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Chronic Cough
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Chronic Cough
See Also
Pediatric Chronic Cough
Definitions
Adults
Chronic Cough
Cough
duration longer than 8 weeks (less than 4 weeks in children under age 15 years)
Subacute
Cough
Cough
duration from 3-8 weeks
Acute
Cough
Cough
duration shorter than 3 weeks
Causes
See
Chronic Cough Causes
Pertussis
is responsible for 20% of severe cough in adults and teens >2 weeks presenting to emergency departments
Senzilet (2001) Clin Infect Dis 32:1691-7
Most common causes of adult cough
Upper Airway Cough Syndrome
(
UACS
)
Asthma
Nonasthmatic eoisnophilic
Bronchitis
Gastroesophageal Reflux or laryngopharygeal reflux disease
History
Gene
ral
Tobacco Smoking
Packs per day
Morning cough
Post-nasal drainage (typically presents with globus
Sensation
)
Allergic Rhinitis
Sinusitis
Asthma
Night cough
Environmental irritants
Atopic
Family History
Gastroesophageal Reflux
Cough
Worse supine (exception in
Reflux Laryngitis
which is worse in upright position)
Cough
relieved with
Antacid
s?
Frequent throat clearing
Chronic Bronchitis
or
COPD
Productive cough
Tobacco
Smoker
Medications
ACE Inhibitor
s
Beta Blocker
Airway Hyperresponsive
Non-productive cough
Recent
Upper Respiratory Infection
or
Bronchitis
Bordatella
Pertussis
Chlamydia pneumoniae
Mycoplasma pneumoniae
Influenza
RSV
Parainfluenza
History
Red Flags (Cancer,
Tuberculosis
)
Night Sweats
Weight loss
Hemoptysis
Hoarseness
Recurrent
Pneumonia
(e.g. atypical infection, congenital lung abnormality,
Immunodeficiency
, aspiration)
Tobacco
history 20 pack years or smoker over age 45 years
Exam
Red flags or acute findings
Gene
ral
Unintentional Weight Loss
or
Failure to Thrive
Head and
Neck Exam
Supraclavicular Lymphadenopathy
Lung Exam
Dyspnea
Tachypnea
Hypoxia
Wheezing
Asthma
Chronic Obstructive Pulmonary Disease
(
COPD
)
Tracheomalacia
Rhonchi
Upper airway secretions
Interstitial Lung Disease
Skin Exam
Digital Clubbing
Cyanosis
Imaging
Chest XRay
Indicated in most cases of Chronic Cough (productive vs non-productive does not direct imaging)
Conditions resulting in abnormal findings
Bronchiectasis
Bronchogenic Carcinoma
Tuberculosis
Sarcoidosis
Peristant
Pneumonia
Chest
CT Indications
Elucidate abnormal
Chest XRay
Management
Initial Interventions
Gene
ral
Consider
Chest XRay
unless cause is obvious
Algorithm applies to non-urgent cough evaluation
Red flags (see above) or Chronic Cough in
Immunocompromised
patients require urgent evaluation
Focus on most common causes of Chronic Cough in adults first (see above)
Avoid
Lung
toxins
Tobacco Cessation
See
Occupational Asthma
Discontinue
ACE Inhibitor
if using
Convert to
Angiotensin Receptor Blocker
Reassess after 4 weeks (cough resolution occurs within 1 to 12 weeks)
If suspect post-
Bronchitis
airway hyper-responsiveness
Consider
Pertussis
Consider
Inhaled Corticosteroid
s
Consider inhaled
Ipratropium Bromide
(
Atrovent
)
If suspect
Asthma
Eliminate
Asthma
triggers
Inhaled Bronchodilator
Inhaled Corticosteroid
Consider
Leukotriene Receptor Antagonist
(e.g.
