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, 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 have the physician do right off the bat to rule that out 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 Aprill 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 on 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, it’s called post nasal drip or allergic rhinitis, okay post nasal drip or allergic rhinitis.
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 inge, you’ve got itchy eyes or allergies itchy eyes, so think about all those things in terms of post nasal drip or allergic rhinitis and I would say 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 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 to pro iris, 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 those symptoms fit that’s great, okay let’s go on to the next possibility, the next possibility is also around 9% and that 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 gastroesophageal reflux disease it can sometimes come in and irritate that airway and cause what we call GERD.
So where do we see GERD occurring, 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, so an acid taste in the morning, you obviously have the symptoms of gastro esophageal 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 ear, nose and throat physician, they’d see that erythema test 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 where you can get protonix pantora’s, 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 to 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 percent so this is probably the majority and that’s asthma, okay so they don’t wheeze they just cough 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 cough, there’s gonna be triggers maybe they’ve got down feather pillows or down feather comforters, so look for triggers like 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 lecture, some pulmonary functions has 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 it 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, think about gastroesophageal reflux disease and think about allergic rhinitis.