Treatment for chronic viral infection,herpes zoster meningitis treatment guidelines idsa,origin energy bill too high,herpes treatment forum - How to DIY

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Blog about the latest news and commentary pertaining to affordable health insurance and healthcare. It's easy to understand why most people are confused about the difference between a virus and a bacteria infection.
The main difference between a virus infection and a bacteria infection is that antibiotics have no affect on viruses. Although viruses and bacteria are different and not treated the same, they are spread in the same manner. DISCLAIMER: The content or opinions expressed on this web site are not to be interpreted as medical advice. Cough is the most common single reason for primary care physician visits and is a common source of referrals to pulmonologists.1 In otherwise healthy persons, self-limited cough can occur as part of local irritation due to a viral rhinitis or respiratory infection. Because cough is a symptom that is a common pathway for a variety of diverse conditions and has no reliable objective monitoring tools, physicians' management of cough is actually quite variable. For a symptom such as cough, simply excluding certain serious causes can go a long way to reassuring the patient as well as the clinician and allowing a period of observation. Cough is a protective physiologic reflex that augments mucociliary clearance of airway secretions. Although physiologic cough has a characteristic acoustic profile and is universally recognizable, there is no clinical test that can document and confirm the presence of cough.
Rapidly adapting receptors and C fibers are two afferent nerve subtypes that have been extensively studied and are theorized to play important roles in the regulation of cough. Cough is the single most common symptom prompting outpatient medical visits in the United States.6 Persistent cough is a common reason for referral to a pulmonologist or allergist.
Most patients seek medical attention because of complications of cough, either psychological or physical. Although somewhat arbitrary, it is useful to classify cough by duration as a means of narrowing the differential diagnosis.
The most common cause of acute cough, as defined by a time course of less than 3 weeks, is considered to be the common cold. Acute bronchitis, as the term implies, is a lower respiratory tract syndrome and another common source of acute cough. Distinction between the common cold and acute bronchitis is often impossible to make and usually clinically irrelevant in otherwise healthy persons. A common diagnostic challenge encountered in the outpatient setting is determining the need for a chest radiograph.
Several prospective studies have attempted to delineate the causes of chronic persistent cough and have reached the same conclusion.
In January of 2006, the American College of Chest Physicians published a guideline on the diagnosis and management of cough. UACS is the single most common cause of chronic cough, accounting for 8% to 87% of cases, either exclusively or in combination with other factors.2,13 Categories of UACS-induced cough include allergic rhinitis (seasonal or perennial), perennial nonallergic rhinitis (vasomotor or nonallergic rhinitis with eosinophilia), postinfectious UACS, bacterial sinusitis, allergic fungal rhinitis, occupational rhinitis, rhinitis medicamentosa, and pregnancy-associated rhinitis. The pathogenesis of cough in UACS involves stimulation of afferent receptors in the upper airway, rather than run-off of secretions into the lower airway. The presence of copious sputum is associated with an increased likelihood of chronic sinusitis, but neither the clinical examination nor historical features reliably differentiate it from other causes of UACS.11,13 Excessive sputum production, defined as greater than 30 mL per day, can be a manifestation of asthma, GERD, and bronchiectasis. In most series, asthma is the second most common cause of chronic cough in adult nonsmokers, present in 14% to 55% of cases.16,17 Historical features of wheezing, chest tightness, or exertional dyspnea in response to triggers such as strong odors or perfumes, cold air, or allergens should suggest the diagnosis. The physical examination and spirometry can be entirely normal in patients with chronic cough due to asthma.
In some cases, reflux-mediated irritation of laryngeal receptors or episodic microaspiration underlie GERD-induced cough.
The esophageal pH monitoring study will be negative in patients with nonacid reflux, and if this condition is suspected, barium esophagography may be helpful. Most patients with GERD do not have endoscopic findings that suggest acid reflux, such as esophagitis or Barrett's epithelium, and a normal endoscopy does not rule out GERD as a source of cough. A subset of patients has been recognized with increased sputum eosinophils in the absence of demonstrable bronchial hyperresponsiveness.
