Transcript: Managing Chronic Cough In Adults

​Liz Rohr:
Well, Hey, there. It's Liz Rohr, from Real World NP, and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

In this episode, we're going to be talking about chronic cough, and the diagnostic approach and kind of management principles when it comes to chronic cough in patients.

So definitions, acute cough is typically less than three weeks. Sub-acute is typically three to eight weeks. And I actually have an episode about sub-acute cough. It was a video episode and it was recorded before the pandemic, so it does not include COVID considerations in that episode. But if you want to think about the other considerations aside from COVID definitely check that episode out, I will link to that here and talks about specifically approach to when to use antibiotics.
 

And then this episode is about chronic cough, so that's a cough of more than eight weeks. I feel like I've seen different definitions of whether eight weeks or three months, things like that, but it's approximate, right? Approximately that.

So first, I want to talk about history, approach to history, differentials and red flags, and then some work-up steps, and kind of like next treatment steps after that.

So, real quick, before we get into history, three really common causes of chronic cough.

Number one is actually not a respiratory cause it is a GI cause, which is GERD. And so many people have GERD, and some people have the typical symptoms of heartburn with spicy foods, and worse after meals, things like that. Some people have silent reflux, where they don't have any signs of typical heartburn, but they do have a phlegmy cough after meals, and it can be worse before bedtime. And then they can wake up with a sore throat, or halitosis from having all that extra acid in their throats overnight.

So just a little PEARL there, GERD can be a common cause. Asthma can also be a common cause, which we know a lot about asthma. And then another common cause is allergies. And I start off the episode saying that is because most of the time, once you've ruled out red flags, those are the first things that you're going to think about working up, and potentially doing a treatment trial to see if they improve. So, allergies are things like postnasal drip. So patients can have a runny nose, or itchy watery eyes, it's seasonal, like the typical stuff, but some people just have this little throat-clearing cough. And I actually do that for patients in the visit, which maybe they think I'm crazy, but I'm like, "Do you have a cough like this?" I guess I amuse myself. But anyway, don't ever feel silly for doing things like that in your visits, but that is one potential thing that you might see when it comes to allergies, like a postnasal drip without the other typical symptoms.

Again, that could be typical GERD, or typical allergy presentations, or slightly more variant types. So with that said, whenever you get into your histories, I absolutely recommend that systematic approach. If this is the first episode you've heard, I use the OLD CART acronym to guide my systematic approach to all my history questions. I also ask if it's better, worse, or the same, and if they've had it before. Absolutely must have asked those questions, to orient yourself, to get the information you need. There are some additional questions, though, that we ask, that are really tied into the differentials as well. And I'm always a little bit torn when I make episodes of like, do I get into history questions first? And then we talk about the differentials, and then you can kind of see how they're tied together versus do we talk about the differentials first, and then the history questions?

I never know. If you have an opinion, please let me know. But maybe it'll be 50/50, who knows.

But basically, let's talk about the history questions that are additional to OLD CART acronym. So we want to ask about medication use.

So medications, that is one other kind of quick and easy thing to assess, especially with ACE inhibitors, because so many people take ACE inhibitors, and that bradykinin-related cough, that absolutely can be a cause of a chronic cough. Especially if it's a dry cough. So we want to ask about medications. Medication reconciliation is always important, but especially important in chronic cough.

The next pieces are history questions related to, again, the non-respiratory causes. So you're asking all of those GERD-related questions.

The next one is getting into more of the respiratory symptoms, as well as the systemic potential symptoms that is getting more into your red flag of concern.

So we want to ask about, again, characteristics of the cough included in OLD CAR, but let's just talk about some specifics, right? Is it a dry cough? Is it a phlegmy, mucusy, cough? Is it there all the time? Does it come and go? Are there specific triggers for it? Is it specific times of day? Especially, is it first thing in the morning? Worse at night? Worse when you're laying down? Worse when you're walking around? Things like that.

It's a little bit of a gross thing, but it's part of our job, so we want to ask about the characteristics, if somebody has an expectorant, right? If they have anything that comes up when they cough, is it mucus? Is there any blood? Is there a color? Is it frothy? Is it, lots of... Any other characteristics you want to elicit about the mucus or phlegm is helpful, especially for GERD.

And I record these episodes with a couple of outtakes pretty much every time, so I can't remember if I've said this already, but the post-meal phlegmy cough is pretty characteristic for GERD. So that is a silent reflex thing to keep in your brain if I haven't said that one already. And then we want to start to get also into those red flag symptoms, and I'll talk about red flag differentials next.

So red flag symptoms you want to elicit are there any systemic symptoms? Do they have fever? Do they have night sweats? And do they have weight loss? Absolutely must ask those questions, with a chronic cough, right? Cause when you think about it, most people, if we're talking about numbers, statistically, most people are going to have GERD, allergies, and then you treat those two, and then it gets better. But we can never assume. We always have to be careful about making sure that we've asked all the questions and challenge all of our assumptions, to make sure we don't miss anything.
 

So let's talk about some of the red flags. So things that are really concerning. I mean, these may be obvious, but let's just recap them to you.

If somebody has those systemic symptoms, fevers, night sweats, unintentional weight loss, again, when it comes to weight loss, we always want to ask specific questions of, is this intentional or unintentional? How much over what period of time? Asking those questions, do they have any altered mental status? Especially your elderly patients, or patients who are over the age of 65? Do they have hemoptysis? We've already talked about that, eliciting that question, but that is a red flag. Is this worsening chronic shortness of breath... I didn't say this in the history, but we do want to ask about shortness of breath, and this is a chronic shortness of breath that's potentially worsening, especially with activity? Do they have associated chest pain?

