Diagnosis and Treatment of Cough

1.

A 57-year-old man is seen for evaluation of cough. He has been experiencing cough with nasal drainage for the past 3 weeks. These symptoms were preceded by sinus congestion and nasal drainage that lasted for about 1 week. He denies having sputum or experiencing fever or chills, and he states that he has otherwise been feeling well. On examination, the patient has no fever. His oropharyngeal examination is normal, and his lungs are clear. He does frequently clear his throat during the examination.

How would you confirm the diagnosis of upper airway cough syndrome (UACS) for this patient?

Laryngoscopy with biopsy

Bronchoscopy with endobronchial biopsy

Observing a clinical response to oral steroids

Observing a clinical response to levofloxacin

Observing a clinical response to antihistamine and decongestants

UACS is defined as cough caused by mechanical stimulation of the cough reflex by secretions emanating from the nose or sinuses and, possibly, by increased sensitivity of the cough reflex because of physical and mechanical irritation by secretions. Why cough develops in only a minority of patients with rhinosinus disease is not known. Typically, patients with UACS describe the sensation of fluid dripping down into their throats, nasal discharge, or the need to frequently clear their throatsâ??other persons in the patient's vicinity may also notice frequent throat clearing by the patientâ??and physical examination of the nasopharynx and oropharynx reveals mucoid or mucopurulent secretions or a cobblestoned appearance of the mucosa. Unfortunately, none of these criteria, by themselves, is very sensitive or specific. Moreover, in some patients, chronic cough may be the only symptom of UACS (so-called silent UACS). Therefore, the diagnosis of UACS is often made on the basis of response to empirical therapeutic trials. Indeed, because postnasal drip and throat clearing are common complaints in the general population and in patients with chronic cough from other conditions, cough can be definitively ascribed to UACS only when it responds to specific therapy for UACS. Because it is the most common cause of chronic cough in adults in the United States, UACS should be the first diagnosis considered when the patient is a nonsmoker, is not taking an ACE inhibitor, and has a normal or near normal chest radiograph. Empirical therapy for UACS should begin with a trial of a first-generation antihistamine-decongestant unless contraindicated (e.g., because of benign prostatic hypertrophy, hypertension, or glaucoma). Intranasal ipratropium bromide may also be effective; the nonsedating antihistamines are not effective, however, unless the patient has allergic rhinitis or some other histamine-mediated disease process. If the patient experiences resolution or partial resolution of cough in response to treatment, then UACS is considered to have been the cause, or a contributing cause, of cough and the antihistamine-decongestant is continued. Noticeable improvement should occur within a few days. If the response to empirical therapy is only partial and the patient continues to have nasal symptoms suggestive of rhinosinus disease, then the addition of a topical nasal steroid, nasal anticholinergic, or nasal antihistamine should be considered. Persistent UACS symptoms despite topical therapy are an indication for sinus imaging, to look for evidence of occult sinusitis.