Chronic bronchitis is characterized by a productive cough on most days for 3 months in 2 consecutive years.
The cause of cough in chronic bronchitis is multifactorial, with bronchial secretions and airway inflammation playing a primary role. Pertussis, or whooping cough, is a severe and debilitating cough illness that can last for weeks to months.
Chronic cough may be unexplained despite comprehensive workup and empirical treatment trials in a substantial number of patients.
Disorders of any of the locations of cough receptors (external auditory canal, tracheobronchial tree, pleura, pericardium, diaphragm, esophagus, stomach) can cause chronic cough.
The management of chronic cough typically involves some combination of simple screening studies (chest x-ray and spirometry), additional specific diagnostic studies (methacholine provocation, sinus imaging, or a pH probe), and empirical therapy for the three most common entities (rhinitis, asthma, GERD) (see Figure 1). Evaluation and treatment using our algorithm (see Figure 1) assume that failure to remedy the cough using trials of empirical therapy will precipitate appropriate diagnostic testing. Common causes for diagnostic frustration include inadequate diagnosis and inadequate treatment.
Initial therapy for most postnasal drainage syndromes should include an antihistamine-decongestant combination (Table 2). Initial empirical therapy with an antihistamine-decongestant has been shown to be effective in a large percentage of patients who present with chronic cough. The presence of bronchial hyperresponsiveness should be demonstrated by provocation testing or reliable history before initiating oral steroids. The cause of chronic cough may be otherwise clinically silent, and it is not uncommon for there to be more than one contributing factor.
In the absence of smoking and angiotensin-converting enzyme inhibitors, upper airway cough syndrome, asthma, and gastroesophageal reflux disease are the most common causes of chronic cough in patients with a normal chest radiograph.
In most cases, empirical therapy targeted at the most common diagnoses leads to significant improvement or resolution of cough, obviating the need for extensive diagnostic testing.
Inadequate length of treatment, insufficient medication intensity, and patient nonadherence are common reasons for treatment failure. Ultimately, determining the underlying cause of cough is accomplished by demonstrating a response to therapy. Pneumonia is an acute or chronic inflammation of lung tissue, which affects the alveoli and lung structure (lung tissue).
Opportunistic pneumonia : affects people with weakened immune systems (people with AIDS, chemotherapy).
The bedridden pneumonia : bedridden patients with heart failure, this form of pneumonia is due to a constant bed rest and poor ventilation of the lungs. And possibly antipyretics, mucolytics or cough suppressants and inhalations of substances moderately dilating the airways may be useful.
The evolution of the disease is highly dependent on the patient’s general condition and the pathogen. After recovery from pneumonia, patients often feel even slaughtered for several weeks and tend to have fits of coughing.
Copyright © 2012 Rayur, All trademarks are the property of the respective trademark owners. There are many different types of NHL that form from different types of white blood cells (B-cells, T-cells, NK cells).
Mycosis fungoides and the Sézary syndrome are types of NHL that start in white blood cells in the skin.
Anatomy of the lymph system, showing the lymph vessels and lymph organs including lymph nodes, tonsils, thymus, spleen, and bone marrow. Lymphoma statistics based on data from large groups of patients to be used as a general guide. Supportive information on managing the physical and emotional effects of cancer and treatment for both patients and caregivers. In Mediterranean countries and in some parts of Asia, 30-50% of cases are HBeAg positive and 50-80% are HBeAg negative.
When you are sick, these two terms are often used interchangeably to describe what type of infection you have. A virus usually has more widespread symptoms where a bacteria infection tends to stay within one area, such as the throat. Please consult with your doctor or medical practictioner before utilizing any suggestions on this web site. Chronic or persistent cough, defined as lasting more than 8 weeks, is usually not caused by a life-threatening disorder.
An optimal, cost-effective approach to the management of chronic cough remains controversial. The cough reflex is characterized by the generation of high intrathoracic pressures against a closed glottis, followed by forceful expulsion of air and secretions on glottic opening.
