based cough syrups may help

Question 13

TREAT Subacute cough

Answer 13

ocomplete HP determine cause from the list of “usual suspects”

Treat aggressively for 1 month.
If symptoms persist, you have not been aggressive enough.

If the symptoms are gone (eg, the PND) but the cough persists, determine the 2nd most likely cause and treat that very aggressively for 1 month. Keep it up until the cough goes away.

The treatment may be worse than the disease.

Question 14

TREAT • Sinusitis

Answer 14

o amoxicillin, erythromycin, Septra

oPseudoephedrine, nasal steroids, NSAIDs

o prolonged treatment

Question 15

TREAT Post nasal drip

o

Answer 15

Nasal steroids

Antihistamines (brompheniramine, chlorpheniramine, clemastine)

Question 16

TREAT Eosinophilic bronchitis

TREAT ASTHMA

Answer 16

o Inhaled steroids

ICS
B2 AGONIST

Question 17

o	Raise the head of the bed
o	Minimize alcohol, caffeine, and fat in the diet
o	Tums at bedtime
o	H2 antagonists
o	Proton pump inhibitors

Answer 17

TREAT GERD

Question 18

Tuberculosis (consumption)

Answer 18

a. Mycobacterium tuberculosis, inhaled in aerosol form, initially sub-clinical pneumonia, with spread to regional lymph nodes and suppression

Primary TB is the initial illness
+SX
+CR
-PPD

Latent TB w/o symptoms of active disease
+PPD
-CXR
-SX

Active TB is 90% a reactivation of the initial illness and is contagious
+CXR
+SX
-PPD

Question 19

2. Symptoms/signs

Answer 19

Fever
cough
weight loss
sputum production
hemoptysis

Physical exam may be normal

may show adenopathy (cervical, axillary)

chest signs (consolidation, percussion dullness) or normal

Question 20

3. Labs

Answer 20

X-ray focal infiltrates (usually upper lobe for reactivation disease), adenopathy, small pleural effusions, maybe just a granuloma for latent disease
b.

Question 21

Sputum

Answer 21

AFB smear

ii. Cultures take 6 weeks to be negative
iii. PCR may be available for faster testing
iv. Sensitivities should be obtained on all specimens
d. Bronchoscopy or biopsy are always an option, if you need a specimen

Question 22

Treatment

Answer 22

CDC reportable disease
NEVER ADD ONE DRUG TO A FAILING REGIMEN
NEVER ADD ONE DRUG TO A FAILING REGIMEN

Directly observed therapy (DOT)

California, begin 4 drugs initially, until you know sensitivities
first line therapy is:
1. Isoniazid (INH)
2. Rifampin (RIF)
3. Pyrazinamide (PZA)
4. Ethambutol (ETH)
iii. Follow symptoms, CXR, sputum smear and culture

Question 23

Latent Disease

Answer 23

\+PPD
\+CXR
\+SX
10% Reactivate
Treat Rifampin qd 4mo

Question 24

Skin tests

Answer 24

i. Intra-DERMAL injection of PPD, read within 48-72 hours of placement, looking for induration not erythema
ii. Criteria of a positive test depends on the risks of the patient you are testing
1. >5mm: HIV, risks for HIV, recent contacts of active cases, X-ray consistent with TB
2. >10mm: increased risk diseases (diabetes, renal failure, immunosuppressed, silicosis, recent weight loss)
3. >15mm: patients who never should have had the test in the first place
iii. Remember BCG and the booster effects