#241 Chronic Cough

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Pretty much, we are responsible if you screw up. You should always do your own homework and let us know when we're wrong. Welcome back. Hey, Matt, how you doing? This is the curbsiders. That's the great Dr. Stuart Brigham interrupting me as usual. The great Dr. Paul Williams is also here. Tonight we are talking about chronic cough.

with Dr. Brad Hayward. And before we get to that, I wanted to remind you that this and most other episodes are available for free CME and mock credit through our partnership with VCU Health Continuing Education. You can go to curbsiders.vcuhealth.org and set up a free account. So with that, Paul, would you tell the audience, what do we do on this show?

I'm happy to. We are the Internal Medicine Podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. And as you mentioned tonight, we talked to close personal friend, deep mentor from our residency training, the great Dr. Brad Hayward. I'm going to let Cyrus tell us all about the episode and about our special guest.

Awesome. Hey, thanks, Paul. So tonight we were thrilled to record an episode on cough with our guest, Dr. Brad Hayward. Dr. Hayward is an assistant professor of clinical medicine at Weill Cornell Medical College in New York City in the division of pulmonary and critical care medicine. He serves as an APD for the PCCM fellowship training program. And additionally, he has pursued fellowship in palliative medicine, holding a dual appointment in the division of palliative medicine.

His goals are to combine and further the fields of pulmonary and critical care and palliative medicine. And in this episode, he teaches us about the common causes for subacute and chronic cough, how to diagnose the cause for cough in these patients, and how to approach therapy. So without further ado... Let's get it on. Excellent. Hey, hey, Paul. So did you know there's actually a new term for the arts in this COVID era falling postmodernism? It's called Kafkaesque.

I mean, you didn't even give me a chance to respond. I know. You already got a pun in. Yeah, sorry. All right. Kafka-esque. All right. Fade to black. Brad, thank you for joining us. We've been talking about doing some pulmonary topic with you for a long time now. Glad for the audience to meet you. So tell them a one-liner about yourself and give them a hobby or interest outside of medicine.

Sure. So I'm a 39-year-old pulmonologist, intensivist, and palliative care doctor who's dedicated to teaching practical aspects of my fields. My social history is notable for curating an Instagram for my dog Arnie, watching trashy reality TV shows, and sometimes running marathons, but often claiming that I hate it. What kind of... Trashy reality TV shows. I've got to ask. Well, I mean, as you know, there's many, but 90 Day Fiance is currently on loop.

There's that, Below Deck Med. I mean, the options are endless. So, yeah, normally, and I'm still going to ask about a book, even though in the interest of full disclosure, I may not get to it until 2024. um if if the world survives but in the short term i would like to hear more about below deck med now i'm fascinated so what is that well there's apparently this whole world of like uh super rich yachters and um

It's like set in the Mediterranean. That's the med part. And then it's about the cast that is below deck that takes care of all these super rich people. They're called like yachties. They come from all over the...

world, I guess, to work on these super yachts. And there's always, of course, like a lot of drama below deck. So that's pretty much the premise of it. That's much better than when I thought it was actually medically related. I'm actually much more interested now than I was previously. That sounds great. Yeah, no, no, it's strictly superficial and trashy. Oh, perfect. For the audience, Paul does not like any medicine in his downtime. It's pure escapism. That's good, yeah. Yeah, that's similar.

Yeah, no, even in even my professional life, I really try to minimize medicine as much as possible. So were we going to get a book then, too? Yep. Yeah. Favorite book. My favorite book. I think we normally frame it as a book that doctors should read. So either one is a valid option. Yeah. I mean, the book that I think that all doctors should read is one called Mastering Communication with Seriously Ill Patients.

by Anthony Back and Bob Arnold. And it's essentially like a roadmap and an outline of the approach to having palliative care type discussions with patients. And it also provides... you a way and a framework of addressing patients emotions which i think is really challenging for everybody and it can work outside in terms of addressing like friends emotions or other people so i think it's a pretty good book and i would recommend it

Yeah. So what's the best advice you ever received as a learner or as a teacher? I think the best advice that I've had as a learner in terms of working with patients is that we have. two ears and one mouth than to use them in that proportion. So it's hard to listen sometimes to patients when we have a short period of time or you want to start asking questions like about cough or other things.

i found myself um if i deliberately don't say anything for a period of time it actually is more efficient in the end and they sort of tell you they're So I try to keep that proportion in mind. So I think that's probably the best advice I've had. Our sponsor today is Panacea Financial.

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payments on their PRN personal loan, go to PanaceaFinancial.com today to learn more. Panacea Financial is a division of Sona Bank and member FDIC. Paul, could you start us off with a case from Cash Slack Memorial? Sure. I'm happy to. We went all out with a name on this one. So I'm going to tell you about Ms. Esmeralda Wheezy.

She is a 33-year-old female. She's presenting to her primary care provider at Cashback Memorial for a cough. She states that six weeks ago, she had a week of intermittently productive cough. She felt easy fatigability. She felt congested. She had some sinus pain along some chest pain with deep breaths.

She went to an urgent care and was diagnosed with bronchitis. And after about 10 days or so, she felt more or less back to her baseline with the exception of a cough that has persisted. So she's coming to us now, hoping for some kind of relief and also an explanation as to why she still has a cough. But before...

Before we save Ms. Wheezy, I think it's probably always helpful to define our terms. So I wonder if you wouldn't define for us, especially in terms of the timing cough and sort of how we should how we should conceptualize it. Sure. So acute cough is cough less than three weeks. Typically, that cough is like a viral respiratory infection.