Explanation

UACS is defined as cough caused by mechanical stimulation of the cough reflex by secretions emanating from the nose or sinuses and, possibly, by increased sensitivity of the cough reflex because of physical and mechanical irritation by secretions. Why cough develops in only a minority of patients with rhinosinus disease is not known. Typically, patients with UACS describe the sensation of fluid dripping down into their throats, nasal discharge, or the need to frequently clear their throatsâ??other persons in the patient's vicinity may also notice frequent throat clearing by the patientâ??and physical examination of the nasopharynx and oropharynx reveals mucoid or mucopurulent secretions or a cobblestoned appearance of the mucosa. Unfortunately, none of these criteria, by themselves, is very sensitive or specific. Moreover, in some patients, chronic cough may be the only symptom of UACS (so-called silent UACS). Therefore, the diagnosis of UACS is often made on the basis of response to empirical therapeutic trials. Indeed, because postnasal drip and throat clearing are common complaints in the general population and in patients with chronic cough from other conditions, cough can be definitively ascribed to UACS only when it responds to specific therapy for UACS. Because it is the most common cause of chronic cough in adults in the United States, UACS should be the first diagnosis considered when the patient is a nonsmoker, is not taking an ACE inhibitor, and has a normal or near normal chest radiograph. Empirical therapy for UACS should begin with a trial of a first-generation antihistamine-decongestant unless contraindicated (e.g., because of benign prostatic hypertrophy, hypertension, or glaucoma). Intranasal ipratropium bromide may also be effective; the nonsedating antihistamines are not effective, however, unless the patient has allergic rhinitis or some other histamine-mediated disease process. If the patient experiences resolution or partial resolution of cough in response to treatment, then UACS is considered to have been the cause, or a contributing cause, of cough and the antihistamine-decongestant is continued. Noticeable improvement should occur within a few days. If the response to empirical therapy is only partial and the patient continues to have nasal symptoms suggestive of rhinosinus disease, then the addition of a topical nasal steroid, nasal anticholinergic, or nasal antihistamine should be considered. Persistent UACS symptoms despite topical therapy are an indication for sinus imaging, to look for evidence of occult sinusitis.

2.

A 27-year-old woman with no significant medical history presents for initial evaluation of cough of 4 months' duration. Her cough is worse with exertion and at night and has occasionally wakened her from sleep. She denies experiencing any wheezing. She does not smoke, and she has no history of atopic skin changes. On physical examination, the patient's respiratory rate is normal. The cardiopulmonary examination is also normal.

For this patient, which of the following interventions should be undertaken at this time?

Trial of oral steroids

Trial of inhaled steroids

Pulmonary function tests with methacholine challenge

Transthoracic echocardiogram

Bronchoscopy with transbronchial biopsy

Asthma should be suspected as the cause of chronic cough under any of three circumstances: (1) the patient complains of episodic wheezing, shortness of breath, and cough, and wheezing is heard on chest examination; (2) pulmonary function testing demonstrates reversible airflow obstruction, even in the absence of wheezing; or (3) methacholine inhalation challenge testing is positive in a patient with normal or near-normal results on routine spirometry, even in the absence of wheezing. Chronic cough can be the sole presenting manifestation of asthma (i.e., cough-variant asthma). In a prospective study of chronic cough, cough was the only symptom of asthma in 28% of the asthmatic group. Cough-variant asthma is important to recognize, not only so that the cough can be alleviated but also because airway remodeling occurs and these structural changes in the airway are an important target of asthma therapy. Nonspecific pharmacologic bronchoprovocation challenge testing is extremely helpful in ruling out asthma as a possible cause of cough. Although it only has a positive predictive value of 60% to 80%, it has a negative predictive value that approaches 100%. Therefore, a negative methacholine challenge essentially rules out asthma as a cause of chronic cough. An exception would be the patient who may have occupational asthma in its earliest stage. In such cases, however, the methacholine challenge should become positive as the workplace exposure continues. False positive results on methacholine challenge testing have been reported to occur in 22% of patients being evaluated for chronic cough. Therefore, it must be emphasized that a positive test, by itself (i.e., in the absence of a favorable response to therapy) is not diagnostic of asthma as the cause of cough. Because not all wheezes are from asthma and because the presence of bronchial hyperresponsiveness does not necessarily mean that asthma is the cause of cough, the diagnosis of asthma as the cause of chronic cough requires that the cough respond to specific therapy for asthma and that the patient's subsequent clinical course is consistent with asthma. In this regard, the diagnosis of asthmatic cough is not made in any patient who has experienced an obvious respiratory tract infection within the previous 2 months, because cough and bronchial hyperresponsiveness can be transient and self-limited in this setting.

