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1 From the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
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, non-specific therapies theoretically aimed at reducing mucus production in the lower respiratory tract are not likely to be helpful.
Key Words: bronchorrhea • cough • sputum
Submitted on November 8, 1994
Accepted on May 2, 1995
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