Pulmonologist Sumedh S. Hoskote discusses the challenges of diagnosing chronic coughs, exploring potential triggers like smoking, asthma, and GERD. They highlight the importance of comprehensive evaluations and treatment strategies for patients with unexplained chronic coughs.
Chronic cough evaluation requires a comprehensive approach involving history, imaging, and pulmonary function tests.
Cough reflex involves complex mechanisms including sensory information processing, receptor types, and brainstem activation.
Deep dives
Causes and Impact of Chronic Cough
Chronic cough is a common problem, affecting millions of people. It can have various causes, including smoking, inhalational exposures, use of certain medications like ACE inhibitors, upper airway cough syndrome, asthma, non-asthmatic eosinophilic bronchitis, and gastroesophageal reflux disease (GERD). The impact of chronic cough can be significant, often leading to negative perceptions, embarrassment, and interference with daily activities. There can also be medical complications such as stress urinary incontinence, cough syncope, and fractures. Prompt evaluation and management are essential to alleviate symptoms and improve the patient's quality of life.
Understanding the Physiology of Cough
Cough is a complex reflex that involves both involuntary and voluntary components. Its purpose is to protect the respiratory system by expelling irritants, foreign material, or mucus. The cough reflex is initiated by sensory information carried by the vagal nerve endings from various anatomical regions, such as the upper airway, larynx, trachea, bronchi, and lungs. The information is then processed in the brainstem, leading to the activation of respiratory muscles and the release of an explosive cough. Multiple receptor types are involved in the cough mechanism, and drug development is targeting some of these receptors. The physiology of cough also involves integration at subcortical and cortical levels, which accounts for the voluntary control and potential associations with chronic cough and central sensitization disorders.
Evaluation and Management of Chronic Cough
The evaluation of chronic cough involves a thorough history-taking to identify potential triggers, such as smoking, occupational or inhalational exposures, and medication use. Red flag symptoms, including hemoptysis, weight loss, and history of foreign body aspiration, require urgent referral for further evaluation and testing. Pulmonary function testing, chest X-ray, and occasionally laboratory tests help in determining the cause of the cough. Additional imaging studies, such as chest CT scans or sinus CT scans, may be necessary based on the clinical findings. Depending on the cause, management strategies may include lifestyle modifications, nasal saline rinses, nasal steroids, medication for GERD, and targeted pharmacotherapy. Reassurance and communication are crucial in addressing patient concerns and managing symptoms effectively.
A patient with an unexplained cough is commonly seen in an outpatient primary care practice. While there are several potential causes, fortunately, most are relatively benign. However, determining the cause can be challenging and its best to use an organized approach in the evaluation. Using the patient’s history, chest imaging studies, pulmonary function and occasionally laboratory tests, we’re usually able to determine the cause. What are the most common causes of a persistent cough? What approach is recommended in the evaluation? And what should we do when no cause is apparent? We’ll discuss “The Unexplained Chronic Cough” in this podcast with our guest, Sumedh S. Hoskote, M.B.B.S., a pulmonologist in the Division of Pulmonary and Critical Care at the Mayo Clinic.
Connect with the Mayo Clinic’s School of Continuous Professional Development online at https://ce.mayo.edu/ or on Twitter @MayoMedEd.
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