Explanation

Asthma should be suspected as the cause of chronic cough under any of three circumstances: (1) the patient complains of episodic wheezing, shortness of breath, and cough, and wheezing is heard on chest examination; (2) pulmonary function testing demonstrates reversible airflow obstruction, even in the absence of wheezing; or (3) methacholine inhalation challenge testing is positive in a patient with normal or near-normal results on routine spirometry, even in the absence of wheezing. Chronic cough can be the sole presenting manifestation of asthma (i.e., cough-variant asthma). In a prospective study of chronic cough, cough was the only symptom of asthma in 28% of the asthmatic group. Cough-variant asthma is important to recognize, not only so that the cough can be alleviated but also because airway remodeling occurs and these structural changes in the airway are an important target of asthma therapy. Nonspecific pharmacologic bronchoprovocation challenge testing is extremely helpful in ruling out asthma as a possible cause of cough. Although it only has a positive predictive value of 60% to 80%, it has a negative predictive value that approaches 100%. Therefore, a negative methacholine challenge essentially rules out asthma as a cause of chronic cough. An exception would be the patient who may have occupational asthma in its earliest stage. In such cases, however, the methacholine challenge should become positive as the workplace exposure continues. False positive results on methacholine challenge testing have been reported to occur in 22% of patients being evaluated for chronic cough. Therefore, it must be emphasized that a positive test, by itself (i.e., in the absence of a favorable response to therapy) is not diagnostic of asthma as the cause of cough. Because not all wheezes are from asthma and because the presence of bronchial hyperresponsiveness does not necessarily mean that asthma is the cause of cough, the diagnosis of asthma as the cause of chronic cough requires that the cough respond to specific therapy for asthma and that the patient's subsequent clinical course is consistent with asthma. In this regard, the diagnosis of asthmatic cough is not made in any patient who has experienced an obvious respiratory tract infection within the previous 2 months, because cough and bronchial hyperresponsiveness can be transient and self-limited in this setting.

3.

A 57-year-old man presents for initial evaluation of cough. The cough has been present for 6 months. Initially, it was intermittent in nature, but it now occurs daily. He denies having any sputum or experiencing fever, chills, weight loss, shortness of breath, chest pain, dyspnea on exertion, or orthopnea. He quit smoking cigarettes 30 years ago after having smoked 1 pack a day for 5 years. He drinks 2 or 3 alcoholic beverages most nights. His medical history is significant for type 2 diabetes mellitus and hypertension. He takes metformin, hydrochlorothiazide, and lisinopril. On examination, the patient weighs 245 lb, and he has a body mass index (BMI) of 30. Except for the patient's obesity, results of HEENT, neck, cardiopulmonary, and abdominal examinations are within normal limits. Over the past 6 months, the patient has tried cough suppressants, nasal steroids, and antireflux therapy, without results.

What is the most likely cause of this patient's chronic cough?

Chronic bronchitis

Allergic rhinitis

GERD

Heart failure

Use of angiotensin-converting enzyme (ACE) inhibitors

Cough is a well-known side effect of ACE inhibitors. The pathogenesis may be related to bradykinin sensitization of afferent sensory nerves in the airways. Stimulation of cough appears to be a class effect of these drugs and is not dose related. In patients who experience a cough with one ACE inhibitor, cough usually develops when another ACE inhibitor is substituted. Although the reported frequency of cough associated with ACE inhibitors has varied widely, from 0.2% to 33%, prospective studies have shown that ACE inhibitors account for 2% of chronic cough. Cough has been reported to appear within a few hours of taking a first dose in many patients, but it may not become apparent for weeks, months, or even longer. In a prospective study of lisinopril rechallenge in patients who had previously experienced an ACE inhibitorâ??induced cough, the median time for cough to redevelop was 19 days, and the median time to resolution during placebo washout was 26 days. ACE inhibitor induced cough is diagnosed by stopping the drug and observing resolution of the cough.