That's usually the only cause of acute cough, and so we typically don't go much further in our investigation of the cause if that's the timing. Subacute cough is three to eight weeks, and chronic cough is greater than eight weeks, and that's where... there's the large differential diagnosis. But for acute cough of less than three weeks, it's usually a respiratory infection and we don't do much about it.

Brad, I think that's one of the hardest things when you see patients when they're in the midst of it, like that first three weeks or even that first eight weeks where they're really worried about this cough as the thing that's persisting. probably since you're getting referrals, you probably don't see the patients in that period as much. But usually one thing that I try to tell people when they're in the midst of like a cough or cold is...

probably the cough will be the last thing to go away. It should go away by the eight-week point. I'm not sure if you have a way that you approach that. Yeah, I mean, we don't always see them in that acute period, but I try to set the expectations with the patients ahead of time is that... This is going to be a process that's...

you know, it's irritating and it's annoying to not be able to get rid of this cough, but eventually we may find a cure for it and it may just get better on its own. But just setting the expectation that it's not something that we're going to be able to fix overnight, even if we do figure out what the etiology is.

So it kind of manages their expectations ahead of time. Brad, we always like to really dig in deep to ask what part of the history do you really key in on when you're seeing a patient like this? Because I think that's... In primary care, certainly that's within our wheelhouse. So what is important about cough? I mean, patients, we were talking to a doctor, an otolaryngologist about sinusitis, and she was telling us that patients bring in like...

tissues filled with snot to her office. And I imagine similar things may happen with chronic cough, like people bringing in like a fresh loogie, if you will, for you to inspect. Is that helpful? And if it is or if it isn't, what is helpful when you're asking people about cough and you're evaluating it? Yeah, I mean, it's not helpful when they bring in the tissues filled with sputum.

you know, in a big garbage bag that they've been collecting. So it's not helpful. You're saying that's happened to you? Many times, yes.

Yeah, I mean, even though I'm comfortable with sputum, it's really not that welcome. But in terms of history, some of the things that are important, especially because if the patient is coming... to me as a specialist they probably have been thinking about this for a while so some of it is just letting them go and say just tell me about your cough because they've already started investigating like oh i notice it happens when i eat gluten or

you know, when I am around my grandchildren or something like that. So really just letting them tell you and say that there's not really anything, you know, that would be weird or out of bounds, just so that they'll be able to freely share. Things that are really important are, you know, have you had this cough before? Have you had any recent respiratory infections or illnesses? Or did you feel like you had a cough or cold or anything recently? Is the cough productive or not?

And the reason that that can be helpful is if it's a productive cough, then we think of things like bronchiectasis or sinus disease. If it's nonproductive, then could it be related to medications or intrinsic lung disease itself? Asking patients about a history of asthma is important. And one of the things that I... usually do with that is that when they say they have a history of asthma, asking them

How did you get that diagnosis? Like, did you do pulmonary function tests, like breathe in and out of a tube? Because it seems like everybody at some point in their life gets a diagnosis of asthma without actually having asthma. So I always am very skeptical about that diagnosis. So asking them about...

Do they actually have asthma? For example, do they have like atopic symptoms? Do they respond to bronchodilators? You know, have they been on inhaled steroids before? Have they been hospitalized? Do they visit the ER often? for episodes of bronchitis. Those things might be consistent with asthma, but just having a history on your chart doesn't necessarily mean that it's the truth. Asking about seasonal allergies.

Do you get itchy eyes? Do you have itchy skin? Other things around the change of the seasons, like either in the spring or the fall. I do ask about reflux. So, you know, do you ever notice when you lay down at night that you have heartburn? Do you have like a bad or sour taste in your mouth? And then asking them when they notice this happening, not necessarily just reflux, but in general, the cough.

So do they notice it more in the morning? Do they notice it more at night? Do they notice it more when they're in their workplace or when they're in their apartment? it when they moved their environment because at least in new york people move apartments pretty frequently so sometimes it can be associated with the change in their environment in that sense

So that's some of the questions. And then, of course, additional questions would be looking at their medication history. So are they on an ACE inhibitor or not? Because that can be a frequent cause of cough. Only you're so lucky that that's why they're coming to you. It's happened maybe once and I felt very...

I felt very good about that, picking that up. But most of the time, I think the referrals, at least, I think most primary care doctors are pretty quick to take them off of the ACE. It's like that where if they're still smoking, you're like, all right.

Please, please go away. Come back when you're not smoking and then we'll we'll talk. Yeah. Yeah. And I guess we'll get more into it. I want to ask about the GERD as a cause. I feel like I almost try to will my patients into admitting they have reflux because then I can give them something like it. Like, have you.

Do you have heartburn symptoms? No. Like, I mean, you've had heartburn at one point in your life, right? And they're like, yeah, I do. Like, great. Then two weeks of PPI. Let's see how we're doing that. But I feel like, is that? That kind of begs the question of nerd is a thing, too. The non-erosive.

reflux disease great great stuff um yeah but how how high yield how high yield is is is the gird or at least we're trying to gun down gird like we think about silent reflux sometimes i know we'll get to management but is there any even utility and just trying to

the PPI approach or is that sort of frowned upon in pulmonary circles? No, I mean, it's very, I don't know if I'd say encouraged, but they don't necessarily have to have a symptom of... acid reflux, or even if we suspect silent reflux, because I'm not sure if we're talking about it during this part or not, but one of the etiologies is not necessarily that the acid is coming up in their throat and going down into their...

