Managing Chronic Cough In Adults
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Show notes:
You have a patient who has been coughing for weeks, maybe even a couple of months. You’ve already ruled out COVID; where do you turn next? Which questions do you ask? Which labs do you order – and why?
Managing Chronic Cough In Adults
This week, let’s talk about chronic cough – what it is, how it differs from acute cough, when to refer the patient, and more:
Common causes – things like GERD, asthma, allergies
The special history questions to ask and how they will help with your differentials
What to watch for in the physical exam
Labs and other tests to order
Red flags
Coughs are common in primary care, and you will see them frequently. Knowing whether you are seeing a more common presentation or something more unusual will help you to create the best plan to take care of your patients. This confidence ensures your patient is cared for in the most appropriate setting and that referrals happen at the most appropriate time.
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WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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confident, capable, and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff, you're in
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the right place.
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In this episode, we're going to be talking about chronic cough and the diagnostic approach
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and kind of management principles when it comes to chronic cough in patients.
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So definitions, acute cough is typically less than three weeks, subacute is typically
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three to eight weeks.
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And I actually have an episode about subacute cough.
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It was a video episode and it was recorded before the pandemic.
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So it does not include COVID considerations in that episode.
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But if you want to think about the other considerations aside from COVID, definitely
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check that episode out.
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I'll link to that below and talks about specifically approach to when to use antibiotics.
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And then this episode is about chronic cough.
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So that's a cop of more than eight weeks.
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I feel like I've seen different definitions of whether eight weeks or three months,
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things like that.
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But it's approximate, right?
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Approximately that.
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So first I want to talk about history, approach to history, differentials and red
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flags, and then some workup steps and kind of like next treatment steps after
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that.
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So real quick, before we get into history, three really common causes of chronic
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cough. Number one is actually not a respiratory cause and a GI cause, which
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is GERD.
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And so, so, so many people have have GERD and some people have the typical
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symptoms of heartburn with spicy foods and worse after meals, things like
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that. Some people have silent reflux where they don't have any signs of
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typical heartburn, but they do have a flimmy cough after meals and it can be
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worse before bedtime.
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And then they can wake up with like a sore throat or halitosis from having
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all of that extra acid in their throats overnight.
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So just a little pearl there.
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GERD can be a common cause.
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Asthma can also be a common cause, which we know a lot about asthma, right?
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And then another common cause is allergies.
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And I start off the episode saying that is because most of the time, once
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you've ruled out red flags, those are the first things that you're going to
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think about working up and potentially doing a treatment trial to see if they
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improve.
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So, yeah, so allergies are things like post-nasal drip, right?
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So patients can have a runny nose or itchy, watery eyes.
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It's seasonal, like the typical stuff.
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But some people just have this little, like, throat clearing cough, like,
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and I actually do that for patients in the visit.
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Maybe they think I'm crazy, but I'm like, you have a cough like this?
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I guess I amuse myself.
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But anyway, don't ever feel silly for doing things like that in your visits.
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But that is one potential thing that you might see when it comes to allergies, like
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a post-nasal drip without the other typical symptoms.
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Again, they could be typical GERD or typical allergy presentations or slightly
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more variant types.
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So with that said, whenever you get into your histories, I absolutely recommend that
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systematic approach.
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If this is the first episode you've heard, I use the old CART acronym to guide my
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systematic approach to all my history questions.
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I also ask if it's better, worse or the same and if they've had it before.
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Like, absolutely must have asked those questions to orient yourself to get the
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information you need.
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There are some additional questions, though, that we ask that are really tied
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into the differentials as well.
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And I'm always a little bit torn when I make episodes of, like, do I get
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into history questions first and then we talk about the differentials and then
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you can kind of see how they're tied together versus do we talk about the
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differentials first and then the history questions, right?
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I never know. If you have an opinion, please let me know.
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But maybe it'll be 50-50, who knows?
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But basically, let's talk about the history questions that are additional to
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old CART acronym, right?
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So we want to ask about medication use.
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So medications, that is one other kind of like quick and easy thing to
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assess, especially with ACE inhibitors, because so many people take ACE
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inhibitors and that, like, bradykin related cough, like that absolutely can be
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a cause of a chronic cough, especially if it's a dry cough.
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So we want to ask about medications.
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Medication reconciliation is always important, but especially important in
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chronic cough.
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The next pieces are history questions related to, again, the non-respiratory
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causes. So you're asking all of those GERD related questions.
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The next one is kind of getting into more of the respiratory symptoms as
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well as the systemic potential symptoms that is getting more into like your red
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flag of concern, right?
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So we want to ask about, again, characteristics of the cough is
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included in old CART, but let's just talk about some specifics, right?
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Is it a dry cough?
