Diagnóstico Diferencial da Tosse Aguda do Adulto

Summary of key points and recommendations
Introduction
Key points
- Cough is a forced expulsive manoeuvre, usually against a closed glottis and which is associated with a characteristic
sound.
- Cough frequently presents as a troublesome symptom to clinicians working in both primary and secondary care.

Acute cough
Key points
- Acute cough is defined as one lasting less than 3 weeks.
- Acute cough is the commonest new presentation in primary care and is most commonly associated with viral upper
respiratory tract infection.
- In the absence of significant co-morbidity, an acute cough is normally benign and self-limiting.
- It is the commonest symptom associated with acute exacerbations and hospitalisations with asthma and COPD.
- The cost of acute cough to the UK economy is estimated to be at least £979 million. This comprises £875 million to loss of
productivity and £104 million cost to the healthcare system and the purchase of non-prescription medicines.
Recommendations
- Indications for further investigation include haemoptysis, prominent systemic illness, suspicion of inhaled foreign body,
suspicion of lung cancer.
- Patients report benefit from various over-the-counter preparations; there is little evidence of a specific pharmacological
effect.

Management of specific aggravants
Key point
- Most cases of troublesome cough reflect the presence of an aggravant (asthma, drugs, environmental, gastrooesophageal
reflux, upper airway pathology) in a susceptible individual.

Asthma/eosinophic bronchitis
Key points
- Cough may be the only manifestation of these syndromes.
- No currently available tests of airway function can reliably exclude a corticosteroid responsive cough.
Recommendation
- Cough is unlikely to be due to eosinophilic airway inflammation if there is no response to a two week oral steroid trial.

Drugs
Recommendation
- No patient with a troublesome cough should continue on ACE inhibitors.

Environment
Key point
- One of the commonest causes of persistent cough is smoking and appears to be dose related.
Recommendation
- Smoking cessation should be encouraged as it is accompanied by significant remission in cough symptoms.

Gastro-oesophageal reflux disease (GORD)
Key points
- Failure to consider GORD as a cause for cough is a common reason for treatment failure.
- Reflux associated cough may occur in the absence of gastrointestinal symptoms.
Recommendations
- Intensive acid suppression with proton pump inhibitors and alginates should be undertaken for a minimum of 3 months.
- Antireflux therapy may be effective in treating cough in carefully selected cases.

Upper airway pathology
Key points
- Rhinosinusitis is commonly associated with chronic cough.
- There is an association between upper airway disease and cough but a poor association between the various symptoms
and cough.
- There is disparity in the reported efficacy of antihistamines.
Recommendations
- In the presence of prominent upper airway symptoms a trial of topical corticosteroid is recommended.

Undiagnosed or idiopathic cough
Key points
- Chronic cough should only be considered idiopathic following thorough assessment at a specialist cough clinic.
- The clinical history of reflux cough is often present in patients with idiopathic cough.
- A typical lymphocytic airways inflammation is seen in idiopathic cough.

Treatment of cough due to other common respiratory diseases
Key point
- Cough can be a debilitating symptom in many common acute and chronic respiratory diseases.
Recommendation
- Suppression may be relatively contraindicated especially when cough clearance is important.

Symptoms associated with acute cough prompting a CHEST RADIOGRAPH
Haemoptysis
Breathlessness
Fever
Chest pain
Weight loss

Causes of acute cough with a normal chest radiograph
Viral respiratory tract infection
  Respiratory syncytial virus
  Rhinovirus
  Influenza
  Parainfluenza
  Adenovirus
  Respiratory corona virus
  Metapneumovirus
Bacterial infection (acute bronchitis)
Inhaled foreign body
Inhaled toxic fume

Taking a history: At risk groups and danger signs
Although cough is very common and usually self-limiting, it is sometimes the first indication of a serious condition.
For most of these patients cough is not the only symptom and the presence of a number of others should prompt a chest radiograph. These features—as well as a history of foreign body inhalation—should always be ruled out by direct questions.
Acute cough with increasing breathlessness—while usually due to acute bronchitis—should be assessed for asthma or anaphylaxis and treated appropriately.
Acute cough with fever, malaise, purulent sputum, or history of recent infection should be assessed for possible serious acute lung infection.

Physical examination
At the outset of the common cold there may be clinical evidence of a rhinitis and pharyngitis with inflamed nasal mucosa and posterior pharynx with adherent or draining secretions. Inspection of the ears may reveal serious otitis. A computed tomographic (CT) study of the nasal passages and
sinuses in the common cold has shown that widespread rhinosinusitis, which clears on resolution of the infection, is most typical.
Acute cough is common in any patient presenting with pneumonia. Physical findings on examination of the chest are often very helpful and include dullness on percussion, bronchial breathing, and crackles on auscultation.[/quote]





- A H Morice, L McGarvey, I Pavord. Recommendations for the management of cough in adults. Behalf of the British Thoracic Society Cough Guideline
Group. Thorax 2006;61(Suppl I):i1–i24. doi: 10.1136/thx.2006.065144
- Richard S. Irwin, MD, FCCP, Chair. Diagnosis and Management of Cough Executive Summary. ACCP Evidence-Based Clinical Practice Guidelines. CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT.[/quote]