COUGH – BTS guidelines
DR O ADEYO
GPVTS ST2
16/04/13
Cough
 Acute cough
 Chronic cough



History
Examination
Investigation
 Specific cough syndromes
 Cough clinic referral
 Questions/discussion
Acute cough
 < 3 weeks
 Mostly associated with viral URTI
 In absence of significant co-morbidity, usually self-limiting
 Little evidence for OTC preparations but patients report benefit
Impact on UK economy
 £875 million to loss of productivity
 £104 million cost to the healthcare system and OTC medication
Acute cough
 Further investigate




Haemoptysis
Prominent systemic illness
Suspicion of inhaled FB
Suspicion of lung Ca
Chronic cough
 > 8 weeks
 10-20% of adults
 Female and obese
 10% of respiratory ref to 2◦ care
 Decrement in QOL comparable with severe COPD
 Most have dry or minimally productive cough
 Significant sputum - 1◦ lung pathology
 Heightened cough reflex is the 1◦ abnormality
History
 Age + sex
 Smoking
 Characteristic

Onset

Duration

Relation to infection

Sputum

Diurnal variation

Severe coughing spasms/paroxysms

Incontinence

Origin of sensation

Cough triggers + aggravants

Food

Cough on phonation
History
 Medication
 Occupation/hobbies/pets
 PMH
 FH

May be familial (inherited anatomical abnormality,
neurological condition)
Physical examination
 Signs of respiratory disease or cardiac failure
 More often examination reveals less specific findings
 ENT exam
 If FH - neuro exam of legs to look for signs of familial
neuropathy.
Baseline investigations in 1◦ care
 CXR
 All chronic cough
 Acute cough with atypical sx
 Assessment of pulmonary function
 Spirometry – all chronic cough
Helpful in identifying cough caused by chronic airway obstruction
 Normal does not exclude asthma


Avoid using single PEF or PEF to assess bronchodilator
response in diagnosis of airflow obstruction as cause of cough
Specific cough syndromes
Specific cough syndromes
 Cough variant asthma
 Eosinophilic bronchitis
 GORD
 Upper airway disease and cough
 Undiagnosed or idiopathic cough
 Cough due to other common respiratory disease
Cough variant asthma
 Chronic cough is the main (if not the sole) symptom
present
 it is considered to be a variant type of asthma as well as a
precursor to the development of classical asthma
 Clinical indicators include
 Nocturnal, post-exercise, post-allergen exposure
 Progresses to typical asthma in 17–37% of patients
 Hyperresponsiveness is present
Cough variant asthma
 In these patients eosinophils in sputum, bronchoalveolar
lavage (BAL) fluid, and in bronchial biopsy specimens is
characteristic
 Measurement of airway hyperesponsiveness


Inhalation of methacoline
If negative excludes asthma but does not rule out steroid responsive cough.
 Management
 Follow guidelines for asthma except no evidence for LABA
 Evidence exists for use of Leukotriene receptor agonist
 Responds to treatment with inhaled steroids
Eosinophilic bronchitis
 Patients have cough and eosinophils in sputum but
spirometric tests and airway hyperresponsiveness is normal
 50% of patients with CVA have associated EB
 Management
 Responds to inhaled steroids
 Use BTS asthma guidelines for guidance on dose, preparation and
duration
GORD
 Pt’s have increased cough reflex sensitivity which improves
with antireflux therapy



Microaspiration of gastric content into larynx and tracheobronchial
tree
Vagally mediated oesophageal reflex stimulated by acid or non-acid
volume reflux
Oesophageal motor dysfunction and reduced oesophageal clearance
GORD
 Management
 PPI – omeprazole 20 -40 BD before meals – at least 8 weeks

Prokinetic agents – metoclopramide 10mg TDS may be required in
some

Consider stopping medication that can potentially worsen GORD (
biphosphonates, nitrates, ca channel blockers, theophylline,
progesterones)

Antireflux surgery in carefully selected cases
Upper airway disease and cough
 Cough commonly accompanied by
 Nasal stuffiness
 Sinusitis
 Post-nasal drip
 In presence of prominent upper airway sx
 1 month trial of topical steroid recommended
 Can be a diagnostic approach
Undiagnosed or idiopathic cough
 Chronic cough should only be considered idiopathic
following thorough assessment at a specialist cough clinic
 Clinical hx of reflux is usually present
 A typical lymphocytic airways inflammation is seem
 Middle aged women
 Present with chronic dry cough which starts at time of menopause
 Often appears to follow a viral respiratory tract infection
Undiagnosed or idiopathic cough
 Organ specific autoimmune disease is present in up to 30%
- autoimmune hypothyroidism is particularly common
 Treatment is disappointing and is largely limited to non-
specific antitussive therapy such as dextromethorphan and
drugs with weak evidence of benefit such as baclofen and
nebulised local anaesthetics (lidocaine, mepivicaine)
 Low dose morphine recently shown to be helpful
Cough due to other common respiratory diseases
 Cough suppression undesirable in certain conditions
 LRTI (acute tracheobronchitis + pneumonia)
 COPD


Control of sx and reduction of exacebations
No studies on effectiveness of any particular treatment on the cough
itself
 Lung Ca


Radiotherapy
Opiod and non-opiod antitussives recommended
 Diffuse parenchymal lung disease


Mostly breathlessness though frequently reported
Limited information on treatment
Referral to cough clinic
 Lack of availability of relevant diagnostic testing in 1◦ or 2◦ care
 Failed trial of empirical treatment directed at asthma, GORD or
rhinosinusitis
 History suggestive of serious cough complication such as syncope
or chest wall trauma
 Patient preference
 Recruitment and participation in clinical trials of antitussive
therapy
References
 BTS Guideline. Recommendations for the management of cough in adults. A H
Morice, L McGarvey, I Pavord, on behalf of the British Thoracic Society Cough
Guideline Group
 Gp Practice Notebook – a UK medical reference
Cough
Thanks for listening
Any questions?