Explanation

Cough is a well-known side effect of ACE inhibitors. The pathogenesis may be related to bradykinin sensitization of afferent sensory nerves in the airways. Stimulation of cough appears to be a class effect of these drugs and is not dose related. In patients who experience a cough with one ACE inhibitor, cough usually develops when another ACE inhibitor is substituted. Although the reported frequency of cough associated with ACE inhibitors has varied widely, from 0.2% to 33%, prospective studies have shown that ACE inhibitors account for 2% of chronic cough. Cough has been reported to appear within a few hours of taking a first dose in many patients, but it may not become apparent for weeks, months, or even longer. In a prospective study of lisinopril rechallenge in patients who had previously experienced an ACE inhibitorâ??induced cough, the median time for cough to redevelop was 19 days, and the median time to resolution during placebo washout was 26 days. ACE inhibitor induced cough is diagnosed by stopping the drug and observing resolution of the cough.

4.

A 65-year-old man presents for evaluation of cough. He has been experiencing episodes of cough for the past 2 to 3 months. The cough is worse at night. The cough does not produce sputum. The patient denies experiencing any weight loss, fever, or chills. He is a lifetime nonsmoker. He denies having any occupational exposures to lung irritants. He reports occasional epigastric discomfort, especially at night. His medical history is significant for hypertension and osteoarthritis. He takes hydrochlorothiazide and occasionally ibuprofen and acetaminophen. On examination, the patient weighs 240 lb. He has a BMI of 32. HEENT, neck, cardiovascular, pulmonary, and gastrointestinal examinations are normal. A chest x-ray is unremarkable. The patient has tried an empirical regimen of inhaled steroids and montelukast, without response.

Of the following, which is the most appropriate approach to confirm a diagnosis of chronic cough associated with GERD in this patient?

Resolution of cough after discontinuing hydrochlorothiazide

Resolution of cough after initiation of oral steroids

Resolution of cough after initiation of antireflux therapy

Response to botulinum toxin injection to lower esophageal sphincter

24-Hour esophageal pH monitoring

GERD should be suspected as the cause of chronic cough whenever a patient complains of frequent episodes of typical gastrointestinal symptoms such as daily heartburn and regurgitation, especially when the chest radiograph or clinical picture suggests an aspiration syndrome. Chronic cough may be the only symptom of GERD; in prospective studies, such so-called silent GERD has accounted for 43% to 75% of cases. In the absence of gastrointestinal symptoms, chronic cough can be confidently attributed to GERD if the patient is a nonsmoker, is not taking an ACE inhibitor, has a normal or near-normal chest radiograph, and asthma, UACS, and nonasthmatic eosinophilic bronchitis have been ruled out; 92% of patients with silent GERD fit this clinical profile. Failure to obtain a history of nocturnal coughing does not exclude GERD as a cause of cough. When the chest radiograph is normal, cough from GERD most commonly occurs while the patient is awake and upright, and it usually does not occur or is not noted at all during sleep. Confirmation of GERD as the cause of cough requires that the cough disappear when the patient starts antireflux therapy. Nevertheless, if treatment with proton pump inhibitors fails to eliminate cough in a patient who fits the clinical profile for GERD-induced chronic cough, GERD may nevertheless be causing the cough, albeit through a nonacid mechanism. The precise mechanism by which GERD causes cough is not known. Although GERD can stimulate cough by irritating the upper respiratory tract without aspiration (e.g., larynx/hypopharynx) or by irritating the lower respiratory tract with aspiration, GERD appears to most commonly cause chronic cough by stimulating an esophageal-bronchial reflex in the mucosa of the distal esophagus.