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Is it a flimmy mucousy cough?
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Is it there all the time?
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Does it come and go?
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Are there specific triggers for it?
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Is it specific times of day, especially?
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Is it first thing in the morning, worse at night, worse when you're
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walking around, things like that.
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It's a little bit of a gross thing, but it's part of our job.
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So we want to ask about the characteristics if somebody has a
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expectorant, right?
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If they have anything that comes up when they cough, is it mucous?
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Is there any blood?
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Is there a color?
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Is it frothy?
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Is it lots of, you know, any other characteristics you want to elicit
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about the mucous or the phlegm is helpful, especially for GERD.
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And I can't, I record these episodes with a couple of outtakes pretty much
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every time, so I can't remember if I've said this already, but post, uh,
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meal, flimmy cough is pretty characteristic for GERD.
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So that is like a silent reflux thing to keep in your brain.
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If I haven't said that one already.
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And then we want to start to get also into those red flag symptoms.
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And I'll talk about red flag differentials next.
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So red flag symptoms you want to elicit are, are there any systemic symptoms?
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Like, do they have fever?
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Do they have night sweats?
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And do they have weight loss?
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Absolutely must ask those questions with a chronic cough, right?
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Cause when you think about it, most people, if we're talking about numbers,
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statistically, most people are going to have GERD allergies and then you
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treat those two and then it gets better, but we always, we can never
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assume we always have to be careful about making sure that we've asked all
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the questions and, and challenge all of our assumptions to make sure
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we don't miss anything.
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So let's talk about some of the red flags.
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So things that are really concerning.
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I mean, these may be obvious, but let's just recap them to you.
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If somebody has those systemic symptoms, fevers, night sweats,
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unintentional weight loss, again, when it comes to weight loss, we always
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want to ask specific questions of, is this intentional or unintentional?
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How much over what period of time?
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Asking those questions, do they have any altered mental status,
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especially your elderly patients or patients who are over the age of 65?
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Do they have hemoptysis, right?
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We've already talked about that eliciting that question,
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but that is a red flag.
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Is this worsening a chronic shortness of breath?
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I didn't say this in the history, but we do want to ask about shortness
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of breath and this is a chronic shortness of breath that's potentially
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worsening, especially with activity.
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Do they have associated chest pain?
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We also want to ask about smoking history.
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I don't think I said that yet because I skipped over it when I was
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talking about GERD, but we always want to ask about smoking history.
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But if somebody has a smoking history with a chronic cough, you
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want to keep that in your mind as like, you know what, let's be a
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little bit more cautious with this person and then kind of getting
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into the physical exam parts.
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We're going to be looking for signs of cyanosis or like oxygen deprivation.
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So do they have clubbing of their fingers or like active signs of cyanosis?
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When it comes to smoking history, I wanted to add that too.
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When I was a new grad, I've said this in a couple of episodes.
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I was just kind of so eager to check off my questions that it's,
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and I think it's just totally normal just to normalize that,
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that it's like, Oh, do you smoke?
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And then it's like, yes.
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Okay.
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Do you have, and I would like to move on, but like one of the
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important parts that you'll see over time is that you just have to
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look, see what it, like, what does it look like, right?
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Do they smoke every day?
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How much do they smoke a day?
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How many years has it been?
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All of that is important too.
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So when it comes to physical exam and testing and management, we
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always want to do a cardiac exam, a respiratory exam, looking
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at their lower extremities.
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We want to do a head, neck, and ear exam and eyes, H-E-E-N-T
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basically, because we're trying to see again, where are
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differentials here?
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We're looking at GERD, allergies or something more respiratory.
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Again, I take multiple shots of each of these episodes because
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I scramble my words.
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I should probably share some outtakes because they can be
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funny, but I can't remember if I've said already about
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assessing if they, what happened at the beginning of their
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cough, like if this was three months ago, did it start
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because they had COVID, right?
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Or they had some sort of infectious illness that went away
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and now they still have the cough, right?
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That's just, I just want to put that in there because I'm
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like, I mentioned that one yet, but the next steps, again,
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cardiac, respiratory, lower extremity, H-E-E-N-T, we want to
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think about some labs potentially.
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So CBC with differential, we might be able to pick up some
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sort of like infectious process versus some sort of
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like chronic hypoxia might be causing some elevated
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hematocrit and hemoglobin perhaps.
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And by the way, if you need help with lab interpretation,
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definitely check out the lab interpretation crash course for
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new nurse practitioners.
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Actually we renamed it because it's for all nurse practitioners,
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but check that out in the links below.
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And we want to consider, do they need a tuberculosis test?
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Quantiferon Gold is more of that gold standard.
