Cough Management Lecture Slides Oct 4, 2024 PDF

Cough Management Eric Leung, MD FRCPC October 4, 2024 Master of Physician Assistant Studies Objectives 1. Demonstrate a basic understanding of the approach to managing most common causes of cough in adult 2. Discuss management of cough as a symptom (antitussives, bronch...

Cough Management Eric Leung, MD FRCPC October 4, 2024 Master of Physician Assistant Studies Objectives 1. Demonstrate a basic understanding of the approach to managing most common causes of cough in adult 2. Discuss management of cough as a symptom (antitussives, bronchodilators) 3. Understand when cough might be the presenting symptom for airways disease (ie. Asthma/COPD) 4. Recognize red flag symptoms and when to consider additional workup for unresolving cough Case 1 A 30-year-old male presents to your office with a 6 month history of dry cough. He recalls that he initially contracted an upper respiratory tract infection when at a family gathering. He had sinus congestion, productive cough, and myalgias. His other symptoms resolved but now a dry cough has persisted. It has since worsened and his cough now occurs when talking, laughing, and exercising. ROS: no GERD, sleep apnea symptoms, nocturnal wakening, eczema/atopy, asthma history, lower extremity swelling. On examination, vitals 120/80mmHg, 70bpm, 95% room air. BMI 25. No apparent distress. Respiratory, cardiovascular, and abdominal exam is unremarkable. Case 1 He has also tried an inhaled corticosteroid, proton pump inhibitor, and antibiotics without any benefit. Investigations performed: Chest x-ray: normal Pulmonary function testing: normal What is the diagnosis? What is the diagnosis? Cough hypersensitivity syndrome Morice, et al. ERJ 2021 What treatment should be tried? Chronic cough is burdensome Results in: Stress incontinence Social embarrassment and isolation Vomiting, syncope, exhaustion Quality of life impairment Economic burden (work absenteeism and health care utilization) Identifying treatable traits Asthma Gastroesophageal reflux Obstructive sleep apnea Post nasal drip ACE inhibitor Smoking Pulmonary disease (ie. COPD, ILD, bronchiectasis) Cardiac disease (ie. Heart failure) Treating treatable traits Asthma – ICS or ICS/LABA Gastroesophageal reflux – PPI (may only improve acidity) Obstructive sleep apnea – CPAP Post nasal drip – sinus rinse/nasal spray ACE inhibitor – stop Smoking – stop Pulmonary disease (ie. COPD, ILD) – direct at condition Cardiac disease (ie. Heart failure) – direct at condition Case 2 A 70-year-old male presents to the emergency department with progressive shortness of breath and productive cough of yellow to green phlegm over a 4 day period. He is not able to do more than walk from room to room in his home (baseline mMRC 1). He typically coughs up clear phlegm. He has a 40 pack year smoking history and continues to smoke about half a pack per day. He denies any fevers, chills, or night sweats. He has not had any sick contacts or other exposures and he gets the annual influenza and COVID vaccination. This is his third presentation for the same symptoms. PMHx: COPD (moderate, diagnosed 5 years ago), hypertension, type 2 diabetes Meds: Inspiolto Respimat, ramipril, metformin On examination, his vitals are 110/70, 120bpm (regular), 37.3C, 93% on 4Lpm O2. There is an wheeze throughout the expiratory cycle in all lung fields. A-P diameter increased. Tracheal laryngeal height 3cm. Heart sounds are distant. No edema. Case 2 Investigations: Blood work: Normal CBC (eosinophils 0.4), electrolytes, creatinine, troponin ABG (on 4Lpm): 7.33/45/63/27 Viral panel pending CXR: Hyperinflation EKG: Sinus tachycardia Image taken from radiopedia.org What is the diagnosis? What treatments should be given? Case 2 continued He improves with treatments during his 4 day hospital stay and is ready for discharge. His cough is back to baseline (mostly dry with occasional sputum production). Apart from counselling on smoking cessation, should any other changes be made to his treatment? Case 2 continued He improves with treatments during his 4 day hospital stay and is ready for discharge. His cough is back to baseline (mostly dry with occasional sputum production). Apart from counselling on smoking cessation, should any other changes be made to his treatment? Addition of inhaled corticosteroid (eosinophils 0.4, exacerbation) and pulmonary rehab referral COPD pharmacotherapy 2023 CTS COPD guideline COPD pharmacotherapy 2023 CTS COPD guideline Case 3 A 21-year-old otherwise healthy female presents to your office with cough and shortness of breath that has been progressive over the last 3 months. She is visiting from India with a student visa. She endorses fevers and sweats but no chills. She has lost about 20 lbs during this time. She is a never smoker and denies a history of pulmonary infections. On examination, vitals are 100/65mmHg, 100bpm (regular), 37.8C, 94% on 1Lpm. BMI 17. She appears malnutritioned. Chest exam reveals bronchial breath sounds in the left upper hemithorax. Cardiac and abdominal exam unremarkable. No rashes or joint swelling. No adenopathy. Case 3 Investigations performed: Blood work: Normal CBC, electrolytes, creatinine. Albumin 25 CXR: Left upper lobe cavitary lesion EKG: Sinus tachycardia What other testing and management should be included? What is the most likely diagnosis? Rates of TB (in 2022) ? Map of TB rates World Health Organization What is the management? Let’s take a break! Case 4 An 80-year-old male presents to the ED with a 6 month history of increasing dyspnea and cough. It is associated with night sweats and weight loss of 35 lbs. He also endorses orthopnea and has been sleeping with 3 pillows. He recently quit smoking when the symptoms started but has accumulated a 50py smoking history. PMHx: COPD (mild), hypertension, dyslipidemia Medications: Incruse Ellipta, perindopril, rosuvastatin On examination, vitals 110/70mmHg, 90bpm, 37C, 93% room air. BMI 18. Reduced breath sounds, decreased tactile fremitus, dull percussion to the left lower hemithorax. Cardiac and abdominal exam unremarkable. No adenopathy. Case 4 Investigations performed: Blood work: Normal CBC, electrolytes, creatinine, NT-proBNP, troponin. CXR: Left pleural effusion. What is the next best test? Approach to pleural effusion Lights criteria Protein