Respiratory pre referral checklists

CHRONIC COUGH IN ADULTS

  • Cough is a normal physiological reflex that protects the lungs and airways
  • CHRONIC COUGH > 8w
  • Challenge is to identify any underlying disease

Are there RED FLAGS Symptoms? = consider 2 week wait referral
  • Weight loss/anorexia (unintentional)
  • Haemoptysis
  • smokers
  • Dyspnoea
  • Chest Pain
  • Hoarseness
  • abnormal CXR
  • fatigue
  • clubbing
  • supraclavicular lymphadenopathy
/ y/n
Initial assessment:
  • Describe in own words.
  • Demonstrate (is it a cough rather than throat clearing?)
  • Explore concerns eg cancer
  • History specifics
  • egRED FLAGS- as above
  • productive? –may suggest underlying airways disease ( asthma/copd/ bronchiectasis) or infection
  • Aggravating factors
  • ACE- sx usually settle after stopping 4w
  • Smoking-9/10 settle after stopping
  • Viral-usually normal cough reflex after 4w
  • Occupational cause
  • Examination-chest, throat( tonsillar enlargement),lymphadenopathy, ears ( wax can stimulate cough), BMI( OSA can be associated with chronic cough), clubbing
/ y/n
Have Investigations been performed?
  • CXR-¼ cancers missed on CXR if JUST COUGH
  • Spirometry ? COPD/asthma ? reversibility, restriction
  • Bloods
  • FBC ? eosinophilia=?steroid responsive, usually asthma.
  • Consider pertussis serology if concerns
/ y/n
Perform STEROID TRIAL
Is the cough steroid responsive? (usually asthma)
  • Prednisolone 30 mg/day for 2 weeks or
  • Consider Inhaled corticosteroid 4-6w (but caution re poor compliance leading to equivocal result)
  • Eg Pulmicort turbohaler 200mcg BD or Flixotide Accuhaler (100mcg BD)
IF steroid responsive consider
  • Asthma- see reference below for management
/ y/n
NEGATIVE STEROID TRIAL-Have other aggravating factors/ diagnoses been considered?
Consider SEQUENTIAL treatment:
  • Antireflux treatment. Suggest Lansoprazole 30mg bd or equivalent for 2/12.
  • small number respond to PPI
  • r/v after 8 weeks, discontinue if no response.
  • Upper airway cough syndrome
  • Allergic RHINITIS/ post nasal drip/ chronic sinusitis
  • consider nasal steroid trial/ antihistamineeg beclomethasone dipropionate 50 mcgs bd
  • r/v 2-8 weeks-discontinue if no response
other diagnostic considerations:
  • obstructive sleep apnoea/tonsillar enlargement
  • Significant underlying disease eg. heart failure, bronchiectasis, COPD, pertussis, TB, interstitial lung disease etc.
/ y/n
CONSIDER REFERRAL
  • 2ww criteria eg haemoptysis
  • RED FLAGS
  • Diagnostic uncertainty
  • Refractory cases
  • ? further investigations/ imaging required
  • For SALT -good evidence for COUGH SUPPRESSION THERAPY-should be reviewed by respiratory medicine first
  • Consider ENT
  • eg for OBSTRUCTIVE SLEEP APNOEA/ tonsillar enlargement
  • upper airways cough syndrome
  • but otherwise low yield for pathology
/ y/n
  • References:
  • Cough guidelines in need of updating.
  • BTS guidelines are now very dated
  • The Australian guidelines seem the most sensible and up to date currently
Cough:
Asthma:

Thanks to Dr Sean Parker, Dr Les Ashton, November 2015

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