Cough

Cough

Patients with cough frequently present toprimary and secondary care facilities. Cough can be classified under acute, sub acute, and chronic categories based on the duration of cough. Often, acute cough will spontaneously resolve without any medical interventions; however,other life threatening, or lethal causes of cough should be ruled out. Similarly, subacute and chronic cough will require further investigationsand careful evaluation because cough can also be caused by extrapulmonary causes. Managing cough as a ‘defense mechanism versus a symptom’ can be a challenging task to primary care practitioners.

Stage 1

Abstract Conceptualization

Abstract Conceptualization

Stage 2

Active Experimentation

Active Experimentation

Patient assessment & History collection

Ask relevant questions to find out the duration of cough and verify if it is acute, sub acute or chronic cough. Confirm any history of recent viral infection, smoking, use of ACEI or betablocker, occupational exposure to allergens, environmental or food allergies, asthma, COPD, GERD, cardiac conditions and symptoms such as shortness of breath, chest pain, dysphagia,etc. During physical examination, assess s/s of viral URTI/ rhino sinusitis, evaluate general presentation, perform respiratory assessment, check vital signs, listen to cardiac sounds, and notice cough pattern (3).

Acute cough

Acute cough is defined as cough with a duration of less than 3 weeks and often follows a recent viral upper respiratory tract infection. In the absence of any comorbidities, almost all cases will spontaneously resolve without any interventions. However, in presence of hemoptysis, prominent systemic illness, suspicion of inhaled foreign body, suspicion of lung cancer, pulmonary embolism etc., emergency medical assistance is required.During physical examination, assess s/s of viral URTI, evaluate general presentation, perform respiratory assessment, check vital signs, cardiac sounds, watch for pedal edema, and evaluate cough pattern. When pneumonia is suspected (fever, chills, chest pain with breathing, crackles, egophony or fremitus, and chest examination findings of focal consolidation),offer antibiotics.Verify if any pre-existing h/o COPD, asthma, CAD, or exposure to occupational, environmental or food allergens. If any recent initiation of ACEI or beta blockers is noted, consider switching to another antihypertensive drug class. Similarly, if any shortness of breath with underlying h/o CAD, pedal edema, and abnormal cardiac sounds, initiate an urgent evaluation to rule out CHF. Acute rhino sinusitis under one week should not be treated with antibiotics.Patients report benefit from various over‐the‐counter preparations; there is little evidence of a specific pharmacological effect (6). When cough lasts for more than 2 weeks with paroxysms of coughing, post tussive vomiting, and inspiratory whooping sound, rule out pertussis by doing a nasopharyngeal swab. Hemoptysis, breathlessness, fever, chest pain, weight loss are the signs that indicate possible need for chest x- ray (3).

Subacute Cough

A cough lasting less than 8 weeks, but more than 3 weeks is known as subacute cough. Post infectious cough (after viral URTI) is the most common cause. Physical examination and detailed history collection are required to rule out upper airway cough syndrome, asthma, GERD, bronchitis, pneumonia, and other serious illness. The term upper airway cough syndrome implies cough associated with post nasal drip, direct upper airway irritation, or inflammation of upper airway receptors. Acute bronchitis will present with an acute cough, which is usually productive. The cough lasts for less than 3 weeks in 50% of patients, but for more than 1 month in 25% of patients (5).Sub acute upper respiratory tractions may be treated with first generation antihistamines, oral decongestants, ipratropium, and short acting corticosteroids. Acute sinusitis with subacute cough, will benefit from antibiotic treatment. Similarly, offer asthma, COPD treatment, if an acute flare up of these conditions are suspected. Patients who exhibit s/s of pertussis should be treated with macrolides (1). If any occupational, environmental, dietary allergic causes are suspected, address them accordingly.Stop the medication that is responsible forcough. To learn more about the management of acute bronchitis, refer to the following: http://www.cfp.ca/content/54/2/238

Chronic Cough

A cough that lasts more than 8 weeks is known as chronic cough. Asthma, bronchiectasis, chronic bronchitis, non-asthmatic eosinophilic bronchitis, upper airway cough syndrome, allergic rhinitis, non-allergic rhinitis, chronic rhinosinusitis, gastroesophageal reflex disease, cough and pulmonary neoplasia, cough caused by medication, post infectious cough, and psychogenic cough are the common causes of chronic cough (3). Patients with suspected GERD should be given a trial of PPI with appropriate dietary, lifestyle instructions. Patients who are at risk for tuberculosis need to be thoroughly screened to r/o TB.

