Chronic Cough Explained Clearly – Remastered

okay well welcome to another MedCram
lecture we're gonna talk about chronic cough now this is something that is
defined as anybody who has at least eight weeks of cough the first thing you
want to do if this is going on is generally speaking you want to get a
chest x-ray and rule out infectious etiology this is a big problem if you
got an infectious etiology you're thinking about things like tuberculosis
you're thinking about pneumonia this is stuff that you ought to do right off the
bat to rule that out so but let's just say you've got a normal chest x-ray and
then the other thing you want to rule out is to make sure you're not on
something called an ACE inhibitor that's a medication that usually ends in April
like captopril lisinopril enalopril ramipril these ACE inhibitors can cause
coffee increasing bradykinin and so really if somebody's got a chronic cough
that you're trying to work out on a test the first thing you want to do is make
sure you've got a chest x-ray to rule out infectious problem and then look at
their med list to make sure they're not an ACE inhibitor I would say about 30%
of patients with an ACE inhibitor are gonna have some sort of a chronic dry
cough okay so once you've ruled these out what are the possibilities let's
talk about what those possibilities are so there are three possibilities that I
like to look at in terms of chronic cough and the first thing I'd like to do
is start off with one from the top if you will so if you know you've got
here's here's my little picture here of a head the nose and mouth okay you know
that the nasal passageway goes down this way and you've got your tongue if you've
got allergic rhinitis in this area you're gonna make a lot of secretions
and those secretions are gonna pool and then tickle down into the back of the
throat and it's going to cause you to clear your throat and that's what we
call post nasal drip or allergic rhinitis okay post nasal drip allergic
rhinitis so what are the symptoms of that clearing your throat a
lot okay if you look in the back of the throat you see this thing called
cobblestone in' you've got itchy eyes or allergies itchy eyes okay so think about
all those things in terms of post nasal drip or allergic rhinitis and I would
say out of out of all the people who have a chronic cough or what we've
eliminated this accounts for about 9% of that so think about that the next time
someone comes in with a chronic cough it's quite possible that we could be
dealing with someone with post nasal drip so what's the treatment for that
well you want to try to identify the things that's calling the out that's
causing the allergies but the treatment generally speaking is intra nasal
steroids okay so you've heard of things like Nasonex you've heard of flonase
you've heard of a stolen or asked a pro or these are all kind of intranasal
steroids or antihistamines okay the other thing that's indicated for
allergic rhinitis is singulair so that might be something else that you could
use for a possible chronic cough and so if that's if those symptoms fit that's
great okay let's go on to the next possibility the next possibility is also
around 9% and then instead of coming from the top down it comes from the
bottom up so here you've got your airway but right next to your airway in fact
right behind your airway is your esophagus which goes down to your
stomach and if you've got stuff in there and you get something called gastro
esophageal reflux disease it can sometimes come in and irritate that
airway and cause what we call GERD okay so where do we see GERD occurring GERD
is occurring when or GERD related cough can happen actually in young people you
don't have to be old typically what you see is an acid taste in the morning
let's lighten that up here so you can see it a bit better so an acid taste
the morning you obviously have the symptoms of gastroesophageal reflux
disease that's heartburn sometimes you might have erosions from the acid in the
back of your throat or specifically in your teeth you might have erythema there
if someone were to look down into your throat like it ear nose and throat
physician they'd see that IV era that montes so what is the treatment for that
so you can use a proton pump inhibitor you can actually get that over-the
counter called prilosec or you can get protonix pent oprah's all there's so
many different types of proton pump inhibitors but there's some other things
that you can do you can take the head of your bed and put it on two bricks so
that it's facing up alternatively you could also get a wedge the purpose of
this is to keep the head of your bed up so that the abdominal contents don't
come up and bathe the trachea they stay down but other things that you can do is
no eating three hours before lying down and then there's this sphincter which is
right here at the stomach and there are a few things that we know about that can
cause that sphincter to open up and you want to avoid those things so those
things that we would avoid especially at night would be alcohol caffeine spicy
foods and chocolate okay so if that seems to be what seems to be fitting in
there occurred then these are the kind of things that you might want to make
sure that you're not doing the last one is probably the most common this is
about 39% so this is probably the majority and that's asthma okay so they
don't wheeze they just COFF or maybe they do wheeze but they don't have to
but just coughing could be a symptom of asthma and that alone might do it and so
what are these type of patients they're gonna have the symptoms of asthma except
instead of wheezing they're gonna coughs oh there's going to be triggers maybe
they've got down feather close or down feather comforters to look
for triggers like down or pets in the bedroom or allergies you're not going to
really know that this is what's going on unless you do a pulmonary function test
now look at the med cram lectures on pulmonary function test to get some idea
what asthma should look like and then the other thing the most diagnostic
thing that you will do is a methacholine challenge test and this is where they
take in a breath and do a fev1 maneuver and then you give a methacholine and you
see how they do if they drop down then you know that they are susceptible to
methacholine which means they're asthmatic and then you give them an
albuterol treatment and they come back up again if that happens then you know
the methacholine challenge test was positive then it's asthma you're talking
about and in that if that's the case then you're gonna use intra or inhaled
intra bronchial or inhaled steroids that's exactly how you treat asthma
here's the trick though most of the time this chronic cough is not due to just
one of these it's actually due to multiple and you'll see that there's
overlap between these different areas so you might have to employ different
treatments in all of these different places so think about that the next time
you have a patient with chronic cough think about cough variant asthma which
is this one think about gastroesophageal reflux disease which is this one and
think about allergic rhinitis thanks very much you

You May Also Like