Management of acute and chronic cough Dr Veronica

Management of acute and chronic cough Dr Veronica White MD FRCP Clinical Lead, TB service Barts Health NHS Trust

Definition “Cough is a forced expulsive manoeuvre against a closed glottis and which is associated with a characteristic sound”

Acute and chronic cough Ø Acute cough: lasts < 3 weeks Ø Chronic cough: lasts > 8 weeks Ø ? 3 -8 weeks – difficult to define

Acute cough Ø Commonest new presentation to primary care Ø Most commonly associated with viral URTI Ø Normally benign and self-limiting Ø Commonest symptom associated with acute exacerbations and hospitalisations with asthma and COPD

Acute cough – statistics (2006) Ø Approx £ 100 spend per annum on non-prescription cough medicines Ø 12 million consultations with GPs per annum Ø Cost to economy £ 979 million

Management Ø In general – advice only Ø Little evidence of pharmacological benefit from over the counter preparations Ø “Honey and lemon” best home remedy(!) Ø Voluntary suppression of cough may be sufficient to reduce symptoms Ø Opiate antitussives not recommended

Management Worrying history/symptoms: l Haemoptysis l Breathlessness l Fever l Chest pain l Weight loss l Evidence of vocal cord palsy l History of foreign body inhalation

Common serious conditions associated with isolated cough ● Neoplasms ● Infection e. g. TB ● Foreign body inhalation ● Acute allergy – anaphylaxis ● Interstitial lung disease

Chronic cough

Taking a history Ø Age and sex – more common in middle aged women Ø Smoking Ø Occupation/hobbies/pets Ø Family history

Taking a history Ø Characteristics: l l l Onset and duration; ? diurnal variation; ? coughing on phonation Relation to infection Sputum Severe coughing spasms/paroxysms Incontinence Chemical triggers; posture; food

Taking a history Ø Past medical history l l l l Asthma, eosinophilic bronchitis COPD Bronchiectasis Lung cancer Pertussis infection; atopic disease Cardiovascular disease Autoimmune disease

Baseline investigations Ø Primary care l l Chest X-ray Spirometry Ø Secondary care l l Bronchoscopy High resolution CT

What I tell patients…. Five commonest cause of chronic cough with normal CXR Asthma Ø Hayfever/post nasal drip Ø GORD Ø Recent URTI Ø Smoking Ø

Management Ø Asthma – treat as per BTS guidelines Ø GORD – 8 weeks of high dose PPI Ø Upper airways disease – antihistamine, nasal spray

Management Also: Ø Smoking – STOP! Ø Post viral cough - ? low dose steroid inhaler Treat these empirically first

Other diagnosis Ø COPD Ø Infection – bacterial, TB Ø Interstitial lung disease including sarcoidosis Ø Bronchiectasis Ø Drugs – (ACE) inhibitors Ø Foreign body

Intractable cough Can lead to musculoskeletal chest pain, cough rib fracture, urinary incontinence. Ø Cough syncope has also been described where an individual collapses after a severe fit of coughing. Ø

Intractable cough Aggressive treatment: Ø inhaled steroid Ø high dose oral steroids Ø codeine linctus – not in simple coughs Ø Patients with cough associated with an underlying malignancy - diamorphine and morphine - help both the pain and distress

Specialist cough clinics Ø Selective diagnostics and empirical trials of treatment – cost effective Ø Refer to specialist clinic when empirical treatment has failed Ø Systemic, cost effective approach Ø Management algorithms improve outcome

Specialist investigations Ø Bronchial provocation testing Ø Oesophageal testing Ø Sinus imaging Ø Fibreoptic laryngoscopy Ø Cough provocation test

Summary Ø Most acute cough is benign, but look for additional, worrying symptoms Ø Chronic cough: take a good history; baseline investigations Ø Treat presumed/probable underlying cause Ø Refer to specialist clinic if necessary

Red flags Ø Haemoptysis Ø Breathlessness Ø Fever Ø Chest pain Ø Weight loss Ø Evidence of vocal cord palsy Ø History of foreign body inhalation

If CXR abnormal Refer urgently to relevant service: 2 WW lung cancer Ø ILD clinic – Dr Gavin Thomas Ø TB clinic – Dr Veronica White, Max Caplin clinic, Mile End Ø Oncology Ø

Update on TB East London

Epidemiology Ø UK cases in 2013 – 7892; 38% in London Ø Barts Health – largest TB service in UK - 600 cases per annum; tertiary referrals Ø Tower Hamlets – 100 cases Ø Newham – 335 cases

Making a diagnosis Ø Ø Cough +/- haemoptysis Fever Ø Night sweats Ø Weight loss

Making a diagnosis Ø Blood tests – not specific Ø X-rays Ø Samples – sputum, pus, biopsy Ø Scans such as CT and MRI

Baseline investigations Ø Sputum or pus for AFB Ø CXR

However…. _x 000 c_Pulmonary TB _x 0010_Non pulmonary TB

Coming soon…. Ø Screening of new entrants for latent TB in primary care Ø Funding and commissioning will come via CCG Ø Chemoprophylaxis will be given in TB clinics

Summary Ø Symptoms can be insidious Ø Ask about systemic symptoms – often forgotten (by patient and medics) Ø Multi- organ disease; TB can occur at any site Ø Samples/biopsies are crucial – send for AFB

In Summary Ø If in doubt, refer. Max Caplin Clinic, Mile End Hospital Fax: 0208 1214185 TBenquires@bartshealth. nhs. uk

Discussion…