Chest
Volume 108, Issue 4, October 1995, Pages 991-997
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Clinical Investigations: Misc-Ellaneous: Articles
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

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Study objective

To determine (1) the spectrum and frequency of causes of chronic cough with a history of excessive sputum production (CCS) and (2) the response of these causes to specific therapy.

Study design

Prospective; study utilizing the anatomic diagnostic protocol originally developed to diagnose chronic cough.

Patients

Seventy-one immunocompetent adults who complained of expectoration of greater than 30 mL of sputum per day.

Location

University hospital pulmonary outpatient clinic.

Results

Patients were seen an average of 4.2 times over 4.6 months before a specific diagnosis was made. The cause of CCS was determined in 97%. It was due to one cause in 38%, 2 in 36%, and three in 26%. Postnasal drip syndrome (PNDS) was a cause 40% of the time, asthma 24%, gastroesophageal reflux disease (GERD) 15%, bronchitis 11%, bronchiectasis 4%, left ventricular failure 3%, and miscellaneous causes 3%. Among patients with a normal chest radiograph who were nonsmokers and not taking an angiotensin converting enzyme inhibitor, CCS was due to PNDS, or asthma, or GERD, or all three in 100% of cases. Chest radiograph, methacholine inhalation challenge, 24-h esophageal pH monitoring, bronchoscopy, and spirometry with bronchodilator each had a sensitivity and negative predictive value of 100%. Chest radiograph and barium swallow had positive predictive values of only 38% and 30%, respectively.

Conclusions

(1) The anatomic diagnostic protocol for cough is also valid for CCS; (2) the major causes of chronic excessive sputum production and chronic cough are so similar that CCS should be considered a form of chronic cough; (3) the evaluation of CCS is more complicated and takes longer than the evaluation of chronic cough; (4) the major strength of the laboratory diagnostic protocol is that it reliably rules out conditions; (5) the outcome of specific therapy is almost always successful; and (6) the term “bronchorrhea” can be misleading if it is applied to excessive sputum production before a specific diagnosis of its source is made since the most common cause of excessive sputum that is expectorated (PNDS) is a disorder of the upper respiratory tract. Therefore, nonspecific therapies theoretically aimed at reducing mucus production in the lower respiratory tract are not likely to be helpful.

Section snippets

Materials and Methods

From February 23, 1988 to March 2, 1992, 97 consecutive and unselected, immunocompetent patients with CCS defined as cough with production of greater than 30 mL of sputum per day for at least 3 weeks, were seen by one of us (R.S.I.) in our pulmonary outpatient clinic. Of these, 26 failed to return for follow-up and were eliminated from analysis. The remaining 71 patients made up our study group. Seventy-three percent were referred by another physician; 27% were self-referred. The entrance

Spectrum and Frequency of the Causes of Chronic Cough With a History of Excessive Sputum Production

Our study group consisted of 39 men and 32 women with an average age of 58±17 years (range, 18 to 86 years). They had complained of cough productive of more than 30 mL of phlegm per day for an average of 69±95 months (range, 1 to 480 months). Using posttreatment diagnostic criteria, the cause of CCS was determined in 69 of 71 (97%) patients. The only patients who failed to respond to treatment adequately were (1) a woman who met pretreatment diagnostic criteria for PNDS and GERD, had an initial

Discussion

Human respiratory mucus is a mixture composed of approximately 95% water, 1% protein, 0.9% carbohydrate, and 0.8% lipid.1 The constituents of mucus are produced by a variety of cells in the lining of the respiratory tract, including goblet cells, submucosal gland cells, plasma cells, Clara cells, and alveolar type II pneumocytes. The normal volume of mucus produced by the lower respiratory tract in humans has been estimated to range from 10 to 100 mL/d.1 Mucus is also produced in the upper

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    Presented in part at the Annual Meeting of the American Thoracic Society, San Francisco, May 1993 (abstract published in Am Rev Respir Dis 1993; 147:A871).

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