Chronic Cough

Aka: Chronic Cough

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II. Definitions: Adults

  1. Chronic Cough
    1. Cough duration longer than 8 weeks (less than 4 weeks in children under age 15 years)
  2. Subacute Cough
    1. Cough duration from 3-8 weeks
  3. Acute Cough
    1. Cough duration shorter than 3 weeks

III. Causes

  1. See Chronic Cough Causes
  2. See Chronic Cough Causes in Children
  3. Pertussis is responsible for 20% of severe cough in adults and teens >2 weeks presenting to emergency departments
    1. Senzilet (2001) Clin Infect Dis 32:1691-7
  4. Most common causes of adult cough
    1. Upper Airway Cough Syndrome (UACS)
    2. Asthma
    3. Nonasthmatic eoisnophilic Bronchitis
    4. Gastroesophageal Reflux or laryngopharyngeal reflux disease

IV. History: General

  1. Airway Irritants
    1. Tobacco Smoking (how many packs per day?)
      1. Morning cough
    2. Vaping
    3. Cannabis
  2. Post-nasal drainage (typically presents with globus Sensation)
    1. Upper Airway Cough Syndrome (UACS)
    2. Allergic Rhinitis
    3. Sinusitis
  3. Asthma
    1. Night cough
    2. Environmental irritants
    3. Atopic Family History
  4. Gastroesophageal Reflux
    1. Cough Worse supine (exception in Reflux Laryngitis which is worse in upright position)
    2. Cough relieved with Antacids?
    3. Frequent throat clearing
  5. Chronic Bronchitis or COPD
    1. Productive cough
    2. Tobacco Smoker
  6. Medications
    1. ACE Inhibitors
    2. Beta Blocker
  7. Airway Hyperresponsive
    1. Non-productive cough
    2. Recent Upper Respiratory Infection or Bronchitis
      1. Bordatella Pertussis
      2. Chlamydia pneumoniae
      3. Mycoplasma pneumoniae
      4. Influenza
      5. RSV
      6. Parainfluenza

V. History: Red Flags (e.g. Cancer, Tuberculosis)

  1. Night Sweats
  2. Weight loss
  3. Hemoptysis
  4. Hoarseness
  5. Dysphagia
  6. Dyspnea (esp. nighttime Dyspnea)
  7. Recurrent Pneumonia (e.g. atypical infection, congenital lung abnormality, Immunodeficiency, aspiration)
  8. Tobacco history 20 pack years or smoker over age 45 years

VI. Exam: Red flags or acute findings

  1. General
    1. Unintentional Weight Loss or Failure to Thrive
  2. Head and Neck Exam
    1. Supraclavicular Lymphadenopathy
  3. Lung Exam
    1. Dyspnea
    2. Tachypnea
    3. Hypoxia
    4. Wheezing
      1. Asthma
      2. Chronic Obstructive Pulmonary Disease (COPD)
      3. Tracheomalacia
    5. Rhonchi
      1. Upper airway secretions
      2. Interstitial Lung Disease
  4. Skin Exam
    1. Digital Clubbing
    2. Cyanosis

VII. Imaging

  1. Chest XRay
    1. Indicated in most cases of Chronic Cough (productive vs non-productive does not direct imaging)
    2. Conditions resulting in abnormal findings
      1. Bronchiectasis
      2. Bronchogenic Carcinoma
      3. Tuberculosis
      4. Sarcoidosis
      5. Peristant Pneumonia
  2. Chest CT Indications
    1. Evaluate abnormal or non-diagnostic Chest XRay

VIII. Management: Initial Interventions

  1. General
    1. Consider Chest XRay unless cause is obvious
    2. Algorithm applies to non-urgent cough evaluation
    3. Red flags (see above) or Chronic Cough in Immunocompromised patients require urgent evaluation
    4. Focus on most common causes of Chronic Cough in adults first (see above)
    5. Reevaluate in 4 to 6 weeks after initial measures
  2. Avoid Lung toxins and airway irritants
    1. Tobacco Cessation
    2. Avoid Vaping, Cannabis
    3. See Occupational Asthma
  3. Discontinue ACE Inhibitor if using
    1. Switch to Angiotensin Receptor Blocker (ARB)
    2. Reassess after 4 weeks (cough resolution occurs within 1 to 12 weeks)
    3. Cough resolves spontaneously in up to 50% of patients who continue ACE Inhibitor
      1. Sato (2015) Clin Exp Hypertens 37(7): 563-8 [PubMed]
  4. If suspect post-Bronchitis airway hyper-responsiveness
    1. Consider Pertussis
    2. Consider Inhaled Corticosteroids
    3. Consider inhaled Ipratropium Bromide (Atrovent)
  5. If suspect Asthma
    1. Eliminate Asthma triggers
    2. Inhaled Bronchodilator
    3. Inhaled Corticosteroid
    4. Consider Leukotriene Receptor Antagonist (e.g. Singulair)
  6. If suspect Chronic Bronchitis (or COPD)
    1. Tobacco Cessation
    2. Inhaled Bronchodilator
    3. Inhaled Anticholinergics
    4. Consider oral Corticosteroid (with or without Antibiotic)
      1. See Acute Exacerbation of Chronic Bronchitis
  7. If suspect Gastroesophageal Reflux
    1. GERD precautions (lifestyle changes)
    2. Empiric Proton Pump Inhibitor for 8 to 12 weeks
    3. Consider added H2 Blocker (e.g. Ranitidine), especially for the first week of Proton Pump Inhibitor
    4. Consider Baclofen 20 mg daily for refractory Chronic Cough due to GERD
    5. Xu (2016) J Thoracic Dis 8(1): 178-85 [PubMed]
  8. Consider infectious cause evaluation
    1. Purified Protein Derivative (PPD) for Tuberculosis
    2. Nasopharyngeal swab PCR for Bordetella Pertussis
  9. Consider other causes
    1. Obstructive Sleep Apnea
      1. Present in up to 40% of patients with Chronic Cough
      2. Sundar (2010) Cough 6(1): 2 [PubMed]

