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Chronic Persistent (Cough for > 8 Weeks) Patient has a cough Cough - Chronic Persistent (cough for > 8 weeks) Click for For coughs lasting more for > 8 weeks info < 8 weeks see (chronic persistent cough) 'Cough in Adults' pathway: See Notification of Infectious http://www.enhertsccg.nhs.uk/ Diseases: http://www.enhertsccg.nhs.uk/ Are RED FLAG symptoms Refer to the Hertfordshire Click for History and examination 2WW referral for present? Consider TB, Stop Smoking service as info for including x-ray and suspected lung cancer cancer or other reasons Required patients spirometry for urgent referral Click for Click for http://www.enhertsccg.nhs.uk/ more more info info Suspected COPD or asthma See pathway Spirometry FEV1 / FVC assessment based Diagnosing COPD: on clinical standards is abnormal and a http://www.enhertsccg.nhs.uk diagnosis of COPD or asthma is suspected. Refer smokers to smoking cessation service See pathway Exclude COPD, Bronchiectasis in Adults – Suspected bronchiectasis asthma, bronchiectasis Suspected: Click for and pneumonia http://www.enhertsccg.nhs.uk/ more info Suspected pneumonia Click for more info Click for Productive cough - Click for Dry cough treatment more purulent/ non-purulent more info treatment info If the patient is taking an Click for ACE inhibitor - STOP and more consider alternative info Review within 6-8 weeks Click for more Rhinosinus disease info If no improvement consider Click for other causes more Cough variant asthma Consider bronchoscopy, high info resolution CT scan to fully exclude significant disease Click for Gastro-oesophageal more info reflux disease (GORD) No improvement and Consider referral to difficult diagnosis, refer pulmonary rehab service for cough suppression techniques to secondary care - indivualised approach See pathway Pulmonary Rehabilitation: http://www.enhertsccg.nhs.uk Back to PPaattiieenntt hhaass aa ccoouugghh ffoorr >> 88 wweeeekkss ((cchhrroonniicc ppeerrssiisstteenntt ccoouugghh)) pathway •• CChhrroonniicc ccoouugghh llaassttiinngg ffoorr >> 88 wweeeekkss iiss ccoommmmoonn iinn tthhee ccoommmmuunniittyy.. 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LLaarryynnggeeaall pprroobblleemmss aarree iinnccrreeaassiinnggllyy rreeccooggnniisseedd aass bbeeiinngg ppaarrtt ooff cchhrroonniicc ccoouugghh •• FFoorreeiiggnn bbooddyy iinn llaarrggee aaiirrwwaayyss -- rreeccuurrrreenntt aassppiirraattiioonn,, iinnhhaalleedd ffoorreeiiggnn bbooddyy,, eennddoobbrroonncchhiiaall ssuuttuurreess •• RRaarreellyy,, ccoouugghh mmaayy bbee dduuee ttoo ccaarrddiiaacc aarrrrhhyytthhmmiiaass •• CCoouugghh oonnllyy wwhheenn ssuuppiinnee -- mmaayy bbee dduuee ttoo ccoollllaappssee ooff llaarrggee aaiirrwwaayyss •• DDiiffffuussee ppaannbbrroonncchhiioolliittiiss -- aa rreeccooggnniisseedd ccaauussee iinn JJaappaann,, rreessppoonnddss ttoo llooww--ddoossee mmaaccrroolliiddee aannttiibbiioottiiccss ((bbuutt rreessiissttaanntt ttoo sstteerrooiiddss)) •• CChhrroonniicc ccoouugghh mmaayy bbee aa pprreesseennttaattiioonn ooff aa ccoommpplleexx iinnvvoolluunnttaarryy ttiicc ((ee..gg.. aass ssoommeettiimmeess sseeeenn iinn TToouurreetttteess SSyynnddrroommee)) •• IIddiiooppaatthhiicc oorr ppssyycchhooggeenniicc -- aa ddiiaaggnnoossiiss ooff eexxcclluussiioonn Back to History and examination including x-ray and spirometry pathway Physical examination should concentrate on the afferent sites identified as most commonly associated with cough. Has patient tried antitussive preparations? Chest x-ray and spirometry is mandatory • DO NOT refer for bronchoscopy at this stage unless inhaled foreign body suspected. • DO NOT refer for high resolution CT scan early unless wide-spread crackles present to suggest interstitial disease. • Home PEF monitor unlikely to help, forced blow often initiates cough. Link to question May use a cough visual analogue scale, the Leicester Cough Questionnaire or a capsaicin challenge naire If patient is a smoker it is essential that they stop. If appropriate refer to Hertfordshire Stop Smoking service. Further assessment • Blood tests - FBC (infection, eosinophilia), ESR/CRP (infection, malignancy, connective tissue disorders). Back to Are RED FLAG symptoms present? Consider TB, cancer or other reasons for urgent referral pathway • Copious sputum production (bronchiectasis) • Systemic symptoms - fever, sweats, weight loss (tuberculosis, lymphoma, bronchial carcinoma) • Haemoptysis (tuberculosis, bronchial carcinoma) • Significant dyspnoea (heart failure, COPD, fibrotic lung disease) Does patient have symptoms of TB or cancer including: • Haemoptysis • Chest and/or shoulder pain • Breathlessness • Weight loss • Chest signs • Hoarseness • Finger clubbing • Cervical/supraclavicular lymphadenopathy • Fever • Night sweats • Anorexic Back to History LEICESTER COUGH QUESTIONNAIRE-acute (LCQ-acute) & Examination This questionnaire is designed to assess the impact of cough on various aspects of your life. Read each question carefully and answer by CIRCLING the response that best applies to you. Please answer ALL questions, as honestly as you can. 1. In the last 24-hours, have you had chest or stomach pains as a result of your cough? 1 2 3 4 5 6 7 All of the time Most of the time A good bit of the time Some of the time A little of the time Hardly any of the time None of the time 2. In the last 24-hours, have you been bothered by sputum (phlegm) production when you cough? 1 2 3 4 5 6 7 Every time Most times Several times Sometimes Occasionally Rarely Never 3. In the last 24-hours, have you been tired because of your cough? 1 2 3 4 5 6 7 All of the time Most of the time A good bit of the time Some of the time A little of the time Hardly any of the time None of the time 4. In the last 24-hours, have you felt in control of your cough? 1 2 3 4 5 6 7 None of the time Hardly any of the time A little of the time Some of the time A good bit of the time Most of the time All of the time 5. How often during the last 24-hours have you felt embarrassed by your coughing? 1 2 3 4 5 6 7 All of the time Most of the time A good bit of the time Some of the time A little of the time Hardly any of the time None of the time 6. In the last 24-hours, my cough has made me feel anxious 1 2 3 4 5 6 7 All of the time Most of the time A good bit of the time Some of the time A little of the time Hardly any of the time None of the time 7. In the last 24-hours, my cough has interfered with my job, or other daily tasks 1 2 3 4 5 6 7 All of the time Most of the time A good bit of the time Some of the time A little of the time Hardly any of the time None of the time 8. In the last 24-hours, I felt that my cough interfered with the overall enjoyment of my life 1 2 3 4 5 6 7 All of the time Most of the time A good bit of the time Some of the time A little of the time Hardly any of the time None of the time 9. In the last 2 weeks, exposure to paints or fumes has made me cough 1 2 3 4 5 6 7 All of the time Most of the time A good bit of the time Some of the time A little of the time Hardly any of the time None of the time 10. In the last 24-hours, has your cough disturbed
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