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Short Notes on Chronic Cough 2017 - Dr Mark Burgin

28/11/17. Cough is a symptom that indicates irritation of the lower respiratory tract but can occur with upper respiratory tract problems such as tumours and inflammation.

The symptom was part of the Be Clear on Cancer awareness campaign in 2012-2014 by the Public Health England, working in partnership with the Department of Health and NHS England.

Smokers can feel that they are blamed for their problems and that they are not investigated as comprehensively as non-smoking patients.

It is likely that ‘smoker’s cough’ has become a social explanation so smokers attend less frequently for their cough for fear of being told ‘it is due to your smoking’.

Chest x-ray, spirometry and low-dose computed tomography (LDCT) scanning of the lungs can give useful information to manage the underlying condition causing chronic cough.

ACE inhibitor medication.

ACE inhibitors are used for hypertension and heart failure and have a well-known side effect of cough which can be irritating and cause sleep disturbance.

When starting any medication a medical or nursing practitioner must record consent according to their professional body guidance. (1) (2)

Consent when starting medication should include discussion of options including the benefits and risks and common side effects and the effect of taking no treatment.

Medical advice is to encourage the patient to continue the medication so failing to record this further discussion for the half that continue would be evidence of breach.

The patient information leaflet and not complaining of side effects are not material issues to determine whether consent was adequate.

Throat tumours.

Smokers often suffer from coughs and may not attend unless they have a new symptom such as coughing up blood - they are then referred for a chest x-ray.

If the chest x-ray is clear then they are often reassured that there is nothing to worry about, later the GP may request blood tests if weight loss and throat discomfort develops.

It is only when hoarseness or a lump in the neck develops that the patient is examined with an intra-oral camera or referred to the ear nose and throat ENT or for a CT/MRI scan. (5).

Failing to consider the upper as well as lower respiratory tract in assessing a chronic cough in a smoker is likely to be breach as a smoker with chronic cough has high risk for cancer.

Early diagnosis of throat area tumours is associated with rates of survival well over 50% but with later diagnosis the survival falls well below 50% which makes causation straightforward. (6).

COPD.

Chronic obstructive pulmonary disease is the medical name for bronchitis and has several forms including emphysema, bronchiectasis as well as chronic bronchitis and low dose CT scan (LDCT) is useful determining the anatomy.

The claimant will complain of breathlessness which restricts their activities such as shopping due to loss of aerobic reserve to greater extent than the clinical signs would suggest.

When a person starts walking upstairs their muscles do not increase oxygen uptake for a few seconds allowing them to reach the top before they feel breathless.

Standing at the top they become more breathless and then get their breath back over several seconds, this process is worse in patients with COPD.

Some patients have a fear of bringing on the breathlessness and others have chest pain, palpitation and dizziness and in others it provokes severe coughing.

Negligent disability assessments can underestimate COPD functional restrictions particularly when no LDCT has been performed and the claimant will be awarded lower levels of benefit.

Conclusions.

Chronic cough is a symptom of more serious problems that should be investigated by appropriate investigations in particular for cancer of the respiratory tract.

Cases of COPD can be prevented by smoking cessation and the quality of life problems can be significantly greater than the claimant’s appearance at rest would suggest.

In selected cases the lawyer may need to advise the claimant to arrange a LDCT privately to confirm the true extent of their lung problems.

The chronic cough primer should consider issues such as the effect that perceived social stigma of cigarette smoking has had upon the attendance by smokers to their GPs for respiratory problems.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

  1. Nursing and Midwifery Council code part 4.7 make sure that you get properly informed consent and document it before carrying out any action

  2. Good medical practice (2013) 17. You must be satisfied that you have consent or other valid authority before you carry out any examination or investigation, provide treatment 21. Clinical records should include: b. the decisions made and actions agreed, and who is making the decisions and agreeing the actions

  3. Overlack A. ACE inhibitor-induced cough and bronchospasm. Incidence, mechanisms and management. Drug Saf. 1996 Jul;15(1):72-8

  4. Montgomery v Lanarkshire Health Board [2015] UKSC 11

  5. NICE guideline 2015 Suspected cancer: recognition and referral nice.org.uk/guidance/ng12

  6. Burgin 2016 Calculating Loss of a Chance in Delayed Cancer Diagnosis

  7. Arnett 2008 Aerobic reserve and physical functional performance in older adults. Age Ageing. 2008 Jul;37(4):384-9

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