okay welcome to another MedCram lecture we're going to talk about
chronic cough now this is something that is defined as anybody who has at least
eight weeks of a 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 have the physician 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 i increasing bradykinin and so really if 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 going to 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 my little picture here of a of a head the nose the
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 going to
make a lot of secretions and those secretions are going to 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 app 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 to pro as 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 in 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 erythema
test 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 Pinto Brasil 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 and they're good 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 going to have the symptoms of
asthma except instead of wheezing they go to coughs oh there's going to be
triggers maybe they've got down feather pillows or down feather comforters so
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 it 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 that's the case then you're going to 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 which is that
one thanks very much
you