The adult with chronic cough.

CLINICAL VIGNETTE A 60-year old man presents with a history of chronic cough for 16 months. The cough was present day and night, with little mucus production and some associated feeling of shortness of breath and choking sensation, especially at night. Additional complaints included postnasal drip, runny nose, sensation of mucus in the throat, wheezing, and snoring. The patient was referred for persistent coughwith inadequate response to previous treatment prescribed by his primary care physician, including antihistamines, nasal steroid sprays, oral prednisone, antibiotics, and proton-pump inhibitors. Physical examination was unremarkable, with stable vital signs, including heart rate of 80 beats/ min (regular), respiration of 16 breaths/min (regular), and blood pressure of 128/78 mm Hg. Height was reported as 68.5 inches and weight as 178 lbs. Spirometric values were measured. Forced vital capacity was 4.52 L (106% of predicted value). FEV1 was 3.45 L (100% of predicted value). The FEV1/forced vital capacity ratio was 76%. Forced expiratory flow at 25% to 75% of forced vital capacity was 2.24 L/s (79% of predicted value). Results of chest radiography, computed tomographic scans of the sinuses, and high-resolution computed tomographic scans of the chest were all normal. Fraction of exhaled nitric oxide level was measured at 16 ppb. The patient underwent a methacholine inhalation challenge. FEV1 was reduced 9% at the highest concentration (25 mg/mL). Because the patient’s symptoms did not improve with therapeutic trials for common disorders causing chronic cough, history and review of systems were revisited. On specific questioning, the patient noted that he has had snoring and restless sleep for many years. The patient’s spouse reported that snoring was minimal, and no apnea was observed. However, friends of the patient claimed the patient sounded like a ‘‘racing tractor trailer’’ while asleep. The patient also noted increasing daytime lethargy. He also believed that there might have been an episode of choking while eating chicken at a restaurant a few days before his chronic cough started. This led to consideration of obstructive sleep apnea (OSA) or foreign body aspiration. Pulmonary referral was made, and he underwent bronchoscopy and a sleep study. The full version of this article, including a review of relevant issues to be considered, can be found online at www.jacionline. org. If you wish to receive CME or MOC credit for the article, please see the instructions above. INSTRUCTIONS Credit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the instructions listed below: 1. Review the target audience, learning objectives and author disclosures. 2. Complete the pre-test online at www.jacionline.org (click on the Online CME heading). 3. Follow the online instructions to read the full version of the article, including the clinical vignette and review components. 4. Complete the post-test. At this time, you will have earned 1.00 AMA PRA Category 1 CME Credit. 5. Approximately 4 weeks later you will receive an online assessment regarding your application of this article to your practice. Once you have completed this assessment, you will be eligible to receive 2 MOC Part II Self-Assessment credits from the American Board of Allergy and Immunology. Date of Original Release: September 2012. Credit may be obtained for these courses until August 31, 2014. Copyright Statement: Copyright ! 2012-2014. All rights reserved. Target Audience: Physicians and researchers within the field of allergic disease. Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates these educational activities for a maximum of 1 AMA PRA Category 1 Credit". Physicians should only claim credit commensurate with the extent of their participation in the activity.