MRCP PACES Approaches Approach to Chronic Cough

Differential diagnosis

  • Respiratory
    • Lung cancer
    • Asthma
    • COPD
    • Tuberculosis
    • Pulmonary fibrosis
    • Bronchiectasis
    • Pneumonia
    • Pulmonary embolism
  • Ear, nose and throat
    • Post nasal drip
    • Upper respiratory tract infection
  • Cardiac
    • Mitral stenosis
    • Congestive cardiac failure
  • Gastro-oesophageal reflux disease
  • Neurology (aspiration)
    • Myasthenia gravis
    • Myotonic dystrophy
    • Multiple system atrophy
    • Parkinson’s disease
    • Miller-Fisher syndrome
  • Malignancy
    • Mediastinal mass
    • Carcinoid syndrome
  • Drugs
    • ACE inhibitor
  • Psychogenic cough

Relevant points in the history

  • Cough
    • When did it start?
      • Acute < 3 weeks
      • Sub-acute 3-8 weeks
      • Chronic > 8 weeks
    • How often do you cough?
    • Does it come on predictably at a certain time of the day or year?
    • Does anything bring on the cough?
    • Does anything make it better?
    • Does anything make it worse?
    • Do you have phlegm with the cough?
    • What colour is the phlegm?
    • Is there ever any blood?
    • Do you have chest pain?
    • Do you feel breathless when you cough?
    • Have you noticed any other breathing noises?
    • How has this been affecting your life?
  • Respiratory
    • Lung cancer & tuberculosis
      • Do you, or have you ever smoked?
      • Have you lost any weight?
      • Do you feel like you have no appetite?
      • Have you ever coughed up blood?
      • Do you feel breathless?
      • Have you noticed any change in your voice?
      • Have you had any fever?
      • Have you noticed any sweating at night?
    • Obstructive airways disease
      • Have you ever noticed a cough at night?
      • Have you noticed that this breathlessness is brought on by specific triggers?
      • Have you ever noticed a wheezing noise when you feel breathless?
      • Do you notice that your chest feels tight?
      • Have you ever tried an inhaler?
        • What inhalers have you tried?
        • Has the dose or number of puffs changed recently?
        • How do you use the inhaler?
        • Do you take your inhaler every day as prescribed?
      • Do you have eczema?
      • Have you noticed intermittent episodes of a runny nose?
      • Does anyone in the family have eczema, asthma or a runny nose?
      • Do you keep any pets at home?
      • Do you, or have you ever smoked?
    • Pulmonary fibrosis
      • (If breathless): has your breathlessness been getting worse?
      • Occupational lung disease
        • What is your job?
        • Have you ever worked in an industry which exposed you to dusts such as asbestos?
      • Connective tissue disease
        • Have you noticed that the skin of your hands or face is unusually tight?
        • Have you noticed any rashes anywhere on your body?
        • Do you find any difficulty in swallowing?
        • Have you noticed any whitish bumps on your fingertips?
        • Do your hands go white or blue in the cold?
        • Do you have any mouth ulcers?
        • Have you noticed your hair dropping moreso than usual?
        • When you wake up in the morning, do you notice hair on your pillow?
        • Have you noticed any joint pains?
        • Do you feel stiff early in the morning?
        • Have you noticed that your eyes or mouth are unusually dry?
      • Iatrogenic
        • Do you take any medicines?
        • Have you ever had chemotherapy?
        • Have you ever taken a medicine called amiodarone, methotrexate or nitrofurantoin?
        • Have you ever received radiation to the chest?
      • Post-infectious
        • Have you ever had tuberculosis?
        • Have you had any other chest infections before?
    • Bronchiectasis / pneumonia
      • Have you had any fever?
      • Do you feel you are bringing up a lot of phlegm?
    • Pulmonary embolism
      • Do you get chest pain that gets worse when you breathe in?
      • Have you noticed that one leg has been swollen or painful?
      • Have you been on any long flights recently?
      • Have you had any recent operations?
      • Do you use the oral contraceptive pill?
      • Have you ever had a clot in your leg or your lung?
      • Have you ever been pregnant?
      • How many times have you been pregnant?
      • How many children do you have?
  • Upper respiratory tract
    • Have you had a sore or runny nose recently?
    • Do you find you need to clear your throat often?
    • Do you ever get a sensation of liquid dripping into the back of your throat?
    • Do you have problems with a runny nose?
  • Cardiac
    • Do you ever get chest pain on walking?
    • How many pillows do you sleep on at night?
    • Do you ever wake up in the middle of the night feeling breathless?
    • Have you noticed any leg swelling?
    • Have you ever noticed a red flushing in your face?
    • Have you ever had rheumatic fever?
  • Gastro-intestinal reflux disease
    • Does the cough get worse after meals?
    • Do you ever get a burning sensation in your chest?
    • Is this worse on lying down or on an empty stomach?
  • Neurological
    • Have you ever noticed your eyelids drooping?
    • Do you feel weak?
    • Do you find that your eyes get tired after reading?
    • Have you ever had double vision?
    • Does this get worse throughout the day?
    • Do you ever choke on your food?
    • Have you noticed any tingling in your hands and feet?
    • Aside from the breathlessness, have you been ill recently?
    • Have you had any diarrhoea?
  • Drugs
    • Do you take any medication?
    • Have you ever taken a medicine called an ACE inhibitor, for example enalapril?
    • Have you ever taken NSAIDs or a beta blocker (asthma triggers)?

