Chronic Cough Station

Presenting Complaint - Chronic Cough

History of Presenting Complaint:

• Cough – SOCRATES:
  • Site - NA
  • Onset – gradual onset
  • Character - dry cough. No haemoptysis.
  • Radiation - N/A
  • Associated symptoms – Shortness of breath. He denies having any chest pain or tightness, wheezing, palpitations, or ankle swelling.
  • Time/duration - 3 months. No previous episodes of coughing.
  • Exacerbating/relieving factors – He has not noticed anything that makes the cough better or worse, such as:
    • Diurnal (worse at night or in early morning)
    • Season (worse in winter e.g. COPD; worse in summer e.g. asthma)
    • Environment e.g. home/work, indoors/outdoors
    • Position (worse when lying flat – orthopnoea)
  • Severity - He feels the cough has been getting worse since it started 3 months ago.
• Shortness of Breath – SOCRATES:
  • Site - NA
  • Onset – gradual onset
  • Character - NA
  • Radiation – NA
  • Associated symptoms – NA
  • Time/duration - 1 month
  • Exacerbating/relieving factors – Worse on exertion. No orthopnoea.
  • Severity – The shortness of breath is quite severe, as it’s stopping him from walking to the allotment down the road and tending to his vegetables, which he used to do every day.
• He denies the following symptoms:
  • No joint pain or stiffness (pulmonary fibrosis secondary to rheumatological disease)
  • No rhinitis
  • No nasal drip
  • No sore throat or throat pain
  • No heartburn or indigestion
• Systemic symptoms:
  • He has been feeling increasingly tired, which he attributes to feeling breathless
  • He has noticed he has lost some weight over the past couple of months but does not know how much. He says he is eating more but can’t seem to put the weight back on.
  • No loss of appetite
  • No night sweats
  • No recent illnesses
• Red flag symptoms:
  • Unintentional weight loss
  • No haemoptysis
  • No night sweats
  • No hoarseness

Previous Medical History

• Distal tibia fracture that was managed conservatively as a child.
• He does not like coming to see the doctor. He usually self-medicates but his wife has been persisting he comes in, as he does not seem his usual self.

Drug History

• Nil regular. Nil over the counter

Allergies

• NKDA

Family History

• Father died of lung cancer at the age of 60.
• No family history of atopy, tuberculosis, or pulmonary fibrosis.

Social History

• Enjoys a few pints of beer with his friends on a Thursday night (9 units weekly)
• He used to smoke around 20 cigarettes a day from when he was 15 to 65 (50 pack years)
• No illicit drug use
• Lives with his wife Barbara at home. She had a cold 6 weeks ago.
• No pets at home, including birds and cats
• They are both are independent of activities of daily living.
• Used to work as a builder

ICE

• Ideas: “Do I have some kind of infection?”

• Concerns: “My wife has become worried about this cough. I am just struggling to do my day-to-day activities like going the allotment now.

• Expectations: “I’d like something to make me feel less short of breath.”

Respiratory Examination Findings:

• General Appearance
  • The patient looks well and appears comfortable at rest
  • No signs of respiratory distress
• Inspection
  • No chest wall deformities or evidence of abnormal breathing patterns
  • Clubbing of fingers
• CRT <2 seconds
• No fine tremor or asterixis
• JVP is not raised
• No cyanosis
• Palpation
  • Trachea is central
  • Equal chest expansion
• Percussion
  • Dullness to percussion in the left middle zone
• Auscultation
  • Decreased breath sounds in the left middle zone
  • Focal wheezing
• No lymphadenopathy
• No pedal oedema

Most likely differentials:

• Lung Cancer (more common in smokers and he is presenting with a chronic cough, dyspnoea, and unintentional weight loss)
• Mesothelioma (given this gentleman was a builder and he is presenting with gradual onset of dyspnoea and unintentional weight loss)
• Asbestosis (due to exposure to asbestos as a builder and asbestosis usually lays latent for 10-40 years)
• COPD (due to significant smoking history, chronic cough, and dyspnoea)

Management

• Bedside:
  • Routine observations including O2 sats
• Lab:
  • FBC (to look for anaemia or signs of infection)
  • CRP (raised in infection, inflammation, and/or cancer)
  • LFTs (to assess for liver involvement in metastatic disease)
  • Calcium (hypercalcaemia may be caused by a paraneoplastic syndrome that is often associated with squamous cell carcinoma or may suggest sarcoidosis)
• Imaging
  • Chest X-ray (1^st line investigation)
    • NB – sensitivity is 74%, meaning it misses around 30% of cases of lung cancer. Therefore, a normal chest x-ray does not exclude a diagnosis of lung cancer.
  • Contrast CT scan of chest (to stage tumour and guide bronchoscopy)
  • PET-CT scan or MRI (if required for staging)
• Tissue biopsy
  • Bronchoscopy with biopsy
  • CT-guided biopsy
  • Endobronchial ultrasound (EBUS)

