Monday, 2 May 2016

Cough

Cough seems a strange thing to have on the syllabus, but we do see lots of patients presenting with cough. They often want antibiotics...and these aren't often the answer. The references at the bottom of the page have got some excellent management guidelines.

Acute Cough
Viral Cough - self limiting. No anti-tussive therapy needed. Efficacy of OTC medications is not compelling. Home based remedies like honey and lemon or honey and coffee.

Chronic Cough
Lasts >8 weeks. Mostly women, with an average age of 55. Can treat empirically before investigations.

Differentials
Pertussis
Tuberculosis
Pulmonary fibrosis - get honeycomb on the CT. Make sure you treat any concurrent reflux,
Reflux - if asymptomatic don't treat. Otherwise, PPI BD + ranitidine. Next step pro-kinetics like metoclopramide.

Drug Differentials 
Latanoprost - augments cough-reflex sensitivity
ACE inhibitors - may take up to several months to stop. ACE inhibitors upregulate the cough reflex
Nitrofurantoin
Bleomycin, methotrexate and amiodarone may cause pulmonary fibrosis

Investigations
CXR
-  if >40 and has ever smoked and has cough, fatigue, SOB, chest pain, weight or appetetite loss.
- if >40 and persistent or recurrent chest infection, clubbing, specific lymphadenopathy, chest signs consistent with lung cancer, thrombocytosis.
Spirometry
Consider checking for sleep apnoea - CPAP may help

Treatment
Treat cause - first generation antihistamines can help.
If cold related consider brompheniramine and SR pseudoephedrine. Naproxen can also help.

References
http://www.rcemlearning.co.uk/modules/a-constant-cough/
http://www.rcemlearning.co.uk/modules/bloody-cough/
http://www.rcemlearning.co.uk/exams/unusual-cough/
http://www.doctors.net.uk/ecme/wfrmNewIntro.aspx?moduleid=1692
http://www.doctors.net.uk/ecme/wfrmNewIntro.aspx?moduleid=1388
http://journal.publications.chestnet.org/data/Journals/CHEST/934853/51496.pdf
http://rebelem.com/long-cough-respiratory-illness-last/
https://www.brit-thoracic.org.uk/document-library/clinical-information/cough/cough-guidelines/recommendations-for-the-management-of-cough-in-adults/
https://www.brit-thoracic.org.uk/document-library/clinical-information/cough/cough-guidelines/recommendations-for-the-management-of-cough-in-children/
http://journal.publications.chestnet.org/data/Journals/CHEST/22039/1S.pdf 

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