This has hampered progress in the study of cough, and most of our understanding of the neuronal regulation of cough is derived from animal studies. Rapidly adapting receptors are activated by mechanical forces such as lung inflation and deflation, whereas C fibers are much more sensitive to chemical stimuli, primarily bradykinin. The population point-prevalence of chronic cough depends on smoking status, ranging from 5% to 40%. The most common complications include feeling that something is wrong (98%), exhaustion (57%), feeling self-conscious (55%), insomnia (45%), lifestyle change (45%), musculoskeletal pain (45%), hoarseness (43%), excessive perspiration (42%), and urinary incontinence (39%).2 A host of other physiologic symptoms occur occasionally due to the high intrathoracic and intra-abdominal pressures achieved.
Acute cough has been defined as one with a duration of less than 3 weeks at presentation.1 Some clinicians have proposed a category of subacute cough, with a duration of 3 to 8 weeks. Although there are no case series addressing the frequency of the common cold as a cause of acute cough, epidemiologic data support the relation. It manifests as a persistent cough, with or without sputum production, in patients with a normal chest radiograph.
Pneumonia can also manifest with acute cough, and its manifestation can be more subtle in the elderly. In the presence of a compatible history and examination, further diagnostic testing is usually not necessary.
As a general principle, the positive and negative predictive values of tests for the cause of chronic cough are poor, implying that attribution of cause depends on a response to specific therapy. All patients should undergo evaluation for exposure to common allergens or chemical irritants. Associated symptoms include rhinorrhea, nasal congestion, a sensation of drainage or tickle in the oropharynx, and throat clearing.

Patients with chronic sinusitis can present with a nonproductive cough as their sole symptom.
The presence of air-fluid levels on four-view sinus x-rays is more specific for diagnosing sinusitis, and one report documented a 100% PPV.15 Due to the poor PPV, CT scan of the sinuses is not encouraged routinely for the diagnosis of UACS1. In a subset of asthmatic patients, cough is the primary or sole symptom, a condition termed cough-variant asthma (CVA). The most useful test to support the diagnosis is a bronchoprovocation test with inhaled methacholine. Patients with GERD are commonly asymptomatic, and it can be assumed that the condition is therefore underrecognized. It is important to include a temporal symptom log when conducting pH monitoring so as to document the causality of reflux events vis-à-vis cough.
Esophageal intraluminal impedance plethysmography may also be able to identify patients with nonacid reflux. It is reasonable to empirically treat patients who fit the clinical profile before testing. These patients are typically nonsmokers and have a chronic cough that responds to inhaled corticosteroids. It may be caused by irritant-induced inflammation or by the need to mobilize excessive secretions. Cough completely resolves or significantly decreases in 90% of patients after smoking cessation. Postinfectious cough is a diagnosis of exclusion, and by definition it eventually resolves, but its duration may be prolonged. In referral centers, the prevalence has been reported to be as high as 42% of cases.32 A heightened sensitivity to cough challenge with capsaicin has been demonstrated in these patients.
It is a diagnosis of exclusion and should not be entertained until all other potential causes have been investigated, with therapeutic trials of adequate intensity and duration. Recently, obstructive sleep apnea and chronic tonsillar hypertrophy have been recognized as associations with chronic cough. Patients who lack specific clues by history and examination and who have a normal chest x-ray and spirogram represent the most common management dilemma for the clinician.
Cough may be the sole manifestation of disorders such as asthma, GERD, or UACS, with a paucity of other historical features to suggest the correct diagnosis.
