Cough

1
Cough

• Mudher Al-khairalla

2
A man presents to you with coughing

• What would you like to know?

3
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

4
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Recent or long standing (Chronic)

5
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Chronicity
• Pertussis
• TB
• Foreign body
• Asthma
• Drugs
• Bronchiectasis
• ILD

6
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Brassy?
• Pressure on the trachea?

7
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Hollow/Bovine?
• Laryngeal nerve palsy causing vocal cord
  dysfunction

8
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Barking?
• Acute Epiglottitis

9
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Dry?
• GORD
• Drugs (e.g. ACEI)

10
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Change in character of a chronic cough should
  make you consider other pathology.

11
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Asthma
• Also Early morning

12
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Usually in asthma
• Emotion
• Weather
• Wind
• Rain
• Cold
• Dust
• Allergies
• Exercise
• Drugs

13
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Avoidance of precipitating factors!

14
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Presence?
• Colour
• Volume
• Consistency
• Pattern
• Consider
• Infections
• COPD
• CF
• Bronchiectatsis

15
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Presence?
• Colour
• Volume
• Consistency
• Pattern
• Will be covered elsewhere!

16
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Breathlessness
• Sputum
• Chest pain
• Wheeze
• Hoarseness

17
Meet Mr Coughing 61 years old
www.badvertising.org/pages/0220How20To20BA...
18
Presentation

• Cough productive of white sputum most days over
  the past 2 years
• Life long smoker (30 per day)
• Gets breathless going up the stairs

Mr Coughing 61
19
What do you think he has?

1. Asthma
2. COPD
3. Lung Cancer
4. Sarcoid
5. Rhinitis

Mr Coughing 61
20
What do you think he has?

1. Asthma
2. COPD
3. Lung Cancer
4. Sarcoid
5. Rhinitis

Mr Coughing 61
21
What test would you like next?

1. Spirometry
2. Spirometry with reversibility
3. Chest x-ray
4. Peak flow diary
5. Sputum cytology

Mr Coughing 61
22
What test would you like next?

1. Spirometry
2. Spirometry with reversibility
3. Chest x-ray
4. Peak flow diary
5. Sputum cytology

Mr Coughing 61
23
What test would you like next?

1. Spirometry
2. Spirometry with reversibility
3. Chest x-ray
4. Peak flow diary
5. Sputum cytology

• Confirm obstructive picture
• Assess severity
• Lack of reversibility more often found in COPD
  than asthma

Mr Coughing 61
24
How would you like to treat him?

1. Smoking cessation
2. Smoking cessation plus CombiventR 2 puffs QDS
3. Beclomethasone 200 2 puffs BD
4. Pulmonary Rehabilitation
5. Salbutamol 2 puffs PRN

Mr Coughing 61
25
How would you like to treat him?

1. Smoking cessation
2. Smoking cessation plus CombiventR 2 puffs QDS
3. Beclomethasone 200 2 puffs BD
4. Pulmonary Rehabilitation
5. Salbutamol 2 puffs PRN

Mr Coughing 61
26
Unwell!

• He becomes unwell with fevers, sweats, increasing
  cough and sputum volume.
• Sputum is now green
• He also complains of right sided pleuritic chest
  pain and had a few crackles at the right base on
  chest auscultation

Mr Coughing 61
27
What do you think has happened?

1. Lung carcinoma
2. Lower respiratory tract infection
3. Upper respiratory tract infection
4. Pneumothorax
5. Pulmonary Embolism

Mr Coughing 61
28
What do you think has happened?

1. Lung carcinoma
2. Lower respiratory tract infection
3. Upper respiratory tract infection
4. Pneumothorax
5. Pulmonary Embolism

Mr Coughing 61
29
This is his CXR
www.meddean.luc.edu/.../pulmonar/cxr/segm.htm
Mr Coughing 61
30
How would you like to treat him?

1. Oxygen
2. Nebulisers
3. Antibiotics
4. Prednisolone
5. All of these

Mr Coughing 61
31
How would you like to treat him?

1. Oxygen
2. Nebulisers
3. Antibiotics
4. Prednisolone
5. All of these!

Mr Coughing 61
32
6 months later

• After making a good recovery, he presents 6
  months later to his GP who asks you to see him at
  your out patient chest clinic
• You note that he has had at least 3 chest
  infections since his discharge from hospital.
• He still smokes!
• Examining him you note finger clubbing, bilateral
  inspiratory coarse crackles at the lung bases on
  chest auscultation

Mr Coughing 61
33
What investigation would you like next?

1. CT chest
2. High Resolution CT chest (HRCT)
3. Arterial Blood Gases
4. Pulmonary Function tests
5. Bronchoscopy

Mr Coughing 61
34
What investigation would you like next?

1. CT chest
2. High Resolution CT chest (HRCT)
3. Arterial Blood Gases
4. Pulmonary Function tests
5. Bronchoscopy

Mr Coughing 61
35
This is his HRCT
brighamrad.harvard.edu/.../hcache/211/full.html
Mr Coughing 61
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What is the diagnosis?

• Pulmonary fibrosis
• Hypersensitivity Pneumonitis
• Lung cancer
• Lymphangioleiomyomatosis
• Bronchiectasis

Mr Coughing 61
37
What is the diagnosis?

• Pulmonary fibrosis
• Hypersensitivity Pneumonitis
• Lung cancer
• Lymphangioleiomyomatosis
• Bronchiectasis

Mr Coughing 61
38
One year later

• Mr coughing notices that his cough has changed
  character over the past couple of weeks
• He has also noticed 5kg weight loss over the past
  month and had one episode of haemoptysis a week
  ago

Mr Coughing 61
39
This is his CXR
Mr Coughing 61
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What should you do next?

