Cough DSA

Question 1

Acute cough lasts ______ and is usually _______.

Answer 1

Less than 3 weeks

Self-limited.

Question 2

Sub-acute cough lasts _________ and indicated what?

Answer 2

• 3-8 weeks
• Prolonged acute cough or early presentation of chronic cough.

Question 3

Chronic cough lasts ______.

Answer 3

More than 8 weeks.

Question 4

What are the most common causes of acute cough?

Which is the MOST common?

Answer 4

• 1. Viral URI (common cold)
• 2. Lower respiratory infection (bronchitis and pneumonia)
• 3. Bacterial sinusitis
• 4. Rhinitis d/t allergens or environmental irritants
• 5. Asthma or COPD
• 6. Cardiogenic pulmonary edema
• 7. Aspiration or foreign body
• 8. ACE inhibitor
• 9. PE

Question 5

Which viruses are associated with cough and URI?

Answer 5

1. Coronavirus

2. Adenovirus

3. Rhinovirus

Question 6

Which viruses are associated with cough and LRI?

Answer 6

• 1. Influenza A/B
• 2. Parainfluenza
• 3. Respiratory syncytial virus (RSV)

Question 7

How are most viral causes of cough treated?

Answer 7

Symptomatically

Question 8

Influenza is characterized by:

Clinical Dx requires:

Dx:

Answer 8

• -Sudden onset of fever and weakness, followed by cough, HA, muscle aches and nasal/pulmonary sx during the app season.
• -T: >100 (3.7 C) and one of the following sx: [cough, pharyngitis or rhinorrhea]
• • Viral culture of secretions or rapid diagnostic tests (PCR, immunoflurouesce. enzyme immunoassay).
    
    • Rapid tests help in confirming +, but sensitivity is limited and (-) results do not exclude dx.

Question 9

When is anti-viral therapy indicated for patients with influenza?

Answer 9

• Hospitalized patients
• Those with severe, complicated or progressive illness.

Question 10

________ are given to treat Influenza A and B.

When should it be administered and what effect do they have?

Answer 10

Neuraminidase inhibitors.

Give within first 2 days of sx and can reduce duration and complications.

Question 11

What are the preventative treatments for Influenza A and B?

Answer 11

1. Vaccination
2. Antiviral chemoprophylaxis (NA inhibitors); only for:

• patients living in an assissted living facility when there is an influenza outbreak,
• ppl who have higher risk of influenza related complications and have had recent contact with confirmed case,
• unvaccinated health care workers who had a recent contact with confirmed case.

Question 12

H1N1 is a emerging _________ virus

• Symtoms:
• Treat:

Answer 12

• Influenza A
• Cough, fever and rinorrhea
• Chemoprophylaxis (NA inhibitors)

Question 13

What are the non-viral causes of uncomplicated

[acute bronchitis** and **cough] in adults?

Answer 13

1. B. pertussis
2. Mycoplasma pneumonia
3. Chlamdophila pneurmoniae

Question 14

How do we detect cause of acute bronchitis?

How do we treat acute bronchitis?

Answer 14

• Diagnostic tests are not recommended: gram stain and culture of sputum does not reliably detect
  
  • GOLD STANDARD: + bacterial culture or PCP
• Abx is not recommended, unless you think adult pertussis. However, nothing can tell us if its pertussis unless there is a HIGH probability (cough that last more than 2 weeks without an apparent cause + [paroxysms of coughing, inspiratory whoop or posttussive emesis or cough >2 weeks when there is a documented outbreak].

Question 15

If acute bronchitis is d/t pertussis, how do ABX help?

Answer 15

Decrease the spread of the disease because does not stop sx if given after 7-10 days of onset.

Question 16

What is the PRIMARY diagnostic goal when evaluating a patient for acute cough?

Answer 16

Rule out pneumonia: it is the 3 MCC and the most severe.

Question 17

How do we rule out pneumonia as the cause of acute cough?

Answer 17

Pneumonia would have abnormal vital signs:

• 1. HR: over 100/min
• 2. RR: over 28/min
• 3. T: over 100 F (37.7)
• 4. Crackles
• 5. Decrease breath sounds

If patient does not have these, end diagnosing for pneumonia.

Question 18

How do we dx asthma as a cause of acute cough?

Answer 18

Hard to diagnose unless there is a reliable hx of asthma and episodes of wheezing + SOB in addition to the cough.

Question 19

Why is asthma so hard to dx with [transient bronchial hyperresponsiveness] and [abnormal spirometry]?

Answer 19

Occur in all causes of acute bronchitis

Question 20

When should inhaled- short acting B agonists be used as a treatment?

Answer 20

Patients with [cough + wheezing];

no benefit in cough without wheezing.

Question 21

Acute worsening of chronic bronchitis and bronchiectasis presents how?

Answer 21

-abrupt increase from baseline in cough, sputum production and purulence and SOB

Question 22

How do we treat acute cough?

What is their effectiveness?

Answer 22

Main indications: cant sleep, painful cough and debilitating cough

• Self-limited but: antitussive agents, expectorants, mucolytic agents, antihistamines and nasal anticholinergic agents
  
  • Little evidence supports OTC and prescription antitussive meds; placebo
  • Guaifenesin has some benefit

Question 24

What are the most common causes of chronic cough?

Answer 24

In most patients, chronic cough is caused by more than 1 thing.

