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PPS Diplomate Exam > Clinical Practice Guidelines - Chronic Cough > Flashcards

Clinical Practice Guidelines - Chronic Cough Flashcards

1
Q

acute cough

A

< 3 weeks

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2
Q

chronic cough

A

≥ 3 weeks

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3
Q

_____ should be done before any therapy is prescribed.

A

CXR

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4
Q

Most Common Causes of Chronic Cough

A

Asthma
Postnasal Drip Syndrome (PNDS)
Gastroesophageal Reflux Disease (GERD)

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5
Q

Most Common Causes of Chronic Cough in 0-18 mos.

A

Aberrant Innominate Artery
GERD
Cough-Variant Asthma

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6
Q

Most Common Causes of Chronic Cough in 1.5-6 y.o.

A

Sinusitis

Cough-Variant Asthma

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7
Q

Most Common Causes of Chronic Cough in 6-16 y.o.

A

Cough-Variant Asthma
Psychogenic Cough
Sinusitis

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8
Q

A single cause for cough is found _____ of the time.

A

38-82%

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9
Q

Multiple causes for cough are found _____ of the time.

A

18-62%

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10
Q

Therapies should be initiated in the _____.

A

same sequence that the abnormalities were discovered

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11
Q

Asthma with persistent cough without wheezing

A

Cough-Variant Asthma

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12
Q

_____ of children with chronic cough have cough-variant asthma.

A

75%

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13
Q

_____ of children with cough-variant asthma will develop into classical asthma.

A

54%

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14
Q

_____ of children with chronic cough will eventually develop asthma.

A

45%

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15
Q

When there is an identifiable trigger (exercise, nocturnal occurrence, seasonal and episodic attacks, personal or family history) a child is considered an _____.

A

asthma suspect

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16
Q

_____ cough, wheeze, chest discomfort and shortness of breath can sometimes be the only feature of asthma.

A

Exercise-Induced

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17
Q

Referral to an asthma specialist is done when:

A
  1. diagnosis needs to be confirmed by spirometry
  2. normal peak flow in an asthma suspect (> 80%)
  3. below normal peak flow and response to β2-agonist is equivocal (< 20% inc.)
  4. poor response to therapeutic trial
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18
Q

_____ is the recommended initial test for asthma suspects and is feasible starting _____.

A

Spirometry, 5 y.o.

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19
Q

If spirometry is not available, _____ may be used to measure Peak Expiratory Flow Rate (PEFR).

A

Peak Flow Meter

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20
Q

PEFR correlates well with _____.

A

FEV1

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21
Q

Predicted normal PEFR can be calculated for children _____.

A

6-17 y.o. at least 100 cm tall

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22
Q

Predicted Normal PEFR for Males

A

(ht. in cm - 100)5 + 175

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23
Q

Predicted Normal PEFR for Females

A

(ht. in cm - 100)5 + 170

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24
Q

An increase of _____ in PEFR after β2-agonist supports the diagnosis of asthma.

A

> 20%

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25
Q

Further Work-Up for Asthma

A

Exercise Challenge Test
PEFR 2x/day (diurnal variation)
Steroid + Bronchodilator x 5 days

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26
Q

If a peak flow meter is not available, therapeutic trial of _____ may help diagnose asthma.

A

β2-agonist ± steroid

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27
Q

After giving inhaled or nebulized β2-agonist, relief of symptoms are seen in _____ and peaks in _____.

A

5 min., 60 min.

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28
Q

After giving oral β2-agonist, relief of symptoms are seen in _____ and peaks in _____.

A

30 min., 2-3 hrs.

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29
Q

A _____ course of systemic steroids may be given to relieve obstruction and restore response to β2-agonist.

A

5-day

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30
Q

Criteria for Persistent Asthma

A 
> 1 attack/week
nocturnal symptoms > 2x/month
PEFR < 80%
PEFR Variability > 20%
FEV1 < 80%
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31
Q

Asthma Self-Management Behaviors

A
  1. avoid triggers
  2. peak-flow monitoring
  3. asthma diary
  4. proper use of medications
  5. prompt management of exacerbations
  6. asthma action plan
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32
Q

Stridor may be produced by _____ or by any _____ which can predispose to recurrent respiratory infection.

A

aspiration syndrome

anatomic or dynamic problem of the airway

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33
Q

_____ is the congenital floppiness or weakness of the airway which can present as stridor.

A

Tracheomalacia

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34
Q

Tracheomalacia should resolve within _____.

A

18-24 mos.

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35
Q

Patients with vascular rings present with symptoms during _____.

A

infancy or early childhood

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36
Q

Most Common Types of Vascular Rings

A

R Aortic Arch w/ L Ligamentum Arteriosum (95%)

Double Aortic Arch (85%)

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37
Q

Vascular rings can present as _____ cough.