A significant fraction of nonresponders fail treatment due to inadequate intensity or duration of treatment. First- generation antihistamines, such as dexbrompheniramine maleate or azatadine maleate, have been demonstrated to be superior to second-generation (nonsedating) drugs, due to their additional anticholinergic activity.2 If drowsiness is problematic, therapy may be initiated with bedtime dosing before instituting twice-daily dosing. Using a pressurized MDI can aggravate cough which may be alleviated by the addition of a spacer. Caution is warranted when interpreting the results of empirical therapeutic success with asthma therapy; NAEB and postinfectious cough might respond similarly. Patients should avoid reflux-predisposing foods (fatty foods, chocolate, caffeine, alcohol), give up tobacco, elevate the head of the bed, and not eat within 2 or 3 hours before lying down. Cough frequency and sputum production are most effectively decreased by ipratropium MDI (2 puffs qid). Narcotics (morphine, codeine and dextromethorphan) have traditionally been used for cough suppression but have well known and prohibitive side effects with chronic use. The balance between empiricism and testing is often dictated by the patient's clinical course and quality of life. An empiric integrative approach to the management of cough: ACCP evidence-based clinical practice guidelines. Introduction to the diagnosis and management of cough: ACCP evidence-based clinical practice guidelines.
Managing cough as a defense mechanism and as a symptom: a consensus panel report of the American College of Chest Physicians. Global physiology and pathophysiology of cough: ACCP evidence-based clinical practice guidelines. Anatomy and neurophysiology of the cough reflex: ACCP evidence-based clinical practice guidelines. Chronic cough: the spectrum and frequency of causes, key components of the diagnostic evaluation, and outcome of specific therapy. Chronic persistent cough in the adult: the spectrum and frequency of causes and successful outcome of specific therapy.
Chronic cough with a history of excessive sputum production: the spectrum and frequency of causes, key components of the diagnostic evaluation, and outcome of specific therapy. Overview of common causes of chronic cough: ACCP evidence-based clinical practice guidelines. From a prospective study of chronic cough: diagnostic and therapeutic aspects in older adults. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines.
Predictive values of the character, timing, and complications of chronic cough in diagnosing its cause.
Chronic persistent cough: experience in diagnosis and outcome using an anatomic diagnostic protocol. Evaluation and outcome of patients with chronic non-productive cough using a comprehensive diagnostic protocol. Chronic cough due to gastroesophageal reflux disease: ACCP evidence-based clinical practice guidelines.
A prospective evaluation of esophageal testing and a double-blind, randomized study of omeprazole in a diagnostic and therapeutic algorithm for chronic cough. Randomized clinical trial: high-dose acid suppression for chronic cougha€”a double-blind, placebo-controlled study [published online ahead of print November 17, 2010].
Chronic cough due to nonasthmatic eosinophilic bronchitis: ACCP evidence-based clinical practice guidelines. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. Serum immunoglobulin G analysis to establish a delayed diagnosis of chronic cough due to Bordetella pertussis [published online ahead of print October 10, 2011]. Controversies in the evaluation and management of chronic cough [published online ahead of print December 10, 2010].
Cough reflex sensitivity improves with speech language pathology management of refractory chronic cough. Pharmacological and clinical overview of cloperastine in treatment of cough [published online ahead of print March 7, 2011]. Levodropropizine in the management of cough associated with cancer or nonmalignant chronic disease: a systematic review [published online ahead of print August 1, 2011].
The lymph system is part of the immune system, which helps the body fight infection and disease. With this type, there are large, abnormal lymphocytes (a type of white blood cell) in the lymph nodes called Reed-Sternberg cells. Primary central nervous system lymphoma is a rare type of NHL that starts in white blood cells in the brain, spinal cord, or eye. Strep throat, tuberculosis, and urinary tract infections are examples of infections caused by bacteria.
They also have similar symptoms, such as coughing and sneezing, fever, inflammation, vomiting, diarrhea, fatigue, and cramping.
However, the frequency of this complaint, its effect on quality of life, and concern about a serious underlying cause make chronic cough an important problem. A common situation that clinicians face is the presence of a cough of unclear cause in the setting of a normal chest x-ray and normal spirometry, which is the focus of this section.
Because chronic cough is usually due to a benign cause, we recommend a stepwise approach employing empirical therapy targeted at the most common diagnoses, without extensive initial diagnostic testing (Figure 1).
