ASTHMA RESOURCE PACK Section 3 Chronic Cough Guidelines NHS Fife Guidelines for the Management of Chronic Cough in Adults In this section: 1. Introduction 2. Scope Guidelines for Management of Chronic Cough History Physical Examinations Investigations Further Management 3. Protocol for the Management of Chronic Cough in Adults Asthma Resource Pack: Section 3 Chronic Cough Guidelines Version 4 Last Updated: June 2015
1. INTRODUCTION The following recommendations are primarily intended to help healthcare practitioners investigate, diagnose and treat patients presenting with chronic cough. They are based on best practice guidelines issued by the British Thoracic Society (2006). They are compatible with the chronic cough patient pathway of the Centre for Change and Innovation, NHS Scotland (June 2005), and guidance from the European Respiratory Society (2007) and the American College of Chest Physicians (2006). They also provide a guide as to who should be referred to the Respiratory Medicine Service. 2. SCOPE: FIFE WIDE Guidelines for Management of Chronic Cough in Adults Chronic cough is defined as one lasting more than 8 weeks. It may be a prominent symptom of many important chronic respiratory diseases but may be also the sole presenting feature of a number of extra-pulmonary conditions, notably rhino-sinus disease and gastrolaryngeal reflux. It is increasingly recognised that more than one condition may be contributing to cough in any one patient. The key to successful management is to obtain a good history and examination followed by appropriate investigation. It is essential to try and identify the presence of underlying structural disease or pulmonary pathology. History Important points in the history include Cough characteristics and associations. The presence of post-nasal drip, catarrh, rhinitis, facial pain and nasal blockage are suggestive of rhino-sinus disease Worsening by posture, on rising in the morning, during meals, conversation or laughing are suggestive of lower oesophageal incompetence and gastro-laryngeal reflux Worse at night or in cold environments, suggestive of asthma syndromes Is cough dry or productive? A consistently productive cough is suggestive of underlying structural disease such as chronic bronchitis or bronchiectasis Associated wheeze or breathlessness, suggestive of asthma or COPD Medications, particularly ACE inhibitors which can cause cough and will potentiate cough of any cause. They should be stopped if troublesome and alternative vasoactive therapies substituted. Bear in mind it may take 3 months for such an ACEI - associated cough to settle. Betablockers and NSAIDs maybe the cause of cough if there is underlying asthma History of atopy, more common in asthma or allergic rhinitis Presence of other recognised respiratory diseases associated with cough such as COPD, asthma, bronchiectasis, pulmonary fibrosis, lung cancer, heart failure Age/gender; chronic cough with no structural disease, more common in middleaged females and a challenge to treat empirically Presence of auto-immune disease, especially thyroid disease and diabetes. These individuals may suffer an auto-immune mediated airway inflammation independent of underlying disease treatment Smoking history, smoking is one of the commonest causes of chronic cough although a change in its character should alert the practitioner to possible new and sinister pathology Occupational history including the role of workplace exposures and sensitisers. Page 2 of 5
Physical Examination Abnormal findings in the physical examination make structural disease more likely. The presence of clubbing, crackles, wheeze or focal chest signs are particularly important. Note the individuals BMI as a risk factor for reflux disease. Investigations All patients with chronic cough should have a departmental PA chest radiograph. Assessment of pulmonary function by spirometry. If an obstructive pattern is identified this should be repeated after nebulised Salbutamol or high dose inhaled Salbutamol via a spacer. Further Management Any patient with chronic cough identified as having an underlying structural disease on the basis of symptoms, signs or a chest radiograph should be managed according to the recommended treatment guidelines for the recognised disease. Bearing in mind particularly the possible presence of cancer in a smoker or ex-smoker, and of tuberculosis. Hence the importance of a chest radiograph and consideration of sputum culture, including mycobacteria. Refer to the Fife Respiratory Medicine Service for further assessment if needed. Bear in mind that a cough due to COPD, bronchiectasis or pulmonary fibrosis may not disappear despite optimal management. Patients who are not suspected of having underlying structural disease are more likely to be suffering either from or a combination of rhino-sinusitis, asthma, eosinophilic bronchitis or gastro-laryngeal reflux. Studies have found that a strategy of sequential and additive, if partial response, of empirical treatment of these disorders starting with the most likely is an effective way of improving symptoms in many patients. The cause of a cough may in any individual patient be multifactorial. If there is a partial response it may be appropriate to continue with that specific treatment and consider trials of other therapies. It may not ever be abolished. 