• 1. Upper airway cough sydrome (UACS)
• 2. Asthma
• 3. GERD
• 4. Non-asthmatic eosinophillic bronchitis
• 5. Medication reaction (ACE-i)
• 6. Chronic bronchitis d/t smoking

Question 25

**ALL patients** that we suspect with **chronic cough** should be given what?

Answer 25

* **1. Chest radiography** * **2. Careful history and physical exam findings for ALL common causes.**

Question 26

All patients with **chronic cough** should do what, before workup?

Answer 26

**Stop smoking** and **ACE inhibitors** _4 weeks before._

Question 27

How do we determine the cause of **chronic cough**?

Answer 27

**Look at which therapy eliminates symptoms** associated with cough.

Question 28

What is UACS?

Answer 28

* **Upper airway cough syndrome:** _recurrent_ cough that occurs when mucus from the nose drains down the oropharynx =\> triggers cough receptors.

Question 29

Symptoms of **UACS**?

Answer 29

* **1. Post nasal drainage** * **2. Clears throat alot** * **3. Nasal discharge** * **4. Cobblestone stone appearane on oropharyngeal mucosa** * **5. Mucus dripping from oral mucosa**

Question 30

Treatment of **UACS**? Dx:

Answer 30

* **Tx**: non-sedating antihistamines + decongestant * **Dx**: If drugs treat discharge and cough

Question 31

How do we treat an **unknown chronic cough?**

Answer 31

**Nonsedating antihistamines** + **decongestant** to see if it is UACS

Question 32

What is **cough-varient asthma** and how is it dx?

Answer 32

* **Asthma** (airway hypersensitivity) where **cough is the main symptom.** * Dx when asthma meds treat cough; takes 6-8 weeks.

Question 33

Which test result can exclude **cough-variant asthma** as a diagnosis?

Answer 33

-**Bronchoprovacation test:** (-) test is 100% sensitive to rule out, but a positive test does not indicate, because test is not specific.

Question 34

How does **GERD** cause **chronic cough?**

Answer 34

* **Most common:** vagal mediated distal esophageal tracheobronchial reflex. * Aspiration

Question 35

How do we treat **chronic cough** caused by **GERD**

Answer 35

* First, give **PPI** because noninvasive * Then: **24 hour- esophageal pH monitoring** (most sensitive and specific) * Sx decrease **3 months** after.

Question 36

When do we diagnose **chronic cough** due to **NAEB** (nonasthmatic eosinophillic bronchitis)?

Answer 36

* NL CXR * NL spirometry * (-) methacholine challenge test

Question 37

What is **NAEB?**

Answer 37

**Chronic cough** with **eosinophils in airway,** obtained by sputum or bronchial lavage during bronchoscopy.

Question 38

If a patient has **NAEB**, what should we ask on exam? How do we _treat_?

Answer 38

* - Occupational exposure to sensitizer * - Inhaled glucocorticoids and avoid allergens.

Question 39

What is a hallmark symptom of **chronic bronchitis** caused by **smoking**? Treatment?

Answer 39

* **Cough + sputum.** * Tx: **Stop smoking** to decrease sputum production and airway inflammation. * **Inhaled anticholinergic agents (tiotropium and ipratropium):** decrease sputum production * **Systemic glucocorticoids and ABX:** decrease cough when bad exacerbations

Question 40

What is bronchiectasis? Dx? Tx?

Answer 40

* Chronic bronchitis that causes chronic/recurrent cough with voluminous (\>30 mL/day) of sputum and purulent exacerbations. * **Dx**: CXR and CT show thick bronchial walls and tram-line pattern * **Tx**: ABX, based of sputum culture and chest radio

Question 41

Is stopping smoking good at stopping chronic cough?

Answer 41

**Yes**: decrease in almost 100% of patients.

Question 42

**Cough d/t ACE inhibitors** is related to ________ and occurs when? ## Footnote **Dx:** **Tx:**

Answer 42

* **Class**, not dose. * Hours - weeks/months after 1st dose of ACE inhibitor. * **Dx:** cough stops around 26 days after stopping ACE inhibitors * **Tx:** switch ACE inhibitor with angiotensin receptor blocker.

Question 43

Does **hemoptysis** occur in acute or chronic cough? What is the most common causes?

Answer 43

* Either * Infection (bronchitis or pneumonia) followed by malignancy.

Question 44

What can cause **hemoptysis**?

Answer 44

1. -High pulmonary pressure d/t left sided HF 2. -PE 3. -Lower respiratory causes 4. -Upper airway souces of bleeding (nose) and and GI bleeding

Question 45

All patients with hemoptysis need \_\_\_\_\_\_. What increase risk of malignancy?

Answer 45

* Chest radiography * M, over 40YO, smoking \>40-pack years, sx last longer than 1 week.

Question 46

Pts with increase risk of **malignancy** who have **hemoptysis** need to be reffered where, **if cause of hemoptysis on chest radiography is not IDd?**

Answer 46

* Chest CT * Fiberoptic bronchopy * NECESSARY bc CT doesnt always show lesions

Question 47

**Hemoptysis** patient with history of _LRT infection_ and _NL chest radiograph_ should be treated with \_\_\_\_\_\_\_\_

Answer 47

* **Oral ABX** to see if treats.. * If recurs or persists, get a **broncoscopy**.

Question 48

Patient with massive hemoptysis (over 200mL/day) requires what?

Answer 48

* **1. Urgent impatient eval** * **2. Early consultation with pulomonologist** * 3. **ICU** * **-Airway management** to prevent ASPHYXIATION, not exsanguition/