Examination

  • General
    • Cachexia, general posture
    • Respiratory rate / signs of respiratory distress
    • Cyanosis
    • Pallor
  • Hands and wrist
    • Clubbing
    • Pulse – rate and rhythm
    • CO2 retention flap
  • Cardiovascular
    • Jugular venous pulsation
    • Apex beat – displaced suggests cardiac failure
    • Right ventricular heave (pulmonary hypertension secondary to underlying lung disease)
    • Auscultate for any murmurs (particularly MDM of mitral stenosis)
      • Re-enforcement manoeuvre for MS
    • Listen for loud P2 (pulmonary hypertension)
  • Respiratory
    • Fine end-inspiratory crepitations (pulmonary fibrosis – apical or basal)
    • Coarse crepitations (pneumonia, bronchiectasis)
    • Wheeze (obstructive airways disease)
    • Cervical lymphadenopathy (underlying malignancy)
    • Pleural effusion (malignancy)
  • Neurology
    • Ptosis
    • Proximal weakness
    • Fatigability
    • Count to 20 while looking upwards
    • Grip myotonia
    • Percussion myotonia

Investigations

  • Full blood count looking for eosinophilia
  • Renal function test if suspecting Churg-Strauss
  • Chest radiograph to look for left atrial enlargement, pneumonia, fibrotic change, bronchiectasis, pneumonia
  • Sputum culture and stain for acid-fast bacilli, together with nucleic acid amplification test
  • ECG to look for AF (associated with mitral stenosis)
  • Spirometry
    • Obstructive defect suggesting obstructive airways disease (FEV1/FVC < 0.7)
      • Methacholine challenge if normal to rule out underlying asthma
    • Restrictive defect (TLC, FVC, DLCO low, FEV1/FEV normal or high)
  • Consider oesophagogastroduodenoscopy or oesophageal manometry if trial of omeprazole fails
  • Consider HRCT for fibrosis / bronchiectasis
  • Consider CT thorax if index of suspicion for malignancy high
  • Consider trans-thoracic echocardiogram to look at mitral valve

Management

  • Patient education, multi-disciplinary team approach
  • Anti-tussives
  • Treat the underlying cause (see wheeze above)
  • RHEZ if proven TB
  • Referral to oncology if malignancy detected
  • Trial of omeprazole to see if cough improves
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