Stage-3

Concrete Experimentation

Concrete Experimentation

Clinical management of cough

Clinical management of cough

Refer to the following link for Asthma management guideline: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527232/

COPD management: https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-g

GERD management: http://www.topalbertadoctors.org/cpgs/?sid=14&cpg_cats=52

URTI (viral) Antihistamines+ oral decongestant If subacute: ipratropium and short acting corticosteroids
Acute sinusitis First generation antihistamines, oral decongestant, antibiotics
Asthma ICS, b2-agonists, oral corticosteroids (if severe)
Chronic bronchitis Smoking cessation, avoid irritant, bronchodilator, Corticosteroid
Acute bronchitis Broncho dilator- mixed evidence, antibiotics-minimal result
Non-asthmatic eosinophilic bronchitis ICS
Post infectious cough Resolves its own, decongestants, ICS, nasal ipratropium
GERD PPI, antacids, h2 receptor antagonists
Upper airway cough syndrome Antihistamines, oral decongestants, nasal ipratropium

Diagnostic evaluation

CT chest is the golden test to rule outCa lungs, interstitial lung disease, pulmonary embolism

TB, pneumonia, pneumothorax pleural effusion, —chest x ray is the fist step

GERD- barium upper GI series may give an indication if diagnosis is unclear

COPD- refer for spirometry

Dysphagia-ENT/ SLP consult required

Echocardiogram- if CHF suspected

SOAP notes

S: URTI symptoms X 1 week

cough: productive

breathing problems: no

fevers: low grade x last1 week; no fever since today morning

coryza: yes

sore throat: no

ear pain: no

sinus pain- nil

throat clearing- mild

history of asthma/copd: no

H/o GERD: nil

using inhalers: nil

travel history- nil

O: T: 37.6 C HR: 82

General: NAD, looks well, alert & oriented, no jaundice/palor/cyanosis/diaphoresis

Resp: no distress, no increased work of breathing, AE=AE, no wheeze/crackles/rales

CVS: radial pulse strong/reg, S1S2 n, no S3S4, no murmurs/rubs/clicks, no ankle edema

A: Viral URTI

P: Reassurance given that symptoms will resolve spontaneously

In case of worsening of symptoms, sob, neck stiffness, rashes fever, cough more than 3 weeks, should rtc

Stage 4

Reflection

Reflection

Student Activity

Write a reflection on your learning experience with assessing and diagnosing patients with cough.Illustrate your experience by using Kolb’s learning cycle?

Reference

Goldman, R (2011). Treating cough and cold: Guidance for caregivers of children and youth. Pediatric Child Health 2011;16(9):564-6. Retrieved from https://www.cps.ca/en/documents/position/treating-cough-cold

Canadian Thoracic Society (2019). Diagnosis and management of Asthma. Retrieved from https://cts-sct.ca/guideline-library/

Canadian Thoracic Society (2019). Chronic refractory cough. Retrieved from https://cts-sct.ca/guideline-library/

Canadian Thoracic Society (2019). Diagnosis and management of COPD. Retrieved from https://cts-sct.ca/guideline-library/

Worrall, G (2008). Acute bronchitis.Canadian Family Physician. February 54 (2) 238-239 http://www.cfp.ca/content/54/2/238

Morice, A. H., McGarvey, L., Pavord, I., British Thoracic Society Cough Guideline Group (2006). Recommendations for the management of cough in adults. Thorax, 61 Suppl 1(Suppl 1), i1-24. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2080754/