It's that there's like crosstalk between the nerves and the esophagus and the trachea. So they could be getting irritated in the esophagus from acid, but it's generating as a cough. So they're coughing from that sense. So we do a trial of PPI, whether they say they have acid reflux or not, if it's on the differential. What I find crazy about the whole PPI thing and also kind of depressing is that...

when you read about it, they have to be on it for like two months, maybe three months, like a good trial. And it might take a very long time for it to go away. So it's probably hard to get patient buy-in there. And then... Even if that is the cause, the cough might not get, even if they do have reflux, the cough might not get better. So it's just, it's, it's, it seems like a real pain to figure that out.

Yeah. I mean, on the contrary, it might get better, not because of the PPI and you can at least take credit for that. It just got better anyway. Yeah. And they think I'm the genius who picked it up. It just got better. It's just the tincture of time and maybe a PPI. Okay. So it sounds like you take a pretty thorough history. You were giving us a big differential there, like seasonal allergies.

We talked about GERD. You took a pretty thorough history about asthma. And then also you're asking, like, are they on an ACE inhibitor? I mentioned the smoking thing. So that's kind of the high yield area to start. This patient, this specific patient, Esmeralda, Ms. Wheezy, she had a, about six weeks ago, she had what may be a viral infection. So how do you counsel this type of patient if they happen to make it to you?

in that six week time. I think we just explained similar to what you said you explained to your patients is that the cough might be the last thing to go. So you may feel better from, you know, the malaise or fever that you had, but the cough. usually can linger for over eight weeks after a viral infection. So this would be like a post-viral cough syndrome. And that can come either from rhinitis, which is upper airway cough.

syndrome where there's you know post nasal drip and dripping down the back of your throat or it could just be that the airways become more sensitive and so more easily triggered during that time and so afterwards they may cough like when they go out in the cold or when they're exposed to

someone's strong perfume or other things like that. So I think in counseling them, it's going to take time for it to get better. And that it's really just explaining what I did, that it's related to the virus and it's probably the last thing to go. So what sort of therapy, if any, should we offer a patient like this? If we think it's a post-viral cough, like the time course meets up and they're at the six to eight week mark, or let's say they're at the eight week mark.

They're like, what can I do? We did a recent, I'm not sure if you follow our hot cake series, but we recently talked about this meta analysis where they looked at honey. And certainly lots of limitations there. And I'm not sure I fully believe it. Maybe there's something there or it's just...

Just from what I was reading for this cough episode, it seems like anything that can potentially like soothe the throat and let it cool off seems like maybe that's how it works. But what's your approach and what do you tell people? I mean, I don't have a feeling about honey in particular, but I think

For most of the patients, I ask them, you know, this will probably get better with time, but how disabling is this to you? Like, are you coughing at work all the time that this is so bothersome to you? are you willing to try medications? Because some people, surprisingly, even though they come to us, they just want an explanation, but don't want medications. But for the most part, when they come to us, I'm assuming that they want some sort of treatment. And so...

I usually will ask them about whether they're having post-nasal drip or sinus congestion or not. And if they are, then I would give them an intranasal steroid. And then I also would give them an inhaled steroid. to help with reducing that inflammation in their lungs and that hypersensitivity for about four to six weeks. But the variable there is the intranasal steroid or not. No, that doesn't matter what their flow loops show with or without obstruction. You would just give it to them.

regardless of about four weeks? Yeah, because I mean, it could be the cause could be obstructive lung disease, you know, which would be asthma, or it could be an eosinophilic. disease, which doesn't necessarily have to have obstruction, and the treatment would be the same, which is an inhaled steroid. And again, we think this is a post-viral, right? So are we saying that that induced...

like a reactive, we were saying that induced a reactive airways, not necessarily this person's going to have chronic asthma from now on. And would they, would this person even, cause this is like the first six to eight weeks after an illness with this person. I think Stuart probably wouldn't even have.

FTs yet or spirometry yet? Okay. I feel like something I see done fairly commonly in clinical practice is patients who are diagnosed with a post-viral cough get a short-acting beta agonist. They're just given albuterol. I've heard explanations like it helps sort of get the mucosile elevator going or it helps sort of decrease the airway responsiveness. Is that something that is actually useful from an evidence standpoint?

I mean, I think from a clinical evidence standpoint, I think that by the time the patients are coughing and then they use their albuterol, I think that it's not as effective. So that's why I think using an inhaled corticosteroid is more helpful. just for that longer acting effect because if they have just a few episodes of coughing a day by the time they take their albuterol like the coughing fit is already over

So I think using the inhaled corticosteroid as like not prophylaxis, but just as a continued treatment. Yeah. Maybe like if they were... saying that they're a runner and they're starting to cough in the cold air. Do you find that helpful to give it before they go for a run in this situation, like the short-acting beta agonist? Yeah, I mean, if that's all that they're noticing, or if it's this...

this post-viral cough syndrome and they just notice every time they go out into the cold, you know, to walk to the subway or whatever, they cough and it really bothers them, then I would say, sure, you could use just the albuterol then. But otherwise, I think an inhaled corticosteroid would be helpful. for this period while we're trying to resolve the inflammation. And I just want to ask about the post-viral cough syndrome. Does this also apply to the world's most...

Famous virus, COVID-19. So for the post COVID-19 cough syndrome, is there any evidence or any looking at inhaled corticosteroids for those patients? For those patients, I mean, the ones that I've... seen, a lot of times we'll give them just a course of oral steroids like prednisone for five to 10 days because usually the involvement that they've had.