1. What is the definition of a chronic cough?

A cough that lasts 8 weeks or more

2. What are the causes of a chronic cough?

There are multiple causes of a chronic cough, including:

• Upper respiratory/ENT:
  • Post-nasal drip
  • Allergic rhinitis
  • Foreign body in ear canal
• Lower Respiratory:
  • LRTI
  • Tuberculosis
  • Interstitial lung disease
  • Sarcoidosis
  • Cystic fibrosis
  • Bronchiectasis
  • COPD
  • Asthma
  • Pulmonary oedema
  • Vasculitis e.g. Goodpasture’s syndrome, Wegener’s granulomatosis
• Others:
  • GORD
  • Aspiration caused by dysphagia (e.g. secondary to stroke, Parkinson’s disease, motor neurone disease)
  • Smoking
  • Occupational or Environmental Exposure (e.g. dust, chemicals)
  • Medications
    • Angiotensin -converting enzyme (ACE) inhibitors (dry cough due to increased bradykinin. Cough often resolves within 1-4 weeks after discontinuation)
    • Beta blockers (due to bronchoconstriction)
    • Inhaled corticosteroids (due to throat irritation or fungal infections e.g. oral thrush)
    • Nitrofurantoin (can cause pulmonary toxicity)
    • Amiodarone (can cause pulmonary toxicity)
    • Methotrexate (can cause pulmonary toxicity)
    • Chemotherapy drugs e.g. bleomycin, cyclophosphamide (can cause pulmonary fibrosis or interstitial lung disease)
  • Diaphragmatic irritation (e.g. abscess, malignancy)
  • Yellow nail syndrome

3. What is psychogenic/habit cough?

A cough that has no clear organic cause. It is considered a form of somatisation, where emotional or psychological stress is expressed through physical symptoms. It often occurs in children or adolescents and disappears during sleep or distraction.

4. What is yellow nail syndrome?

A rare disorder characterised by a triad of symptoms:

• Nail abnormalities (e.g. yellow-green discolouration, increased nail curvature and thickening, slow-growing nails, and lack of cuticles)
• Respiratory problems (e.g. chronic bronchitis, pleural effusions, sinusitis, or bronchiectasis)
• Lymphoedema

The exact cause of yellow nail syndrome is not well understood but is thought to be related by dysfunction in the lymphatic system.

5. What are the different types of lung cancer?

Small Cell Lung Cancer (SCLC) (10-15%):

• Small Cell Carcinoma
  • Highly aggressive form of lung cancer that arises from neuroendocrine cells in the lungs
  • Strongly linked to smoking
  • Associated with paraneoplastic syndromes (e.g. SIADH, Cushing syndrome, Lambert-Eaton myasthenic syndrome)
  • Due to the aggressive nature, surgery is less commonly used
• Combined Small Cell Carcinoma
  • A variant of small cell carcinoma where small cell carcinoma is present along with elements of non-small cell lung cancer e.g. adenocarcinoma or squamous cell carcinoma

Non-Small Cell (SCLC) (80-85%):

• Adenocarcinoma
  • Most common subtype (40%)
  • Often occurs in people who have never smoked
  • Associated with the paraneoplastic syndrome hypertrophic osteoarthropathy -> nail clubbing and painful arthropathy that can be similar to inflammatory arthritis
• Squamous Cell Carcinoma
  • Associated with smoking
  • Associated with the paraneoplastic syndrome PTHrP (parathyroid hormone related peptide) -> ↑calcium and ↓phosphate
• Large Cell Carcinoma
  • Associated with smoking
  • Has a poor prognosis

6. What are the clinical manifestations of hypercalcaemia?

Stones, bones, thrones, groans and psychiatric overtones:

• Stones (kidney stones)
• Bones (osteoporosis or weak bones)
• Thrones (constipation, increased urination)
• Groans (gastrointestinal symptoms e.g. abdominal pain, nausea, vomiting, indigestion)
• Psychiatric overtones (e.g. depression, irritability, worsening concentration and short-term memory)

7. What will future lung  screening in the UK involve?

The UK is expected to introduce national low dose CT (LDCT) screening of the lungs for everyone aged between 55 and 74 who have a history of heavy smoking. This includes:

• Those who have smoked for 30 pack years AND still smoke OR
• Those who have stopped smoking during the last 15 years