The role of vagal afferent nerves in initiating the cough reflex is undisputed; however, the function of the various afferent neuronal subtypes in the regulation of cough is not well understood. Signals from the receptors are carried by vagal afferents to a medullary cough center, which then trigger cough activation via efferents mediated by the vagal, phrenic, and spinal motor nerves. Although cough can cause a variety of anatomic and physiologic complications, 98% of patients in one series listed the suspicion of underlying disease to be the major factor prompting them to seek medical attention. The most prevalent symptoms include cough syncope, cardiac dysrhythmias, headache, subconjuctival hemorrhage, inguinal herniation, and gastroesophageal reflux. Although this classification system is widely used and accepted by most experts, there are no case series assessing the relative frequency of causes in either the acute or subacute categories.
Although it is much less prevalent than the common cold, acute bronchitis is the most common diagnosis given to patients presenting to a physician with acute cough.
Despite this, reports have indicated that more than two thirds of patients receive antibiotic therapy for acute bronchitis. Prospective studies have shown that the history and physical examination alone can predict the likelihood of pneumonia and therefore the need for a chest radiograph. Underrecognized causes of acute or subacute cough include pertussis and mycoplasma infection. Additionally, in 18% to 62% of patients, there are two significant causes, and in up to 42% there are three.9a€“11 In studies from cough clinics, the data suggest that there is little or no diagnostic value in descriptive features such as cough frequency, character, or sputum production. Even in immunocompromised hosts and areas where tuberculosis is endemic, UACS, asthma, GERD, and NAEB are the most common causes reported. Given the lack of understanding about whether PND is the cause of cough or a consequence of airway inflammation that is producing cough, the term upper airway cough syndrome was adopted as a more accurate descriptor. Physical examination can reveal nasal congestion or discharge, nasal mucosal bogginess, mucous in the oropharynx, or a cobblestone appearance of the oropharyngeal mucosa. The methacholine challenge test (MCT) is highly sensitive, and a negative test virtually excludes the diagnosis of asthma.
Nevertheless, GERD-induced cough is frequently attributable to a reflex loop involving vagal afferents in the distal esophagus, and proximal reflux is unnecessary in the pathogenesis.21 Reflux into the distal esophagus alone can stimulate the esophageal-bronchial cough reflex. However, there are no published data to suggest that outcomes are improved with this device. However, recent data indicate that empirical treatment of patients with chronic cough who have rare or no heartburn may not improve cough related quality of life or symptoms.24 Similar to other causes of chronic cough, a diagnosis is suggested only when the cough resolves with treatment. Although chronic bronchitis is a common cause of cough in the population, it is present in only 5% of those seeking medical attention for cough.9,10 Cigarette smoke is the most common irritant associated with chronic bronchitis.
In contrast to acute bronchitis, exacerbation of chronic bronchitis should be treated with antibiotics.

For this reason, 8 weeks is a more clinically useful working definition of chronic cough than 3 weeks. Active pertussis infection in adolescents and adults is an underrecognized cause of chronic cough.
Cough due to ACE inhibitors is a class effect and has been documented with all ACE inhibitors. There are no distinguishing historical features to reliably differentiate it from other etiologies.16 Habit cough is a syndrome of persistent, habitual throat clearing that might respond to biofeedback. In addition to ACE inhibitors, drugs such as sitagliptin, inhaled corticosteroids, topiramate, erythromycin, ribavirin and methotrexate have been associated with chronic cough. A major decision involves the extent of specific diagnostic testing as opposed to trials of empirical therapy.
One study found that the diagnosis was correct in 14% of referred patients, but the treatment regimens were insufficient.10 In these cases, diagnostic testing facilitates appropriate narrowing and intensification of treatment.
Over-reliance on historical features or cough characteristics can thwart accurate diagnosis because these are often misleading.