And I have a select population, right? Because I only see people who maybe have come out of the ICU. And so if they're coughing, then I would give them oral steroids for five to 10 days. But if somebody that you suspect had COVID and they still have post-viral cough, I think an inhaled steroid is reasonable. Okay. All right. So for Ms. Wheezy.

She sees, we send her to you for her post-viral cough. She gets inhaled corticosteroids and she also gets a nasal steroid. And what do you know, within the next month, she's better. But I think we have a continuation of the case or a new case here. So, Stuart, did you want to read this one? Sure. So next case is Mr. Winston Wheezy. He's a father to Esmeralda. He's a 58-year-old male who you see a few weeks later also complaining of cough, not unlike his daughter.

however unlike his daughter he cannot think of any causative factor for his cough just saying that his wife has been bringing up his coughing for the last several months he's finally getting to the doctor's office to discuss it so for this patient How would you approach him differently than his daughter? I mean, first, the question would be, you know, what is it about the cough that brought you in?

Is it just because your wife was nagging you or, you know, sometimes people might have a cough and then it has changed in quality in some way. So just trying to figure out what is the reason that.

brought you in today as opposed to last week like is it getting worse or is there something about it you know that's in particular that we should address but if there's nothing nothing you know that comes from that then I would start thinking about the top three causes of chronic cough, which is post-nasal drip or upper airway cough syndrome, cough variant asthma, or GERD.

And so I would start thinking about that in terms of questions that I'm going to ask him about his history. And then also make sure that he didn't have any recent infectious symptoms so that this couldn't be a post-viral cough syndrome. Yeah, he just did a really good job with his daughter.

He wanted to come and see you too. That's really why. Brad, I wanted to... I did want to touch on... Go for it, Paul. I wanted to ask, I mean, we went over your history taking the things that you emphasized in the last case, but I did want to actually touch on...

What environmental exposures do you ask about specifically? Like, say, if a patient is really volunteering or anything, what are the very high-yield things to ask about, especially in chronic cough that might be good environmental exposures to know? Yeah. So, I mean, one would be asking... I mean, I feel like I'm probably failing my pulmonology colleagues by not emphasizing enough some of the social history, but what does he do? Give me a chance for birds here, Brad.

So, yeah. Do you have any birds? And that's, of course, one of our favorite questions. But other history exposures would be like, what do you do for work?

like a sandblaster or something like that, or somebody who works at a construction site where there could be asbestos or just exposure to dust. And that's some of the environmental... history that we might go on but then also like in your house do you notice is there mold in your house um have you seen like in the corners of your shower or bathroom or in your ceiling tiles or something like that like watermark how about the last time you change your filter

In the house, too. Yeah. And so, you know, do you have air conditioners? You know, we could go on and on about the different things that are going on in their house and then, you know, what their work environment is like, what their. home environment is like and you know even going on the birds like um you know do you sleep with pillows that have feathers in them do you have down blankets So it can be pretty revealing what people will tell you in the social history.

I should point out to the audience, if they want to hear us hate on some birds, the ILD episode written by Dr. Paul Williams and company, we really gave it to the birds on that one. They've had it good for too long. Oh, man. I had a thought. Oh, I know what I thought. Paul, this is what I thought you were going to ask about, which is the physical exam.

And so we really didn't go through the physical exam for the first case because the history was was pretty much like a slam dunk for us there. But by the time someone gets to you, Brad, I imagine you have to do like you have to think.

Maybe this could be something other than like the big three, the upper airway cough syndrome, cough, air, and asthma or GERD. So like, what do you pay attention to on a physical exam that might key you in on something else? Yeah. I mean, one would just be, you know, when they're walking to your.

you know, from our waiting room to my office, just seeing how they're walking. Like, for example, like, are they short of breath when they're walking? Because they may be just saying that they have a cough, but it could be that they also have dyspnea and they're just compensating for it, which is a whole different.

category. But then on the physical exam, I mean, looking in their nose to see if they have nasal polyps or irritation, looking at the back of their throat for cobblestoning or not, which might help you with... post-nasal drip, and then of course the standard lung exam, you know, listening for wheezing or ronchi or rails. And one of the things that I also will do is have them do a forced exhalation.

So tell them like that they're blowing like a birthday candle out. And then sometimes you can pick up wheezing that way, which is sort of like a poor man's. Spirometry, I suppose. Do you just listen by, do you put your stethoscope over their trachea when you do that or listen at their lungs or you just listen? Listen at their lungs. Yeah. Like various points in their lungs. Yeah. Okay. Got it.

And then, of course, we look for clubbing. And I think that's most of the relevant physical exam for the cough. And I just have to bring this up as a, I think this is like a tertiary, like a fourth line thing. The looking in the ear for earwax and cerumen impaction as a potential cause of cough is something that I came across. And I was just like, is this a real thing? Like, I have never heard of this. And are you looking in people's ears, like thinking like.

Oh, there's a ball of wax in there and that's what's causing their cough. No, but I think that, I think what you're talking about, I think it's called like Arnold's reflex, I believe. I don't know. Yeah. Where there's like cross talk between some of the like. nerves in your ears with triggering a cough. So I think when you put the otoscope in their ear, you can trigger the cough in that way. So I don't think it's necessarily related to wax itself, but... Okay. So what would be...

What would be the next step? So we've done our physical exam. We've taken a very thorough history, especially about the environment and any exposures, lifestyle things. So what would be the next? the next thing that you do for this patient, let's assume they've had a chest x-ray and that was unrevealing.