IX. Management: Step 1 - Treat empirically for postnasal drip

  1. Diagnoses to consider
    1. Upper Airway Cough Syndrome (UACS)
    2. Acute Sinusitis or Chronic Sinusitis
    3. Allergic Rhinitis
    4. Vasomotor Rhinitis
  2. Medications to consider
    1. Consider Antihistamine (Cetirizine) with or without Decongestant
    2. Intranasal Corticosteroids
    3. Atrovent nasal Inhaler (Vasomotor Rhinitis)
    4. Nasal Saline irrigation
    5. Consider Acute Sinusitis Management
  3. Diagnostics to consider in refractory or atypical cases
    1. Sinus CT
    2. Nasolargyngoscopy

X. Management: Step 2 - Evaluate for Asthma

  1. Consider cough-variant Asthma empiric trial
    1. Trial Bronchodilator with or without Inhaled Corticosteroid (e.g. Albuterol, Advair)
    2. Trial Leukotriene Receptor Antagonist (e.g. Singulair)
    3. Consider Prednisone 40 mg orally daily for 7-10 days
    4. Confirm diagnosis with Pulmonary Function Tests if effective trial
      1. Avoid empiric longterm Inhaled Corticosteroids without a confirmed diagnosis
  2. Perform Pulmonary Function Tests
    1. FEV1 before and after Bronchodilator
  3. Treat Asthma if present
    1. See Allergen Control
    2. Inhaled Corticosteroids
    3. Inhaled Beta Agonist
  4. Diagnostics to consider in refractory or atypical cases
    1. Consider Fractional exhaled nitric oxide (FeNO)
    2. Consider Methacholine Challenge test
      1. High False Positive Rate (25%)
      2. Near 100% Negative Predictive Value

XI. Management: Step 3 - Evaluate Pulmonary and Sinus Disease

  1. Chest XRay
    1. May consider CT Chest as alternative
  2. CT Sinuses

XII. Management: Step 4 - Treat for Gastroesophageal Reflux

  1. High Dose Proton-Pump Inhibitor
    1. Omeprazole (Prilosec) 20 to 80 mg PO qd
    2. Requires 2-3 months of therapy to eliminate cough
  2. Anti-Reflux Esophagitis measures
  3. Diagnostics to consider in refractory or atypical cases
    1. Upper Endoscopy
    2. 24 hour esophageal pH monitoring

XIII. Management: Step 5 - Advanced Lung Diagnostics and Measures

  1. Consider Eosinophilic Bronchitis evaluation
    1. Obtain 3 induced Sputum samples
    2. Negative if Eosinophils <3% in Sputum
    3. Responds to inhaled or Systemic Corticosteroids (but not to Inhaled Bronchodilators)
  2. Consider advanced imaging
    1. CT Chest (if not already done)
  3. Consider Consultation
    1. Pulmonology Consultation (bronchoscopy may be considered)
    2. Otolaryngology
    3. Speech and language therapy
    4. Physiotherapy
    5. Sleep Study (for Obstructive Sleep Apnea)
  4. If pulmonary evaluation negative
    1. Consider GABA ReceptorAgonist
      1. Gabapentin start 300 mg orally twice daily (max: 1800 mg/day)
      2. Pregabalin start 75 mg orally twice daily (max: 300 mg/day)
      3. Improvement within 1 month
        1. Ryan (2012) Lancet 380(9853): 1583-9 [PubMed]
    2. Consider Tricyclic Antidepressant
      1. Amitriptyline start 10 mg orally at bedtime (may increase to 100 mg at bedtime)
  5. Evaluate for less common etiologies
    1. See Chronic Cough Causes

XIV. References

  1. Benich (2011) Am Fam Physician 84(8): 887-92 [PubMed]
  2. Holmes (2004) Am Fam Physician 69(9):2159-66 [PubMed]
  3. Irwin (2000) N Engl J Med 343:1715-21 [PubMed]
  4. Michaudet (2017) Am Fam Physician 96(9): 575-80 [PubMed]
  5. Philip (1997) Am Fam Physician 56(5): 1395-1402 [PubMed]
  6. Smyrnios (1995) Chest 108:991-7 [PubMed]
  7. Sonoda (2024) Am Fam Physician 110(2): 167-73 [PubMed]

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