We also want to ask about smoking history. I don't think I said that yet, because I skipped over it when I was talking about GERD, but we always want to ask about smoking history. But if somebody has a smoking history with a chronic cough, you want to keep that in your mind as, "You know what? Let's be a little bit more cautious with this person." And then getting into the physical exam parts, we're going to be looking for signs of cyanosis or oxygen deprivation. So do they have clubbing of their fingers, or active signs of cyanosis? When it comes to smoking history, I wanted to add that too, when I was a new grad I've said this in a couple of episodes, I was just kind of so eager to check off my questions, that it's, and I think it's just totally normal just to normalize that, that it's like, "Oh, do you smoke?" And then it's like, "yes." "Okay, do you have..." And I would move on, but one of the really important parts that you'll see over time, is that you just have to look, see what does it look like? Do they smoke every day? How much do they smoke a day? How many years has it been? All of that is important too.

So when it comes to physical exam and testing and management, we always want to do a cardiac exam, a respiratory exam, looking at their lower extremities, we want to do a head, neck, ear exam and eyes, HEENT basically, because we're trying to see again, where are our differentials here? We're looking at GERD, allergies, or something more respiratory. Again, I take multiple shots of each of these episodes because I scramble my words. I should probably share some outtakes because there can be funny, but I can't remember if I've said already about assessing if they, what happened at the beginning of their cough.

If this was three months ago, did it start because they had COVID? Or they had some sort of infectious illness that went away and now they still have the cough, right? I just want to put that in there, cause I don't think I mentioned that one yet.

But the next steps, again, cardiac, respiratory, lower extremity, HEENT, we want to think about some labs potentially, so CBC with differential, we might be able to pick up some sort of infectious process, versus some sort of chronic hypoxia might be causing some elevated hematocrit and hemoglobin, perhaps. And by the way, if you need help with lab interpretation, definitely check out the lab interpretation crash course for new nurse practitioners. Actually, we renamed it because it's for all nurse practitioners, but check that out in the links below, and we want to consider do they need a tuberculosis test?

QuantiFERON Gold is more of the gold standard, and then they may at some point need a sputum sample, but that's not really for primary care. But those are kind of the main places of triage of where you want to go. What are we thinking about in terms of further differentials aside from those most common ones, right? Are we thinking about COPD? Are we thinking about heart failure? Are we thinking about some sort of infectious cause? Some chronic bronchitis? Bronchiectasis? Those types of things. Is this long COVID? Related to their coronavirus illness before?
 

And yeah, and basically your next steps, you want to think about that testing of those labs, do they need a QuantiFERON? Do they need a chest x-ray? Versus are you like, "I'm really confident, based on their history in their exam, that this is a GERD or allergies. Do I do a treatment trial of those two things?"
 

We talk all about how to manage allergies, nasal rinses, fluticasone, try not to use a brand name there. Do they need oral allergy medications? Do they shower at night before bed? All of those lifestyle interventions, plus GERD treatment, lifestyle interventions, medications potentially, versus am I really concerned about their smoking history, the way they're presenting those types of things. If I'm not super confident that it's those first two, GERD or allergies, then we're moving on to a chest x-ray, because we really want to make sure that there's no other processes going on. Is there a lung cancer that we potentially could miss? Things like that. Depending on your findings of your chest x-ray, depending on the radiology report, sometimes they say, "You know what? Chest CT is needed for further diagnosis." And then that is really a branching point for you of decision making of is this appropriate for primary care?
 

Is this garden variety? I don't know, asthma maybe? You can probably handle that in primary care, at least the initial treatment based on their history and all that testing, versus is this a place where you refer to pulmonary? And for me, I have ordered a chest CT with an abnormal chest x-ray for a potential bronchiectasis, for example. But with the understanding with the patient of like, "Listen, I'm going to order this test, and also we need to go talk with a pulmonologist to understand how these test results affect you and the further treatment, et cetera, et cetera." Versus you, in your clinic, and your philosophy of practice, need to talk with your collaborator or your supervisor do I order this chest CT? Or do we stop at a chest x-ray and collaborate whether either an e-consult, an email to a provider, a phone consult of like, is this an appropriate referral for you? Do we need spirometry or PFTs? And is that the culture of your practice, that you order those and interpret those, or is that really most appropriate to be either allergy immunology or pulmonary? And a lot of the management really depends on your assessment going forward, but hopefully that's a clear picture of, you know what? Treatment trial, if it's very clear, workup if it's less clear, you have to use your clinical judgment for that piece.

But yeah, when it comes to a treatment trial, one last note about that, is I still am cautious. I'm not going to write that off. And I'm very clear with my patients of like, "You know what? This really sounds to me like it's actually from heartburn. And I know that sounds crazy because you don't feel heartburn, but you have all of these symptoms..." Blah blah, blah, blah, blah. And I tell them that whole thing, and let's try this trial, if it is not improving in two months, one to two months, you're not starting to see some improvement, please let me know, or we make a follow-up appointment to make sure that we don't lose them to follow up.

Because we want to make sure that they're taken care of, because what if they do have some sort of underlying lung condition, and we haven't assessed that yet because of the other things that were alluding us?

So hopefully this will help you feel better about approaching chronic cough in primary care.

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