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And then they may at some point need a sputum sample,
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but that's not really for primary care, but those are
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kind of the main places of triage of like where you
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want to go, like what are we thinking about in terms of
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further differentials aside from those most common ones,
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are we thinking about COPD, are we thinking about heart
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failure, are we thinking about some sort of infectious
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cause, some chronic bronchitis, bronchiectasis,
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like those types of things, is this long COVID
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related to their coronavirus illness before?
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And yeah, and basically your next steps, like you
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want to think about that testing of those labs,
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do they need a quantiferon, do they need a
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chest x-ray versus are you like, I'm really
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confident based on their history in their exam that
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this is a GERD or allergies?
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Do I do a treatment trial of those two things?
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We talk all about how to manage allergies,
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nasal rinses, puticazone, try not to use the
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brand name there, do they need oral allergy
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medications, do they shower at night before bed,
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right, all of those lifestyle interventions plus
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GERD treatment, lifestyle interventions, medications
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potentially, versus am I really concerned about
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their smoking history, the way they're presenting
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those types of things.
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If I'm not super confident that it's those first
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two GERD or allergies, then we're moving on to
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a chest x-ray, because we really want to make
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sure that there's no other processes going on,
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is there a lung cancer that we potentially
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could miss, things like that.
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Depending on your findings of your chest x-ray,
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depending on the radiology report, sometimes
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they say, you know what, chest CT is needed
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for further diagnosis, and then that is really
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a branching point for you of decision making
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of is this appropriate for primary care,
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is this garden variety, I don't know,
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asthma maybe, right, you can probably handle
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that in primary care, at least the initial treatment
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based on their history and all that testing,
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versus is this a place where you refer to pulmonary.
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And for me, I have ordered a chest CT
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with an abnormal chest x-ray for a potential
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bronchiectasis, for example, but with the
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understanding with the patient of like,
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listen, I'm gonna order this test, and also
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we need to go talk with a pulmonologist
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to understand how these test results affect you
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and the further treatment, et cetera, et cetera.
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Versus you, in your clinic, in your philosophy
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of practice, need to talk with your collaborator,
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your supervisor, like do I order this chest CT,
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or do we stop at a chest x-ray
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and collaborate with either an e-consult,
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an email to a provider, a phone consult
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of like, is this an appropriate referral for you,
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do we need spirometry or PFTs, right,
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and is that the culture of your practice
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that you order those and interpret those,
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or is that really most appropriate to be
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either allergy immunology or pulmonary, right?
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And a lot of the management really depends
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on your assessment going forward,
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but hopefully that's a clear picture of like,
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you know what, treatment trial, if it's very clear,
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work up if it's less clear,
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you have to use your clinical judgment for that piece.
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But yeah, when it comes to a treatment trial,
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one last note about that is like,
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I still am cautious, right,
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I'm not gonna write that off
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and I'm very clear with my patients of like,
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you know what, this really sounds to me
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like it's actually from heartburn
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and I know that sounds crazy
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because you don't feel heartburn
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but you have all of these symptoms,
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blah, blah, blah, blah, right,
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and I tell them that whole thing
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and let's try this trial,
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if it is not improving in two months,
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one to two months,
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you're not starting to see some improvement,
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please let me know,
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or we make a follow-up appointment
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to make sure that we don't lose them to follow-up,
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right, because we wanna make sure
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that they're taken care of
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because what if they do have some sort
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of underlying lung condition
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and we haven't assessed that yet
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because of the other things
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that were eluding us, right?
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So hopefully this will help you feel better
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about approaching chronic coughs in primary care.
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If you have not grabbed the Ultimate Resource Guide
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00:14:04.260 --> 00:14:05.220
for the new NP,
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00:14:05.320 --> 00:14:07.880
head over to realworldnp.com slash guide.
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You'll get these episodes
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and straight to your inbox every week
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I really just don't share anywhere else.
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Thank you so much for tuning in,
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hang in there, I'll see you soon.
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That's our episode for today.
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Make sure you subscribe,
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00:14:37.480 --> 00:14:38.940
If you haven't gotten your copy
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00:14:38.940 --> 00:14:40.420
of the Ultimate Resource Guide
315
00:14:40.420 --> 00:14:41.600
for the new NP,
316
00:14:41.880 --> 00:14:45.080
head over to realworldnp.com slash guide.
317
00:14:45.420 --> 00:14:46.800
You'll get these episodes
318
00:14:46.800 --> 00:14:48.700
sent straight to your inbox every week
319
00:14:48.700 --> 00:14:50.080
with notes from me,
320
00:14:50.080 --> 00:14:52.200
patients' stories and extra bonuses
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00:14:52.200 --> 00:14:54.340
I really just don't share anywhere else.
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Thank you so much again for listening.
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Take care and talk soon.
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