And probably by the time they get to you, do you think in primary care we should probably do chest x-ray, spirometry, or is there any other tests for a patient like this? Because I think we're going to call this, this guy has no real... let's say the history and the exam, we can't really find pinpoint anything to cause his cough. What would be the basic testing that we should get? I mean, I think a chest x-ray is helpful, of course, because if there's something abnormal there that could help us.

forming a differential diagnosis or if it's clear that also helps us you know think of things like asthma or just airway disease and then pulmonary function testing if you're able to do spirometry i think is really high yield i don't think you necessarily have to do a whole pulmonary function tests, like including the lung volumes and DLCO, because the spirometry itself is helpful just to see if there's obstruction, like is this asthma or COPD? And if it's not, then we might order.

you know more advanced pulmonary function testing so i don't think that you have to do the whole shebang but you know if you do you know we're always happy to look at it And so those are the things that I think when they come to me that I would look for. And then things that I might do afterwards, I think it depends on the history. So if I'm thinking that this is something related to allergies or an allergic condition.

like in their environment, including mold exposures. I might do a CBC with differential looking for eosinophils. An IgE level can be very helpful, both for allergic conditions and

fungal or mold type conditions or aspergillus. So I often will check those. And then at the same time, I do send an allergy screen in their blood, which... is helpful one from a practical standpoint so if they have end up having like severe persistent asthma and you wanted to use biologic medications they need to have a positive allergen test also

to get it covered. And so it's annoying sometimes to have the patient come back to then just do allergy testing. So oftentimes I'll do it just because if that's where we're going, we may need that. But it also helps give an explanation. So if their allergy screen comes back positive that they have an allergy to dogs, they may have to get rid of their dog.

You know, if it comes back positive that they're allergic to elm trees or something, you can't really avoid that. But it helps us explain, you know, what may be going on. So those are some of the lab tests that I would look for. And yeah, I think that's... the basic things that we would start with. I wanted to just ask about some things that I've read about, but haven't necessarily done myself.

The methacholine challenge or the bronchoprovocation challenge, so spirometry you talked about, that really is just like your... FEV1, your force vital capacity, right? They may or may not do like the bronchodilator response with that, I imagine. But what's the, like, what do you... Adding a challenge to that with like methacholine, is that something that you find helpful in actual practice? And the other one that was mentioned is this exhaled nitric oxide.

which is a test I've read about but haven't actually seen ordered. Yeah. I mean, so the spirometry will give you the flow volume loop. And so... Sometimes just looking at the shape of it. So if there's coving there, it might suggest that there's airway obstruction. And so they may respond to albuterol. And then if they had a normal flow volume loop, though.

Then you might want to do a methacholine challenge test, which is just a series of pulmonary function tests and giving them irritants at different concentrations and comparing it to the normal to see if you can sort of induce asthma in them.

So we don't usually do that in people if we suspect that they have severe asthma, because obviously we wouldn't want to put them at risk for it. But if it's somebody who has normal spirometry to start with, then it's helpful to see if there's a change at a concentration that is more sensitive than the normal.

person. Got it. I see. And this may be case specific, but when do you pull the trigger on the methicoline challenge? Do you have to have some baseline clinical suspicion for asthma or is that just when you have no idea what's going on and you're just kind of throwing speed against the wall and seeing what sticks?

I haven't done it very often because I don't find it that helpful because I think oftentimes the patient's going to end up getting probably a trial of an inhaled corticosteroid, which is really the gold standard of... you know, do they have some sort of asthma or airway obstruction or eosinophilic asthma or respiratory disease? Like they're going to get an inhaled corticosteroid. And if they improve with it, then it...

makes the diagnosis. So going down the diagnostic route of doing all these different tests, I don't know if it's always helpful because in the end, they often end up getting the same treatment anyway, and we see if it worked or not. Okay. So we talked about testing. To summarize, probably from the primary care standpoint, probably a chest x-ray and just plain old spirometry would be a reasonable thing for us to delve into before we send them to you. I probably wouldn't...

I guess you could send allergy screen and some of that other stuff from IgE or an IgE. But I just feel like a lot of the times I'd leave that to the specialist that I'm referring to. And as primary care, if we're seeing this person. I think it would make sense for us to maybe try to treat some of these most common causes first. Is there a particular order that we're supposed to go in? Or does it just like, just based on your clinical suspicion, try to treat GERD, upper airway cough syndrome?

and the cough varying asthma. And then if that doesn't work, then we send them to you. Can you talk a little bit about how we might approach that if we're taking the first crack at this person with like idiopathic cough? Yeah. I mean, I think that... If the history doesn't point you to one of those three, then I often would go with upper airway cough syndrome or post-nasal drip. And so using an intranasal steroid or sometimes just antihistamines can be helpful.

for the patient. And then if it doesn't work, then you can refer them to me. And if you had already done that, then I might try giving them the treatment for GERD. And if that doesn't work... and I don't feel like that there's cough variant asthma, then we might start thinking about the other rare causes. But if you started one of the three treatments, then I might do the next highest thing that I suspect.

So I don't think you can really go wrong, but I would go with treating post-nasal drip to start with. So just real quick clarification question. When you say antihistamines, do you mean oral or intranasal antihistamines? You could do one or the other. So depending on if they have, mostly I would give them just oral antihistamines.