Benzonatate is a valuable option for cough suppression; however, side-effect profile includes seizures and cardiac arrhythmias. Complete resolution of chronic cough can take weeks to months, and both the physician and patient need to set realistic treatment goals. A virus may produce phlegm that is clear or cloudy, but a bacterial infection may produce phlegm that is green, yellow, bloody or brown. The aggregate cost of treatment for cough exceeds several billion dollars in the United States alone. It is important to elicit which specific cough-related symptoms are bothersome for the patient as a guide to the pace and scope of diagnostic testing. Cough that lasts longer than 3 weeks but does not become chronic falls into the subacute category.
Elderly patients are more likely to receive broad-spectrum antibiotics, and nine out of ten smokers receive antibiotics despite the lack of evidence that smoking itself is a risk factor for bacterial infection.
A diagnosis of pneumonia is unlikely in the absence of tachycardia, tachypnea, fever, and evidence of focal consolidation on chest examination. In addition, the most common causes of chronic cough can manifest with cough as the sole presenting symptom.
Chronic bronchitis, usually resulting from cigarette smoking, is believed to be the most common overall cause of chronic cough, but most smokers with cough typically do not seek medical attention.
The examination findings are nonspecific, however, and may be present in any of the other major causes of chronic cough.
A 20% decrement in forced expiratory volume in 1 second (FEV1) after methacholine inhalation, although indicating bronchial hyperresponsiveness, can have a PPV as low as 74% for diagnosing the cause of cough.19 More recently, measurement of exhaled nitric oxide has proved useful in the evaluation of chronic cough, presumably by identifying cases due to CVA. It is important to recognize that nonacid reflux can cause chronic cough, and these patients do not respond to acid-suppression therapy.
A temporal symptom log can also substantiate GERD as a cause of cough even when pH probe scores lie within the normal range. If induced sputum cannot be obtained or is nondiagnostic, bronchoscopy with bronchial wash can provide useful information.
There is a direct relation between the incidence of chronic bronchitis and the number of cigarettes smoked. Acute respiratory infections, whether viral or bacterial, are a common cause of exacerbations in chronic bronchitis.
Particular vigilance is warranted when there is a change in the character of the cough or sputum, because this may be the manifesting feature of a superimposed bronchogenic carcinoma.
Postinfectious cough is usually caused by respiratory viruses, Mycoplasma spp, Chlamydia pneumoniae (strain TWAR), or Bordatella pertussis. One investigation found a 21% incidence of pertussis in a group of patients with a cough duration of 2 weeks to 3 months.29 In recent years, the incidence of pertussis has increased, most likely due to a combination of waning immunity and increased detection of the illness. The syndrome appears to have a predilection for females who have onset of cough around menopause.
Randomized clinical trials do not provide adequate guidance to help the clinician choose between these two strategies. Finally, there are no diagnostic tests with a sufficiently high PPV to reliably implicate any particular cause of cough.
Because the overwhelming majority of patients have UACS, asthma, or GERD, it is crucial to assiduously investigate the roles of each before further investigations. The cause of cough may be otherwise clinically silent, and 18% to 62% of chronic coughs are due to two or more causes.
The role of bacteria in perpetuating chronic sinusitis is controversial, and treatment regimens are not well defined. Steroids should also be tapered in patients whose MCT was obtained in the setting of a postinfectious cough. Intensive treatment for at least several months should be attempted before referral for further diagnostic testing. A chest radiograph and spirometry are recommended before referring a patient to a specialist. The most common types of NHL in adults are diffuse large B-cell lymphoma, which is usually aggressive, and follicular lymphoma, which is usually indolent. Thus, it remains unclear whether most patients should undergo a trial of empirical therapy (either sequential or concurrent) or an aggressive and targeted diagnostic evaluation. For instance, in patients with a normal chest x-ray who have persistent cough and hemoptysis after antibiotic treatment, a fiberoptic bronchoscopic examination may be indicated to exclude endobronchial malignancy.
Afferent nerves are most concentrated in the epithelia of the upper and lower respiratory tracts, but they are also located in the external auditory meatus, tympanic membrane, esophagus, stomach, pericardium, and diaphragm. Most of the attention by clinicians is devoted to chronic or persistent cough because this is the variety that usually prompts patients to seek medical care.
