What studies, in addition to chest x-ray and spirometry, should be performed in outpatients presenting with chronic cough? When should such patients be referred to specialist centers?
Imran Satia: That is a very important question because one of the commonest reasons for referral to hospitals, to specialist centers, is cough. Cough is a very common symptom for referral. In our practice I think the most important thing before we do any investigations is to take a really good history of the patient’s symptoms. What we find is trying to ascertain the type of cough – whether it is a dry cough, whether it is a productive cough, whether it is an infective type of cough, whether it is associated with coughing of blood. That can help you decide which investigation to do best. Clearly, if there are red flag symptoms, such as weight loss or hemoptysis, then these patients will require an urgent computed tomography (CT) scan and potentially a bronchoscopy.
If those symptoms do not exist, then it is important to look at the drug history, particularly to make sure that they are not on an angiotensin-converting enzyme (ACE) inhibitor, because 14% of cases of chronic cough can be attributed to ACE inhibitors. And this often… after stopping this treatment within a couple of months, many of these patients’ cough can also get better. That is the second thing to say.
The third thing to say is that many of our patients unfortunately still smoke, and smoking is a very salient trigger for coughing. We would advise all our patients to stop smoking because this – as we know from studies – can make coughing worse.
In terms of investigations, I think a chest x-ray is a very important first test to make sure that there are no obvious abnormalities, but chest x-rays can miss sometimes very subtle abnormalities, such as interstitial lung diseases. It is very important to examine the patient to make sure there are no obvious fibrotic crackles or any clubbing in the fingernails. Sometimes that can be useful.
With regards to spirometry, our practice is to do a full pulmonary function test, which includes the flow-volume loop. This would really help patients and help you to understand whether there are any more subtle abnormalities in the small airways or in the throat. If you have the ability, it is important to do a reversibility assessment for assessment of asthma. Here, you could do the lung function at the baseline, you can offer salbutamol with 4 puffs of salbutamol with a spacer device, and after 15 minutes repeat the spirometry to ensure whether or not there is an improvement in the forced expiratory volume in 1 second (FEV1). If there is a significant improvement of more than 12% reversibility or more than 200 to 400 mL of FEV1, then that would be consistent with asthma if they had symptoms of cough and wheeze. In these patients that would be an important thing which practitioners could do in their community or even in a district general hospital.
If you have investigated these symptoms and you have also investigated for reflux disease or asked about reflux disease and treated for 2 months with antacid treatment, with high-dose proton pump inhibitors (PPIs) – omeprazole, usually 20 mg twice a day with an H2 blocker – and the cough is still persistent, troublesome, then that would be a good opportunity to refer to a secondary hospital, respiratory physician to assess the cough further.