And so I don't have a lot of evidence, though, I think, to back that up to say why that versus intranasal antihistamines. Just I don't have a lot of experience with them. And I think the old... The old chest guidelines, like the ones from 2006 on chronic cough, mention antihistamines, like the first generation antihistamine and a decongestant.

for upper airway cough syndrome. And I'm just thinking about like my 75 year old patient and just thinking about, I don't really feel safe giving that treatment to them. So I like your approach better. I'm not sure if you've actually tried. to follow that guideline and give like decongestant and because, yeah. No, because it all seems like a bit, especially because a lot of us have elderly patients. It's hard, you know, to deal with the side effects. And I think they also recommended.

you know, like first generation antihistamines and patients are really lethargic with that. And so I don't know what's better if you're coughing or if you're lethargic. I'm not, you know, like trading one thing for the other. I don't know what's better.

I was thinking about that, and we'll talk about gabapentin, but I can't help but wonder if you're just making them sleep through their cough. Like, you're just blasting someone with diphenhydramine. Like, they're like, I guess I feel better. I don't know. I'm sleeping at night. Yeah, or like a lot of codeine, you know. I...

Yeah, I think the other thing that's really interesting from those guidelines, and I wanted to know your experience as well, is it seems like it takes a really long time. It's not like you give the person the treatment and in three days they feel better. Like even if you guess right. It seemed like they were suggesting that you give it like weeks to months before you give up and say that that didn't work. Yeah. So, I mean, it's really like a...

That's why I set the expectations with the patients ahead of time is like, we're in this for the long haul. So like, let's get to know each other because this is going to be a period of time. And so I often do like six to eight weeks of each trial. if they're not successful. And it's like a test of will. If they're really bothered by this cough and they really want to figure it out, I'm going to keep going with them. But it's like whoever gives up first, I guess, sometimes.

but you know there's some that are really tough it out and we keep going all the way to bronchoscopy but yeah oh man i mean i don't know if that sounds like the uh yeah it's just it's just a grim thing you're just like the person is is has this pain in the ass cough. And you're like, if you could stick with me for the next three to four, three to six months, we'll figure this thing out.

Yeah, it's like a test of will. It's only going to get worse. If we don't figure it out, next comes esophageal manometry, and we're also going to probably do bronchoscopy. So this will only be more uncomfortable for you as we go. Yeah, so we really try to just wear them down, you know, so that they're like... They just accept it and then I'm successful. One test I wanted to swing back to for the cough variant asthma and the non-asthmatic eosinophilic bronchitis.

There's mention of the exhaled nitric oxide, and then also for the eosinophilic bronchitis, the sputum eosinophils. Are either of those tests... useful in clinical practice or necessary? Because it seems like we're just empirically treating people. So maybe it doesn't matter. I mean, I think that I...

We have those available in my office and I never order them. So I think that that, I don't know, you know, if that says that they're helpful or not, or it's just my approach, but I don't, I think that the thing is if they're. eosinophils are positive, they're probably going to get an inhaled corticosteroid. And if they're not, they're probably going to get an inhaled corticosteroid. So again, it doesn't really change that much. So I don't think it's that helpful in this specific case.

What's the duration for the eosinophilic bronchitis, which I can't say that I've seen. Well, if I've seen it, I didn't know that I've seen it. Is that something that... asthma where they might be on inhaled steroids for the rest of their lifelong or at least intermittently throughout the rest of their life. I'm just not sure.

Yeah. I mean, I think it depends on what is the trigger too. Like, is there something allergic in their environment that's triggering this? And so if they move to a new job and it happened to be something that was at the old job, they may not require that. lifelong, but I think always also telling them, you know, we'll always try to step down therapy, which is an important part of asthma therapy. So, you know, if you're on an inhaled corticosteroid, are we able to go down?

you know, and just using beta agonist intermittently or just use an inhaled corticosteroid, you know, maybe a couple months of the year. So it doesn't necessarily mean like a lifelong commitment to, you know, to an inhaled corticosteroid. Okay. I like it. So if they get rid of their damn bird and their cough goes away, then they might not need inhaled steroids for the rest of their life. We're a cat show, Paul. So I guess it makes sense that we don't like birds.

Yeah, no, I feel like that follows. It's on brand for us, which is good. I apologize to all the bird owners out there. I can just see the angry, the angry emails rolling in. I really have nothing. Literally staring at me with evil eyes right now. I really have nothing against birds. All right. So let's check in again.

For Mr. Wheezy, let's say that we were a really enterprising primary care physician and we were actually treating this guy for six months. before he got to you so we treated him for upper airway cough syndrome we gave him inhaled steroids intranasal steroids uh maybe some antihistamines from time to time he was uh and

We also gave him like some oral steroids. We thought maybe he had like an asthma exacerbation or something. We gave him PPI for six to eight weeks. And we did the spirometry, chest x-ray. We really haven't found anything. Now we're sending him to you. So what's like this next line of testing that I imagine...

At this point, and correct me if I'm wrong, one of Paul's questions in pre-recording is like, when should we refer them to you? At this point, I could tell you, I'm going to refer to you because I don't know what's next. Yeah. But should we have done it sooner?

uh i mean i think it depends on your comfort of treating it right like if you're able to go through this algorithm yourself and you feel comfortable with it then i don't think you have to refer but i think if you did i don't think anybody would um if you referred earlier in this i don't think anybody would see it as a wrong

thing or laziness or anything like that. I think it would be appropriate to refer them if you've tried some of the common treatments and you're not sure what's going on, or if there's anything about it that seems not quite right.

and you're worried about something in particular, I think always referring them, you know, an easy consult is an easy consult. And so if it's something, you know, easy for me to get done with, it's not that bad. It's a lot different than when, you know, when you're in residency and everything is. If it's an easy content, I'm happy to do it.