Postinfectious cough due to irritation of cough receptors accounts for most of these cases. Viral cultures and serologic assays are not routinely ordered; hence, the organism responsible is rarely identified.
Treatment of self-limited bronchitis with antibiotics is often fueled by public expectation.
All of these data are derived from studies of patients referred to pulmonologists or cough clinics; however, it is likely that a similar spectrum of causes accounts for most patients seen by primary care providers. Although most patients have at least one symptom or sign, UACS can manifest as cough alone up to 20% of the time.12 Because it is highly prevalent and may be otherwise clinically unapparent, it is reasonable to employ a brief trial of empirical treatment in the approach to diagnosis. The pathogenesis of NAEB is not well understood, although, similar to asthma, an inhaled allergen or environmental agent is theorized to play a role.
Patients experience periodic episodes of violent coughing, and post-tussive emesis is common.
Usually, cough begins within 1 week of starting the medication, but it can begin as late as 1 year later. Most patients with psychogenic cough harbor an intractable fear of a serious underlying medical disease.
Vitamin B12 deficiency has been associated with chronic cough via induction of cough reflex hypersensitivity.
The approach is usually negotiated with the patient, partly based on the level of subjective distress and on the level of exasperation by the patient and the clinician. Diagnostic testing that suggests an underlying cause does not ensure that cough is caused by that etiology. Occupational and environmental exposures should be considered as exacerbating factors in all patients who present with cough. Zafirlukast, a leukotriene inhibitor, has been shown to have an antitussive effect in patients with CVA. Documentation of persistent symptomatic acid reflux should prompt referral to a specialist. Recent introduction of central cough suppressants such as cloperastin37 and peripheral cough suppressants such as levodrpropizine38 and moguisteine39 have been welcome additions although not yet available in the United States. For this reason, a combination of systematic empiricism and limited adjunctive diagnostic testing are appropriate for most patients. Similarly, new cough or a persistent change in the character of cough in a patient with heavy smoking history may necessitate airway examination.
Most commonly, persistent bronchial or sinonasal inflammation caused by a preceding viral upper respiratory infection is the culprit. Ultimately, UACS is a syndrome without a clear definition, and its role in chronic cough is best proven by a response to therapy.
Persistent eosinophilic airway inflammation can lead to progressive airflow obstruction, and NAEB may be implicated as a causative factor in chronic obstructive pulmonary disease (COPD).26 The frequency and significance of NAEB remain incompletely understood. Clinicians should also inquire about passive smoke exposure because it is linked to chronic productive cough. Inadequate treatment regimens are a common reason for failure to alleviate symptoms, and eradication of related symptoms (heartburn, nasal congestion) does not ensure that an underlying cause is sufficiently treated.
Long-term use of topical decongestants should be discouraged to avoid rebound nasal congestion (rhinitis medicamentosa).
Surgical correction with esophageal fundoplication is controversial and can result in significant comorbidity. The discovery of upregulation of the transient receptor potential (TRP) nociceptors in patients with cough reflex hypersensitivity promises new peripherally active agents (TRP receptor antagonists) in the treatment of stubborn cough. Newer generation nonsedating antihistamines are not as effective in reducing cough compared with the older, first-generation antihistamine-plus-decongestant preparations. Because the recommended therapy (older generation antihistaminics) can suppress the cough reflex centrally and peripherally, response to therapy may not necessarily confirm that the diagnosis is accurate.
The role of nonacid reflux in cough pathogenesis is also currently unknown, but it probably accounts for some of the nonresponders.
Bronchodilators are not recommended as adjunctive treatment unless baseline airflow obstruction is present.
Central cough suppressants, such as dextromethorphan and codeine, should generally be avoided; they might serve as a temporizing measure but can distract from the search for a specific cause. Angiotensin II receptor blockers do not cause cough and therefore are useful therapeutic alternatives.

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