1 Rhino-sinusitis, Upper Airway Cough Syndrome This should be suspected if a cough is accompanied by nasal stuffiness, sinusitis and the sensation of post-nasal drip. This is a common and under recognised cause of cough. A lack of nasal symptoms does not exclude the diagnosis but a lack of response to a therapeutic trial makes it less likely. Management should be as for rhinitis (Fife Respiratory MCN guidance link below) with nasal saline wash-outs, nasal steroid and a non-sedating antihistamine. Protocol for the Treatment of Asthma & Rhinitis 2 Asthma/Eosinophilic Bronchitis Cough is a common symptom in those presenting with asthma and in many cases the diagnosis can be confirmed by the demonstration of variable airways obstruction by spirometry with reversibility testing or peak flow recordings over time. Management should be conventional and can be aided by Fife Respiratory MCN guidance. It is clear, however, that a small proportion of patients with asthma may present with an isolated cough, no evidence of variable airflow limitation on spirometry but a positive response to bronchial hyper-responsiveness when tested, so called cough variant asthma. More recently the syndrome of eosinophilic bronchitis has also emerged. This presents as an isolated cough and is characterised by the presence Page 3 of 5
of eosinophilic airway inflammation similar to that seen in asthma but with no evidence of variable airflow limitation on spirometry, peak flow variability nor bronchial hyper-responsiveness on testing. Both of these conditions are thought to be a common cause of chronic cough in those with no evidence of underlying structural disease and normal or near normal spirometry. Both conditions are corticosteroid responsive. Cough is unlikely to be due to either of these conditions if there is no response to treatment with Prednisolone 30-40mgs per day for 2 weeks. If symptoms improve continue treated with an inhaled steroid at doses similar to those used in conventional asthma. 3 Gastro-laryngeal Reflux This is another under recognised and common cause of chronic cough. It may even contribute to structural lung disease. Many patients will have symptoms associated with reflux although cough may occur in the absence of gastro-intestinal symptoms. In view of this, any patient with chronic cough and symptoms of reflux, or those who have failed to respond to other treatments, should have a therapeutic trial of aggressive anti-reflux therapy. This includes high dose acid suppression for at least 3 months as twice daily proton-pump inhibitors with 3 times daily and at night a liquid alginate-containing antacid to provide a raft within the stomach on top of gastric contents, and consider a prokinetic agent. Remember it will not just be acid that is available to reflux; other gastric contents even as a mist. Remember also to stop medications that might potentially worsen reflux (bisphosphonates, nitrates, calcium channel blockers, theophylline preparations, progesterones). This following web link to the Hull Cough Hypersensitivity questionnaire in which a high score provides additional support for a reflux-related cough http://www.issc.info/hullcoughhypersensitivityquestionnaire.html Page 4 of 5
3. PROTOCOL FOR THE MANAGEMENT OF CHRONIC COUGH IN ADULTS History and examination Chest radiograph Spirometry, and reversibility if not normal Stop ACEI and review in 3 months Yes Pulmonary pathology? No Is patient taking ACEI? No Yes Manage conventionally, that may include referral to Respiratory medicine service Symptoms suggest rhino-sinusitis cough syndrome, asthma/eosinophilic bronchitis or gastro-laryngeal reflux Treat most likely diagnosis Treat sequentially for above conditions, with additive treatment if partial response Treat sequentially remaining diagnoses Cough resolved Acknowledgement The author and NHS Fife Respiratory Managed Clinical Network Steering Group acknowledges permission of the NHS Forth Valley Airways MCN to modify and adapt their Guideline for the Management of Chronic Cough in Adults, 2008, a document prepared by Dr W Newman. Page 5 of 5 Refer Respiratory medicine service