,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Chronic CoughA Practical Approach,Definition,Cough lasting,more than 8 weeks,in a nonsmoking,immunocompetent patient who has a,normal chest radiograph,is not receiving therapy with an,ACE inhibitor,and has not been exposed to an,environmental irritant.,ACCP consensus.CHEST 1998;114:133-181,ERS Task Force.ERS Journal;24:553-566,Chronic Cough Practical Consideration.CHEST 1998;1213:639-660,Textbook of Respiratory Disease.Murray-Nadel.Chapter 24.,Chronic Cough,Fifth most common symptom for which outpatient care is sought.,24,263,000 visits in the US in 1991,Prevalence among non-smoking:14 to 23%,38%outpatient pulmonary practice,Cost exceeds$1 billion dollars,ACCP consensus.CHEST 1998;114:133-181,Evaluation of chronic cough.UPTODATE 2005,Chronic Cough Practical Consideration.CHEST 1998;1213:639-660,Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284,The Cough Reflex,Complications,Intrathoracic pressures of up to 300mmHG,Expiratory velocity:500 miles/hr,Textbook of Respiratory Disease.Murray-Nadel.Chapter 24.,ACCP consensus.CHEST 1998;114:133-181,Complications,Most common complaints:,Something is wrong:98%,Exhaustion:57%,Feeling self-conscious:55%,Insomnia:45%,Life style change:45%,Musculoskeletal pain:45%,Hoarseness:45%,Urinary incontinence:39%,Textbook of Respiratory Disease.Murray-Nadel.Chapter 24.,ACCP consensus.CHEST 1998;114:133-181,Complications,Lost of consciousness,Brady and tachyarrhytmias,Syncope,Cerebral embolism,Seizures,Stroke due to vertebral arteries dissection.,Evaluation of chronic cough.UPTODATE 2005,Complications,GERD,Splenic rupture,Inguinal hernia,Increase CPK,Pulmonary&subcutaneous emphysema,Pneumothorax,Lung herniation,Evaluation of chronic cough.UPTODATE 2005,Etiologies,Postnasal drip,Asthma,GERD,Eosinophilic bronchitis,Chronic bronchitis,Bronchiectasis,ACCP consensus.CHEST 1998;114:133-181,ERS Task Force.ERS Journal;24:553-566,Chronic Cough Practical Consideration.CHEST 1998;1213:639-660,Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284,Etiologies,Postinfectious cough,Bronchogenic carcinoma,ACE inhibitors,Vocal cord dysfunction,Single cause:38 to 82%,Multiple cause:18 to 62%,ACCP consensus.CHEST 1998;114:133-181,ERS Task Force.ERS Journal;24:553-566,Chronic Cough Practical Consideration.CHEST 1998;1213:639-660,Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284,Evaluation of chronic cough.UPTODATE 2005,Grading of Evidence,I-Properly randomized controlled trials,II-Well-designed control trials.No randomization.,II-2 Prospective observational,II-3 Retrospective observational,III-Experts opinion,clinical experience,descriptive studies,ACCP consensus.CHEST 1998;114:133-181,Postnasal Drip(PNDS),Single most common cause,Prevalence:8 to 87%,Pathogenesis,Mechanical stimulation of the afferent limb in the upper airways,ACCP consensus.CHEST 1998;114:133-181,ERS Task Force.ERS Journal;24:553-566,Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284,Evaluation of chronic cough.UPTODATE 2005,Postnasal Drip,Clinical Presentation,Dripping sensation,Tickle in the throat,Nasal congestion,Mucus in the oropharynx,Cobblestone appearance of oropharynx,ACCP consensus.CHEST 1998;114:133-181,ERS Task Force.ERS Journal;24:553-566,Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284,Evaluation of chronic cough.UPTODATE 2005,Diagnosis,Symptoms and signs are nonspecific,4 views sinus radiographs:,Timing and use not fully defined,Productive cough,purulent nasal discharge,failure of empiric therapy for chronic rhinitis.(grade II-2),Chronic cough&excess sputum production.PPV&NPV:81&95%,Chronic cough only:57&100%,ACCP consensus.CHEST 1998;114:133-181,ERS Task Force.ERS Journal;24:553-566,Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284,Evaluation of chronic cough.UPTODATE 2005,Diagnosis,Important information:,Preceding URTI,Legal or illegal nasal drugs,Environmental history,Response to specific therapy&the absence of another cause of cough,ACCP consensus.CHEST 1998;114:133-181,Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284,Evaluation of chronic cough.UPTODATE 2005,Therapy,Allergic Rhinitis:,Environmental control,Nasal steroids,First line of treatment,Consider other therapies as possible alternatives.,Consider saline sprays to facilitate cleaning,Nonsedating antihistamines,Cromolyn,ACCP consensus.CHEST 1998;114:133-181,ERS Task Force.ERS Journal;24:553-566,Management of allergic rhinitis.Uptodate.2005,Therapy,Nasal decongestant not recommended,Leukotriene inhibitors,Nasal congestion and LTC4 levels,Less effective than intranasal steroids,Patients experiencing epistaxis with nasal sprays.,Allergen immunotherapy,ACCP consensus.CHEST 1998;114:133-181,ERS Task Force.ERS Journal;24:553-566,Management of allergic rhinitis.Uptodate.2005,Therapy,Perennial Non-Allergic Rhinitis,Often difficult to control with traditional therapy,Intranasal steroids,Topical antihistamine