Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Cough

Cough - Key Features

1. In patients presenting with an acute cough:
a) Include serious causes (e.g. pneumothorax, pulmonary embolism [PE]) in the differential diagnosis.

Consider life-threatening conditions: pneumothorax, PE, heart failure, exacerbation of asthma or COPD, pneumonia

Approach to cough:

Divide patient population	Divide cough
Pediatric: less than 15 yr. Adult: older than 15 yr. Special populations: smoker, immunosuppression, chronic (lung) disease	Acute: less than 3 weeks Subacute: 3-8 weeks Chronic: more than 8 weeks, more than 4 weeks in children

For subacute cough: if history of infection treat as post-infectious until cough becomes chronic (i.e. lasts longer than 8 weeks), if no history of infection, treat as chronic
In children with acute cough, consider croup, bronchiolitis, pertussis and treat

b) Diagnose a viral infection clinically, principally by taking an appropriate history.

No one sign, symptom or test rules out bacterial infection or rules in viral
However, if no red flag symptoms present, no CXR or further investigation is warranted until the cough persists into chronic phase.

History	Red Flag Symptom
Age Details of cough: Duration, ?productive, impact on function, other symptoms (fever, congestion, muscle aches, SOB, chest pain) Other medical conditions: asthma, COPD, Heart Disease, cancer, HIV, immune-suppressed Recent surgery or hospitalization Smoking status Medications, recent use of antibiotics Infectious contacts, vaccination status Occupation (infectious contacts, irritants, allergens) Travel	Sudden fever - Suggestive of influenza, pneumonia, SARS Shortness of Breath, chest pain – r/o life threatening causes Recent surgical procedure – increases likelihood of PE, aspiration, atypical infection Other health problems – ?exacerbation of lung disease (COPD, asthma), risk of atypical infection (immune suppression, IVDU) Smoker: get more infections, tend to persist longer Contact with infected person (influenza, SARS) Recent travel – increases likelihood of atypical infection
Physical Exam	Red Flag Signs
Vitals, weight Listen for cough in office, judge frequency, severity H&N Cardiac – including volume status, signs of heart failure Chest	Unusually ill, abnormal vitals Shortness of breath, respiratory distress High fever Reduced air entry, signs of consolidation, restricted air entry Other signs of DVT Weight loss, weight gain (if fluid overload)

c) Do not treat viral infections with antibiotics. (Consider antiviral therapy if appropriate.)

Acute bronchitis commonly lasts 7 to 10 days; up to 1 month in 25% of patients
Controversial, but may consider Abx if cough lasts >14 d
Abx do not increase/speed up resolution; but decreases “time feeling ill” by 0.5 days
Most people just want the cough to stop: Cough management options

Non-pharma (possibly more effective)	Pharma (expert consensus only)
Decrease or quit smoking Fluids (keep mucus thin) Moist/humid air	Beta agonists (only if wheezing) Codeine, Dextromethapham 1st gen antihistamines

2. In pediatric patients with a persistent (or recurrent) cough, generate a broad differential diagnosis (e.g., gastroesophageal reflux disease [GERD], asthma, rhinitis, presence of a foreign body, pertussis)

In children, divide chronic cough into specific (dx recognizable from description of cough and/or other findings on hx or exam) and non-specific
Specific cough (Table 2)

Type of cough	Diagnosis
Barking or brassy cough Honking Paroxysmal (+/- inspiratory “whoop”) Staccato	Croup, tracheomalacia, habit cough Psychogenic Pertussis and parapertussis Chlamydia in infants
Sign/Symptom	Suggested etiology
Auscultatory findings (wheeze, crackles, differential breath sounds) Cough characteristics (eg, cough with choking, cough quality, cough starting from birth) Cardiac abnormalities (including murmurs) Chest pain Chest wall deformity Daily moist or productive cough Failure to thrive Feeding difficulties (including choking/vomiting) Atypical and typical respiratory infections Neurodevelopmental abnormality Recurrent pneumonia	Asthma, bronchitis, congenital lung disease, foreign body aspiration, airway abnormality Congenital lung abnormalities Any cardiac illness Asthma, functional, pleuritis Any chronic lung disease Chronic bronchitis, suppurative lung disease Compromised lung function, immunodeficiency, cystic fibrosis Compromised lung function, primary aspiration Immune deficiency Primary or secondary aspiration Immunodeficiency, congenital lung problem, airway abnormality

See ACCP Algorithm at end of document.

3. In patients with a persistent (e.g., for weeks) cough:
a) Consider non‐pulmonary causes (e.g., GERD, congestive heart failure, rhinitis), as well as other serious causes (e.g. cancer, PE) in the differential diagnosis. (Do not assume that the child has viral bronchitis).

Wide differential, often with multiple causes in the same person.
Start with hx and p/e as for acute cough, plus CXR. Be wary for constitutional symptoms suggestive of cancer or TB infection.
Three most common causes in adults: Post-nasal drip, asthma, GERD

b) Investigate appropriately.

AAFP Algorithm

4. Do not ascribe a persistent cough to an adverse drug effect (e.g. from an angiotensin‐converting enzyme inhibitor) without first considering other causes.

If cough caused by ACEi, expect resolution within 2 weeks of stopping.

5. In smokers with persistent cough, assess for chronic bronchitis (chronic obstructive pulmonary disease) and make a positive diagnosis when it is present. (Do not just diagnose a smoker’s cough.)

See COPD topic

ACCP Guidelines. Table 2 show above.

Figure 3

Study Guide

Cough

Resources

Worral, G. Acute cough in adults. CFP Jan 2011;57(1):48-51
Coughlin, L. Cough: Diagnosis and Management. AFP 15 Feb 2007; 75(4):567-575

o Summary of American College of Chest Physician Guidelines; has chronic cough algorithm

Worral, G. Acute cough in children. CFP Mar 2011; 57(3): 315–318
Irwin, R. et al. Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines. Chest. 1 Jan 2006; 129(1 suppl):1S-292S

o Really dense; stick with the AFP Summary

Chang, A and Glomb, W. Guidelines for Evaluating Chronic Cough in Pediatrics. Chest. Jan 2006; 129(1 suppl):260S-283S