Yeah. Like in residency, when you call the consultant and they give you like the long sigh on the phone or they ask you some like really angry follow-up questions. Yeah. I remember that. I remember those days. Yeah. Or specifically. So I feel like in my own practice, it sounds like I jump a little bit to cross-sectional imaging probably too early rather than sort of exhausting other workup first. When do you reach for the CT scan for patients?

I mean, I think if you had referred them to me, Matt, like when you were talking about going through everything that you've already done, and they have a chest x-ray that's... if the chest x-ray has something abnormal on it they're probably going to get a ct scan but if they had a normal looking chest x-ray and all these problems i still would probably do a ct scan you know after talking with them and

Because we would be looking for maybe interstitial lung disease that we're not picking up on the chest x-ray itself. And if they hadn't had full pulmonary function tests yet, so I would probably do both of those things. So a CT scan. Doing inspiratory and expiratory images are helpful because it can show air trapping, which helps us know that there's small airways disease.

Oftentimes, when I order a CT scan, I often order it with both of those inspiratory and expiratory views. And then a full pulmonary function test, so including the lung volumes and the DLCO. So that's probably where I would go next, you know, after he had had all of these things done. Who's getting bronchoscopy? The ones that stick with you for six months. Yeah, yeah. I mean, duh.

After we've been doing this dance for six to eight months and you're still coughing, we're probably moving towards the Bronx suite. I think if they had a normal CT scan and they had normal PFTs, I think the only next step would be probably bronchoscopy just to see if there's an endobronchial lesion or something like that that could be causing this. But if you...

haven't found anything yet on that whole workup, then the bronchoscopy might be the next step, but it's not the highest yield in chronic cough. So one of the things in terms of doing it is that, yes, you could see if there's an endobronchial lesion. that you're not picking up on the CT scans, but also it kind of shows your commitment to trying to figure out the patient's cause of cough and that you're going through a whole procedure and bronchoscopy and everything just to figure it out.

If that doesn't do it, then we may be stuck with idiopathic cough syndrome. If I were you doing the bronchoscopy, I would just have fingers crossed that I find like a sprouted pea plant in there or something like having people found like they thought someone had lung cancer, they've got like a cough and things and they find like...

Something wedged in a bronchus down there. I imagine that's a super rare thing, but I would always be fingers crossed that that's what I was going to find. Be so satisfying. These are like pulmonary urban legends. Yes. Let's say you do the bronc and still nothing.

I'm sorry. I got to read this out loud. Cyrus, our fearless producer, Cyrus Askin, is saying that he found a tooth in a right lower lobe one time. Was that a patient with chronic cough, Cyrus? Or was that just somebody that you knew had an... aspirated a tooth. So they may have been a polytrauma. They may have been intubated. But the fact remains that we fished a tooth out of their right lower lobe, which is pretty sweet. That's super cool. Congratulations.

High five. Had nothing to do with cough. All right, next. Okay. It would have been more exciting had you just found it incidentally, like you were working on cough and there just happened to be a tooth down there. That's still pretty. Still cool. Still cool. All right. So Brad, what are we thinking of if the Bronc is normal?

We still don't have a diagnosis and we've done everything, the high-res CT, all the other stuff we already talked about, and we bronc them. What is available to this person that has this idiopathic chronic cough? Yeah. So one of the questions could be, is this a laryngeal sensory neuropathy? So is there something about their laryngeal nerves that are hypersensitive or reacting in some way?

that's causing them to cough. And so this is where something like gabapentin might be helpful. So a trial of gabapentin at a low dose might help them. And that would help with the diagnosis. And I think that There's ways to diagnose that through ear, nose, and throat evaluation, like video stroboscopy and other things. But I've had a few patients that have...

really had benefit with gabapentin. So it makes it seem as if there's some sort of like neurologic hypersensitivity that's calmed down by the medications because there's really no physical other explanation. What sort of doses do you recall? I believe it was low dose from what I was using. I think it was like 100 milligrams of gabapentin TID. I think, is that correct? Yeah, that's pretty much the lowest dose you can give.

I think, yeah, I think they recommend starting with the lowest, the daily dose, starting at 300 milligrams daily and then titrating upwards. But they didn't, I don't think they're very specific to what you titrate to. Yeah. It's very rare. Yeah. I mean, eventually gabapentin will stop a lot of coughing, depending on how much you give it. But it's very rare that we would get to this point, I think, without finding any cause for this person's cough.

Right. And then the last part of it would be like, is this a psychogenic cough? And that's a diagnosis of exclusion, of course, because why is the person coughing so much that they're coming to your office when it's something that is... maybe under conscious control. But that's definitely a diagnosis of exclusion. And I could be misremembering, but I feel like I read somewhere in the guidelines when we're in the territory of unexplained chronic cough about...

fairly early referral to a licensed speech pathologist too is that am i making that up and is that something that is is commonly done because i that's not something that would have ever occurred to me i don't think before researching for this um i yeah i mean so there's like um paradoxical vocal fold motion, which can be a mimicker of asthma. And it's something that they diagnose.

again, through ear, nose and throat evaluation and laryngoscopy. And the treatment is really a psychological treatment through speech and like the speech and language pathologists. They teach the patients how to suppress that. It's either a cough or like a wheezing that they feel that's related mostly to the vocal fold motion that's paradoxical. So that can help them in that standpoint. But it doesn't necessarily always come as cough. That's more of people who have asthma that's just refractory.

to all the medications. And then you start wondering, is there something that I'm missing that's not related to their lungs? There was a New England Journal review on chronic cough that Cyrus had put up. And it was talking about, yeah, the speech pathology, gabapentin or pregabalin, and then low dose morphine, like low dose, slow, slow release morphine, five milligrams twice a day.