A

high-pitched, brassy

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38
Q

Vascular Rings:

CXR

A

ill-defined arch
compression of trachea
hyperinflation
atelectasis

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39
Q

Vascular Rings:

Barium Esophagogram

A

posterior compression of the esophagus

*diagnostic in most cases

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40
Q

Vascular Rings:

Therapy

A

surgery

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41
Q

_____ is the single most common cause of chronic cough in adults and in children.

A

Postnasal Drip Syndrome (PNDS)

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42
Q

Postnasal Drip Syndrome:

Symptoms

A

something dripping down the throat
need to clear throat frequently
mucoid or mucopurulent secretions
cobblestone appearance of mucosa

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43
Q

Postnasal Drip Syndrome:

Pathophysiology

A

chronic laryngeal irritation → mechanical stimmulation of the afferent limb of the cough reflex

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44
Q

Postnasal Drip Syndrome:

Causes

A 
sinusitis (39%)
allergic rhinitis (23%)
perennial non-allergic rhinitis (37%)
post-infectious rhinitis  (6%)
vasomotor rhinitis (2%)
environmental irritant (2%)
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45
Q

_____ is the inflammation of the paranasal sinuses with concomitant inflammation of the nasal passages and surrounding bone.

A

Sinusitis

46
Q

Bacterial sinusitis is associated with symptoms lasting _____.

A

≥ 10 days

47
Q

Bacterial Sinusitis:

Symptoms

A 
purulent nasal/postnasal discharge (3-4 days)
daytime cough which may worsen at night
high fever (≥ 39° C)
48
Q

Bacterial Sinusitis:

Duration - Acute

A

> 10-14 days

< 30 days

49
Q

Bacterial Sinusitis:

Duration - Subacute

A

30-90 days

50
Q

Bacterial Sinusitis:

Duration - Recurrent Acute

A

< 30 days

≥ 10 day intervals

51
Q

Bacterial Sinusitis:

Duration - Chronic

A

90 days

52
Q

Bacterial Sinusitis:

Pathogens

A

S. pneumoniae
H. influenzae
M. catarrhalis

53
Q

Bacterial Sinusitis:

Treatment

A

Beta-Lactam (Amoxicillin)

54
Q

Bacterial Sinusitis:

Treatment - S. pneumoniae

A

Penicillin
Co-Trimoxazole
Chloramphenicol

55
Q

Bacterial Sinusitis:

Treatment - H. influenzae

A

Ampicillin
Co-Trimoxazole
Chloramphenicol

56
Q

Bacterial Sinusitis:

Treatment - Duration

A

once the patient becomes symptom free then +7 days

57
Q

Bacterial Sinusitis:

Treatment - Antibiotic Response

A

48-72 hours

58
Q

Bacterial Sinusitis:

Complications

A

periorbital and intraorbital infections

59
Q

_____ is the IgE-mediated inflammation of the nasal membranes after allergen exposure.

A

Allergic Rhinitis

60
Q

Allergic Rhinitis:

Criteria for Diagnosis

A

allergen
causal relationship
immunologic mechanism
history of atopy

61
Q

Allergic Rhinitis:

Symptoms

A

rhinorrhea
nasal obstruction
nasal itching
sneezing

62
Q

Allergic Rhinitis:

Symptoms - Nasal Congestion

A 
postnasal drainage
chronic cough
frequent sore throats
dry mouth and oropharynx
nasal twang
snoring
sleep disturbance
63
Q

Allergic Rhinitis:

Physical Examination

A 
facial pallor
mouth breathing
pale bluish gray edematous nasal mucosa
watery nasal secretions
cobblestoning of posterior pharyngeal wall
postnasal drip
injection of palpebral conjunctivae
watery eye discharge
puffy eyelids
64
Q

Allergic Rhinitis:

Classification - Intermittent

A

< 4 days/week

< 4 weeks

65
Q

Allergic Rhinitis:

Classification - Persistent

A

> 4 days/week

> 4 weeks

66
Q

Allergic Rhinitis:

Classification - Mild

A

does not interfere with daily living

67
Q

Allergic Rhinitis:

Classification - Moderate-Severe

A

abnormal sleep
impairment of activities
problems at work or school
troublesome symptoms

68
Q

Oral Antihistamines decrease the symptoms of _____ but have less effect on _____.

A

allergy, nasal congestion

69
Q

_____ are the mainstay treatment of allergies.

A

Oral Antihistamines

70
Q

1st Generation Antihistamines may cause _____.

A

sedation
impair performance
anti-cholinergic effects

71
Q

_____ may help smaller children due to their sedative effect.

A

1st Generation Antihistamines

72
Q

2nd and 3rd Generation Antihistamines have a greater _____ ratio with less _____ and are shown to have _____ effects.

A

benefit:risk, sedation and side effects, anti-inflammatory

73
Q

_____ are used as first-line therapy for allergic rhinitis.

A

Nasal Antihistamines

74
Q

Nasal Antihistamines decreases _____ but causes _____.

A

nasal congestion, sedation

75
Q

Nasal Antihistamines are comparable with _____ but are inferior to _____.

A

Oral Antihistamines

Nasal Corticosteroids

76
Q

The limitation of Nasal Antihistamines is the _____.

A

bitter taste

77
Q

Nasal Antihistamines:

Age

A

≥ 5 y.o.