Explanation

GERD should be suspected as the cause of chronic cough whenever a patient complains of frequent episodes of typical gastrointestinal symptoms such as daily heartburn and regurgitation, especially when the chest radiograph or clinical picture suggests an aspiration syndrome. Chronic cough may be the only symptom of GERD; in prospective studies, such so-called silent GERD has accounted for 43% to 75% of cases. In the absence of gastrointestinal symptoms, chronic cough can be confidently attributed to GERD if the patient is a nonsmoker, is not taking an ACE inhibitor, has a normal or near-normal chest radiograph, and asthma, UACS, and nonasthmatic eosinophilic bronchitis have been ruled out; 92% of patients with silent GERD fit this clinical profile. Failure to obtain a history of nocturnal coughing does not exclude GERD as a cause of cough. When the chest radiograph is normal, cough from GERD most commonly occurs while the patient is awake and upright, and it usually does not occur or is not noted at all during sleep. Confirmation of GERD as the cause of cough requires that the cough disappear when the patient starts antireflux therapy. Nevertheless, if treatment with proton pump inhibitors fails to eliminate cough in a patient who fits the clinical profile for GERD-induced chronic cough, GERD may nevertheless be causing the cough, albeit through a nonacid mechanism. The precise mechanism by which GERD causes cough is not known. Although GERD can stimulate cough by irritating the upper respiratory tract without aspiration (e.g., larynx/hypopharynx) or by irritating the lower respiratory tract with aspiration, GERD appears to most commonly cause chronic cough by stimulating an esophageal-bronchial reflex in the mucosa of the distal esophagus.

5.

A 22-year-old woman with no significant medical history is seen for evaluation of cough. Ten days ago, she developed conjunctivitis, nasal drainage, cough, and fever. All symptoms have resolved except for the cough. She is now experiencing paroxysms of cough; on two occasions, she experienced episodes of emesis following cough. There have been no reports of similar symptoms in her community, but the patient does report traveling to see family members 1 month ago. Her cousin had similar symptoms of upper respiratory tract infection; her cousin's symptoms resolved after taking antibiotics. The patient usually smokes 1 pack of cigarettes daily and has done so for 3 years; she has been unable to smoke for the past 5 days.

What is the most likely cause of this patient's subacute cough?

Chronic bronchitis

Viral upper respiratory tract infection

Gastroesophageal reflux disease (GERD)

Bordetella pertussis infection

B. pertussis should be considered as a possible cause of postinfectious cough, especially if B. pertussis infections have been recently reported in the community, the patient has a history of contact with a known case, the cough has followed a biphasic course (mild and nonproductive at first, then violently spasmodic), or the patient presents with the characteristic "whoop" or with a cough-vomit syndrome. Classically, B. pertussis infection has a 1- to 3-week incubation period; a catarrhal phase of conjunctivitis, rhinorrhea, fever, malaise, and cough; and then a paroxysmal phase, during which the cough worsens. Cough from pertussis usually lasts 4 to 6 weeks. The laboratory confirmation of B. pertussis in a clinical setting can be difficult to establish because there is usually a delay between the onset of cough and the suspicion of the disease and because there is no readily available, reliable serologic test for B. pertussis. Cultures of nasopharyngeal secretions are usually negative beyond 2 weeks of infection, and confirmatory serologic testing requires paired acute and convalescent sera samples. Polymerase chain reaction tests for B. pertussis have not yet been standardized. With postinfectious subacute cough from presumed or confirmed pertussis, antibiotic treatment may be helpful if prescribed within the first few weeks.

Explanation

B. pertussis should be considered as a possible cause of postinfectious cough, especially if B. pertussis infections have been recently reported in the community, the patient has a history of contact with a known case, the cough has followed a biphasic course (mild and nonproductive at first, then violently spasmodic), or the patient presents with the characteristic "whoop" or with a cough-vomit syndrome. Classically, B. pertussis infection has a 1- to 3-week incubation period; a catarrhal phase of conjunctivitis, rhinorrhea, fever, malaise, and cough; and then a paroxysmal phase, during which the cough worsens. Cough from pertussis usually lasts 4 to 6 weeks. The laboratory confirmation of B. pertussis in a clinical setting can be difficult to establish because there is usually a delay between the onset of cough and the suspicion of the disease and because there is no readily available, reliable serologic test for B. pertussis. Cultures of nasopharyngeal secretions are usually negative beyond 2 weeks of infection, and confirmatory serologic testing requires paired acute and convalescent sera samples. Polymerase chain reaction tests for B. pertussis have not yet been standardized. With postinfectious subacute cough from presumed or confirmed pertussis, antibiotic treatment may be helpful if prescribed within the first few weeks.

Diagnosis And Treatment Of Cough