• Sputum cytology
• Sputum microscopy
• Bronchoscopy and CT chest staging
• Lateral CXR
• Give him Tranexaemic acid

Mr Coughing 61
41
What should you do next?

• Sputum cytology
• Sputum microscopy
• Bronchoscopy and CT chest staging
• Lateral CXR
• Give him Tranexaemic acid

Mr Coughing 61
42
This is his Bronchoscopy
Mr Coughing 61
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Where is the tumour?

• Left Upper Lobe
• Bronchus intermedius
• Right middle lobe
• Right lower lobe
• Left Lower lobe

Mr Coughing 61
44
What should you do next?

• Left Upper Lobe
• Bronchus intermedius
• Right middle lobe
• Right lower lobe
• Left Lower lobe

Mr Coughing 61
45
www.lumen.luc.edu/.../mech/cases/case9/list.htm
46
www.tbalert.org/resources/resources.php
Mrs Coughing 49
47
History

• This 49-years-old lady has had a dry cough for a
  few months.
• Her BMI is 36
• She doesnt smoke
• She takes Gaviscon plus a tablet for her blood
  pressure which she cant recall

Mrs Coughing 49
48
Which of the following Blood pressure tablets
might be relevant in her symptoms?

1. Ramipril
2. Bendrofluazide
3. Nifedipine
4. Atenolol
5. None of them!

Mrs Coughing 49
49
Which of the following Blood pressure tablets
might be relevant in her symptoms?

1. Ramipril
2. Bendrofluazide
3. Nifedipine
4. Atenolol
5. None of them!

Mrs Coughing 49
50
Which of the following Blood pressure tablets
might be relevant in her symptoms?

1. Ramipril
2. Bendrofluazide
3. Nifedipine
4. Atenolol
5. None of them!

• ACE inhibitors are known to cause cough by
  inhibiting the breakdown of Bradykinin

Mrs Coughing 49
51
Which of the following Blood pressure tablets
might be relevant in her symptoms?

1. Ramipril
2. Bendrofluazide
3. Nifedipine
4. Atenolol
5. None of them!

• Beta Blockers can worsen or precipitate
  underlying asthma

Mrs Coughing 49
52
More history

• She tells you that her cough is quite bad first
  thing in the morning and sometimes wakes her up
  during the night
• She also wheezes whenever she tries to catch the
  bus

Mrs Coughing 49
53
This is her Spirometry

• FEV1 1.6L (76)
• FVC 2.4L (83)
• FEV1/FVC 67

Mrs Coughing 49
54
What is the most likely diagnosis?

1. Asthma
2. COPD
3. Sarcoid
4. Pulmonary embolism
5. Non Specific interstitial pneumonitits

Mrs Coughing 49
55
What is the most likely diagnosis?

1. Asthma
2. COPD
3. Sarcoid
4. Pulmonary embolism
5. Non Specific interstitial pneumonitits

Mrs Coughing 49
56
How would you treat her?

1. Salbutamol 2 puffs PRN
2. Salbutamol 2 puffs PRN Becotide 200 2 puffs
   B.D.
3. Nebulised Salbutamol
4. Theophylline
5. Tiotropium

Mrs Coughing 49
57
How would you treat her?

1. Salbutamol 2 puffs PRN
2. Salbutamol 2 puffs PRN Becotide 200 2 puffs
   B.D.
3. Nebulised Salbutamol
4. Theophylline
5. Tiotropium

Mrs Coughing 49
58
How would you treat her?

1. Salbutamol 2 puffs PRN
2. Salbutamol 2 puffs PRN Becotide 200 2 puffs
   B.D.
3. Nebulised Salbutamol
4. Theophylline
5. Tiotropium

• You need to give her PEF meter and ask her to
  keep a diary
• Review her in a week
• Advise her to return promptly if her symptoms
  worsen

Mrs Coughing 49
59
3 months later

• Your treatment has been helpful
• She has no cough during the night but still has a
  dry cough during the day occasionally
• She also complains of quite bad heartburn and
  indigestion

Mrs Coughing 49
60
What would you advise?

1. Life style measures
2. Anti reflux treatment
3. Dietary modification
4. Exercise
5. All of the above

61
What would you advise?

1. Life style measures
2. Anti reflux treatment
3. Dietary modification
4. Exercise
5. All of the above!

62
Miss Coughing 23
63
Their daughter!

• Usually keeps well
• Eczema as a child
• Presents with dry cough, lethargy and generalised
  aches and pains
• She has also developed a painful red lesion on
  her left shin

Miss Coughing 23
64
www.patient.co.uk/showdoc/40001001/
Miss Coughing 23
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What is your next step?

1. Dermatology referral
2. Arrange skin biopsy
3. Spirometry
4. CXR
5. Peak Flow diary

Miss Coughing 23
66
What is your next step?

1. Dermatology referral
2. Arrange skin biopsy
3. Spirometry
4. CXR
5. Peak Flow diary

Miss Coughing 23
67
This is her CXR
adam.about.com/encyclopedia/1613.htm
Miss Coughing 23
68
This is her CXR
adam.about.com/encyclopedia/1613.htm
Miss Coughing 23
69
What is the likely diagnosis?

1. Tuberculosis
2. Non Tuberculous mycobacterium
3. Breast cancer
4. Lymphoma
5. Sarcoidosis

Miss Coughing 23
70
What is the likely diagnosis?

1. Tuberculosis
2. Non Tuberculous mycobacterium
3. Breast cancer
4. Lymphoma
5. Sarcoidosis

Miss Coughing 23
71
This is their dog
www.harbourvets.co.uk/notice_board.htm
72
Just Kidding!