Singulair
)
If suspect
Chronic Bronchitis
(or
COPD
)
Tobacco Cessation
Inhaled Bronchodilator
Inhaled
Anticholinergic
s
Consider oral
Corticosteroid
(with or without antibiotic)
See
Acute Exacerbation of Chronic Bronchitis
If suspect
Gastroesophageal Reflux
GERD
precautions (lifestyle changes)
Empiric
Proton Pump Inhibitor
for 8 weeks
Consider added
H2 Blocker
(e.g.
Ranitidine
), especially for the first week of
Proton Pump Inhibitor
Consider
Baclofen
20 mg daily for refractory Chronic Cough due to
GERD
Xu (2016) J Thoracic Dis 8(1): 178-85 [PubMed]
Consider infectious cause evaluation
Purified Protein Derivative
(PPD) for
Tuberculosis
Nasopharyngeal swab PCR for
Bordetella pertussis
Management
Step 1 - Treat empirically for postnasal drip
Diagnoses to consider
Upper Airway Cough Syndrome
(
UACS
)
Acute Sinusitis
or
Chronic Sinusitis
Allergic Rhinitis
Vasomotor Rhinitis
Medications to consider
Consider
Decongestant
and
Antihistamine
combination
Consider using
First Generation Antihistamine
Example:
Chlorpheniramine
Non-Sedating Antihistamine
may not be potent enough
Intranasal Corticosteroid
s
Atrovent
nasal
Inhaler
(
Vasomotor Rhinitis
)
Nasal Saline
irrigation
Consider
Acute Sinusitis Management
Diagnostics to consider in refractory cases
Sinus CT
Nasolargyngoscopy
Management
Step 2 - Evaluate for
Asthma
Consider cough-variant
Asthma
empiric trial
Trial
Bronchodilator
with or without
Inhaled Corticosteroid
(e.g.
Albuterol
,
Advair
)
Trial
Leukotriene Receptor Antagonist
(e.g.
Singulair
)
Consider
Prednisone
40 mg orally daily for 7-10 days
Perform
Pulmonary Function Test
s
FEV1
before and after
Bronchodilator
Consider
Methacholine Challenge
test
High
False Positive Rate
(25%)
Near 100%
Negative Predictive Value
Treat
Asthma
if present
See
Allergen Control
Inhaled Corticosteroid
s or
Cromolyn Sodium
Inhaled Beta Agonist
Management
Step 3 - Evaluate Pulmonary and Sinus Disease
Chest XRay
(if not already done)
CT Sinus
es
Management
Step 4 - Treat for
Gastroesophageal Reflux
High Dose Proton-Pump Inhibitor
Omeprazole
(
Prilosec
) 20 to 80 mg PO qd
Requires 2-3 months of therapy to eliminate cough
Anti-
Reflux Esophagitis
measures
Consider diagnostic testing
Upper GI
Upper Endoscopy
24 hour esophageal pH monitoring
Management
Step 5 - Advanced lung diagnostics
Consider
Eosinophilic Bronchitis
evaluation
Obtain 3 induced
Sputum
samples
Negative if
Eosinophil
s <3% in
Sputum
Responds to inhaled or
Systemic Corticosteroid
s (but not to
Inhaled Bronchodilator
s)
Pulmonology
Consultation
Bronchoscopy may be considered
If pulmonary evaluation negative
Repeat
Asthma
medications
Repeat
Antihistamine
and
Decongestant
combinations
Consider
Gabapentin
(1800 mg/day) or
Pregabalin
(300 mg/day)
Improvement within 1 month
Ryan (2012) Lancet 380(9853): 1583-9 [PubMed]
Evaluate for less common etiologies
See
Chronic Cough Causes
References
Benich (2011) Am Fam Physician 84(8): 887-92 [PubMed]
Holmes (2004) Am Fam Physician 69(9):2159-66 [PubMed]
Irwin (2000) N Engl J Med 343:1715-21 [PubMed]
Michaudet (2017) Am Fam Physician 96(9): 575-80 [PubMed]
Philip (1997) Am Fam Physician 56(5): 1395-1402 [PubMed]
Smyrnios (1995) Chest 108:991-7 [PubMed]
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