78
Q

Nasal Corticosteroids are anti-inflammatory agents which affects _____.

A

sneezing
pruritus
rhinorrhea
nasal blockage

*except ocular syptoms

79
Q

Nasal Corticosteroids:

Age

A

≥ 3 y.o.

80
Q

Nasal Corticosteroids:

Onset of Effect

A

2-4 hours

81
Q

_____ are mast stabilizers which include sodium cromoglycate and nedocromil sodium.

A

Nasal Chromones

82
Q

The limitation of Nasal Chromones is _____.

A

QID dosing

83
Q

When decongestants are used alone, they may cause _____.

A

insomnia
anorexia
nervousness

84
Q

When decongestants are used with _____ they may significantly improve symptoms of allergic rhinitis.

A

antihistamines

85
Q

_____ are anti-inflammatory agents acting on the lipo-oxygenase pathway.

A

Antileukotrienes

Montelukast, Zafirlukast

86
Q

Allergic Rhinitis:

Parameters of Response to Therapy

A 
Nasal Symptoms
Physical Signs
Quality of Life
Concomitant Medical Conditions
Side Effects
87
Q

Short Term Complications of Allergic Rhinitis

A 
asthma exacerbation
acute sinusitis
eustachian tube dysfunction
serous otitis media with effusion
sleep-disordered breathing
chronic mouth breathing
decreased cognitive functioning
neuropsychiatric concerns
anosmia
aqeusia
88
Q

Long Term Complications of Allergic Rhinitis

A 
asthma
chronic sinusitis
acute and chronic otitis media
hearing and speech impairment
sleep apnea
craniofacial abmormalities
decrease in productivity
allergic irritability syndrome
anosmia
ageusia
89
Q

Allergic Rhinitis:

Follow-Up Checklist

A

control of symptoms
maintenance of improved quality of life
no impairment of activities
absence of side effects

90
Q

Allergic Rhinitis:

Indications Allergologist/Immunologist Consultation

A 
prolonged duration
identification of triggers
implementation of avoidance of triggers
immunotherapy
decreasing cost of multiple medications
complications/co-morbidities
systemic corticosteroids
significantly affected quality of life
91
Q

_____ are conditions with prominent nasal congestion but lack the criteria for the diagnosis of allergic rhinitis.

A

Non-Allergic Rhinitidis

92
Q

Non-Allergic Rhinitidis

A 
infectious
idiopathic/vasomotor
idiopathic neonatal (autonomic prematurity, GER)
non-allergic rhinitis with eosinophilia syndrome (NARES)
food-induced
mucosal abnormalities
hormonal
drug-induced
foreign bodies
structural abnormalities
tumors
93
Q

GERD-related cough occurs predominantly during the _____ and in the _____ position.

A

day, upright

94
Q

Cough due to GERD has a duration of _____.

A

13-58 mos.

95
Q

GERD can cause _____.

A

heartburn
hoarseness
sore throat
dysphonia

96
Q

_____ of patients with chronic cough have GERD.

A

10-20%

97
Q

_____ of children with chronic respiratory symptoms have silent GER.

A

40-50%

98
Q

GERD

Symptoms

A 
recurrent vomiting
poor weight gain
irritability
heartburn
esophagitis
dysphagia
feeding refusal
apnea
asthma
recurrent pneumonia
upper airway symptoms
99
Q

A therapeutic trial with a _____ or a _____ is a common approach to the diagnosis of GERD.

A

Histamine-2 Receptor Antagonist (H2RA)

Proton Pump Inhibitor (PPI)

100
Q

Relief of symptoms with _____ had a sensitivity of 75% and a specificity of 55% in diagnosing GERD.

A

1 week of Omeprazole

101
Q

Treatment with Omeprazole _____ showed resolution of GERD symptoms within _____.

A

40 mg BID

5-14 days

102
Q

Lansoprazole has been shown to be effective in healing _____ due to GERD.

A

erosive esophagitis

103
Q

GERD:

Lifestyle Changes for Infants

A

changing/thickening formula
prone/lateral decubitus position
1-2 week trial of hypoallergenic formula

104
Q

Thickening of formula should be done by adding _____.

A

1 tbsp. of rice cereal to 1 oz. of formula

105
Q

GERD:

Lifestyle Changes for Children and Adolescents

A

avoid caffeine, chocolate and spicy foods

106
Q

GERD:

Lifestyle Causes

A

obesity
alcohol intake
tobacco exposure

107
Q

_____ is the gold standard for diagnosing GERD.

A

24 Hour Esophageal pH

108
Q

Acid-induced cough occurs simultaneously with the pH drop _____ after an acid reflux episode.

A

5 min.

109
Q

_____ is diagnosed in 3-10% of children with cough of unknown etiology that persists for more than 1 month.

A

Psychogenic Cough

110
Q

Psychogenic Cough is more common in _____.

A

girls

111
Q

Psychogenic Cough is described as _____.

A

barking or honking

112
Q

Psychogenic Cough is managed with _____.

A

suggestion therapy
psychological counseling
psychiatric intervention

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