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