which just seems like, as Paul said, you're just like, the person doesn't care about the cough at that point because they're on morphine. So is that something you've ever used or that you would recommend to the audience? I mean, not for chronic cough. I haven't used that. And, you know, for other conditions, I think it can be helpful, obviously, like end stage COPD or, you know.

pulmonary fibrosis or other conditions. But if we have no explanation for their cough, I feel like using opiates, like at what point would we stop then? You know, like if they're coughing all the time and then like. I guess it just gets into a territory that might be uncomfortable. So I think sometimes people will give codeine for a period of time. And if the patient gets better, especially after their post-viral cough.

you know, has gone away, you know, like a one time prescription of coding just to sort of get through the coughing period. But usually I don't think anybody would want to keep somebody on opiates for a long period of time without any discernible explanation for it. Yeah, that reminds me, and I think they get used all the time. I imagine you have some sort of a thought on this. Guifenesin, dextromethorphan, you mentioned codeine, there's promethazine and codeine.

There's benzonotate, which is a respiratory tract anesthetic. There's all these cough and cold formulations out there. And I see patients on them that have chronic cough. I doubt people have gone through this big thorough workup that we've talked about, but do you find that there's a role for those medications, those just sort of symptomatic cough meds that we all probably prescribed at one point in time?

No, I know. I mean, you would think like as a pulmonologist, like I have a favorite mucolytic or something like that, but I really...

I really don't. And what I usually tell the patients is if you go to any Walgreens or CVS or whatever, half of the store is cough remedies. So that should tell you that none of them are effective because if there was one that was effective... it would be like a small shelf of just two to pick from but instead there's like a giant market so i think it's because none of them are effective and people just cycle through all of them so yeah sometimes patients will say oh you know

Gwaifenesin helps me or dextromethorphan has helped me in the past. And sure, like if they want to try that again, I think it's fine. But I typically don't prescribe them because I don't feel like any of them were that effective. It's got to be a multi-billion dollar industry. And pediatrics, there's actually some statements I've seen saying like you should not use those in pediatric patients like specifically because in kids, I think it's a little bit higher stakes.

And you could probably argue the same about the older adults that we talked about earlier in the show. And I've said this on past episodes. I don't think anybody has an incentive to really study that. Like certainly not the people that are making those agents because people are just buying them. It says cough or cold treatment on there. And so people buy them out of death.

So I don't know that we can fix that on this one, guys. But thank you for... Yeah, I feel like there's some sort of economic study behind it, but it's just... I don't usually recommend any of them because I don't feel like any of them are particularly helpful, and it seems all like a money-making scheme of it. It would be a breath of fresh air if you could clear that up.

Well done, Stuart. I think he's been writing that for the past 45 minutes. Brad, this has been awesome. Thank you. But Lister's at home. Stuart's doing a victory lap. You can't see it, but it is. Brad, thank you for talking us through these very murky waters and giving us your expertise. Can you recap some of the bigger points that you'd like the audience to take away from this?

Yeah, I mean, I think that just knowing that chronic cough, one is that it can be disabling to a lot of people. And so, you know, even though we're joking about it, you know, trying to take it seriously, because some people it's very distressing, but using... a stepwise approach and knowing the top three causes of chronic cough and sort of trying to hone in on one of those three things and treating it. And if there's no treatment for that, you know, either upper airway cough syndrome or...

cough variant asthma or acid reflux, then referring to your friendly local pulmonologist is reasonable to try to figure out what could be causing this. And just that it's a long haul. Awesome. Brad, is there anything that you wanted to plug? We usually give our guests, you don't have to plug anything if you don't want to, but is there anything that you'd like to plug for the audience?

Other than I would like to say that one of the things when I'm rounding with the residents, because I feel out of touch, old person to them now, is telling them that I was once your... uh and paul's senior resident i feel like i'm connecting to the the youth of today so yeah so just letting you guys know that you know there's a lot of like fangirling that goes on when they know

What a formative role I played in your education, I'm sure. You did. Thank you. Thank you for being. Credit all to you. Yeah. Thank you so much. All right, Brad. This has been another episode of The Curbsiders, bringing you a little knowledge food for your brain hole. Yummy. Get your show notes at thecurbsiders.com forward slash podcast and sign up for our mailing list at thecurbsiders.com forward slash knowledge food to get our weekly show notes.

in your inbox. That's right, Paul, because we're committed to providing you with high value practice, change, and knowledge. And to do that, we need your feedback. So please subscribe, rate, and review the show on Apple Podcasts or contact us at thecurbsiders at gmail.com.

Special thanks to our producer for this episode, Cyrus Askin, and to our social media team, Beth Garpt, Garptelli on Twitter, Maddie Mad Dog Morgan on Instagram, and Chris the Chew Man Chew on Facebook. Until next time, I've been Stuart Kent Brigham. Good night. Yes. Big thanks to Cyrus for writing and producing this episode. And I believe to Dr. Kate Grant for doing the artwork for this episode. Until next time, I've been Dr. Matthew Frank Watto.

And I am, and hopefully always will be, Dr. Cyrus Askin. And we would be remiss if we did not thank the great Stuart Brigham for composing the theme music you're doubtless hearing behind you. And we should also thank Claire Morgan of Not Early for editing our audio.

And as always, our main Dr. Paul Nelson-Williams, thank you and goodbye. And a gentle reminder that this and most episodes are available for free CME credit for all healthcare professionals at curbsiders.dcuhealth.org. All you have to do is create an account.