Cough resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Haddadi, M.D.[2] Sara Zand, M.D.[3]

Resident Survival Guide


Cough is a defense mechanism for preventation of airway irritation or aspiration by cleaning excessive secretion or foreign body from the airway and also it may spread infection. Cough is the symptom of involving organs such as upper airway tract, lung, heart, or gastrointestinal tract. Dependent on the duration of cough, it can be categorized to three groups including acute, subacute, chronic. Acute cough is the most common causes of seeking medical attention every year. Chronic cough may affect the quality of life and also may increase mortality based on the underlying disorder. Assessment of the life threatening causes of cough such as obstructive airway disease or pulmonary embolism is of important.


Common Causes


Shown below is an algorithm summarizing the evaluation of acute, subacute, chronic cough.[15][16][17][18]

Acute Cough ≤ 3 weeks duration
History and physical

examination, ask about environmental and occupational factors and travel exposures

± investigations
Life-threatening diagnosis
Non-life-threatening diagnosis
Pneumonia, severe

exacerbation of asthma or COPD, pulmonary embolism, heart failure, other serious

Exacerbation of pre-existing condition
Lower respiratory tract infection
Upper respiratory tract infection
Upper airway cough syndrome
Evaluate and treat first
Acute Bronchitis
Consider tuberculosis (TB) in

endemic areas

or high risk


Subacute Cough ,(3-8 weeks duration)
History and Physical Exam, Ask about red flags ( hemoptysis, smoking , dyspnea, hoarseness, abnormal CXR findings)

environmental and occupational factors,

travel exposures
Postinfectious or life-threatening diagnosis
New onset or exacerbation of pre-existing condition
Not postinfectious
Pneumonia, severe exacerbation of asthma or COPD,pulmonary embolism, heart failure, other serious disease
Upper airway cough syndrome
Gastroesophageal reflux disease
Non-asthmatic eosinophilic bronchitis
Acute exacerbation of chronic bronchitis/COPD

Abbreviations: TB: Tuberculosis; COPD: Chronic obstructive pulmonary disease; GERD:Gastroesophageal reflux disease

Chronic Cough> 8 weeks duration
History, Physical exam and CXR
Life-threatening condition
Consider four most common causes: 1) Upper Airway Cough Syndrome secondary to rhinosinus diseases, 2) Asthma, 3) Non-asthmatic Eosinophilic Bronchitis,4) Gastroesophageal Reflux Disease (GERD)
Smoking, ACEI
Treat based on the cause
Discontinue for at least four weeks
Follow up 4-6 weeks if inadequate response
Initial treatments for each condition
Further investigation if No response to treatment
Consider four most common causes of cough if No response at 4-6 weeks follow up
Follow up 4-6 weeks if inadequate response to optimal treatment
The investigation:

❑ 24h esophageal pH monitoring
Endoscopic, videofluoroscopic swallow evaluation
Barium esophagram
Sinus Imaging
ECG,Holter Monitoring, Echocardiography
Environmental / Occupational Assessment

Abbreviations: CXR: Chest-X-ray; ACEI: Angiotensin converting enzyme inhibitor; GERD: Gastroesophageal reflux disease; HRCT scan:High-resolution computed tomography.


Shown below is an algorithm summarizing the treatment of Cough.[16][19][20][21][22][23]

Acute Cough
Determine if the cause of the cough is one of the life-threatening conditions:
❑Severe exacerbation of asthma or COPD
Pulmonary embolism
Heart failure
❑ Other serious condittons
Cough due to the common cold:
❑ First-generation antihistamine plus a decongestant
❑ Newer-generation nonsedating antihistamines are not effective

Subacute Cough
confirmed whooping cough by culture positive nasopharyngeal swab:
macrolide antibiotics plus isolation for 5 days
Cough not caused by bordetella pertussis:
Inhaled ipratropium (Atrovent)
❑ If cough persists: inhaled corticosteroids
❑ Severe cough:30 to 40 mg of prednisone per day for a brief period)
❑ When other treatments fail: codeine or dextromethorphan (Delsym)

Chronic Cough
First-generation antihistamine/decongestant
❑Partial or complete resolution of cough after one to two weeks shows upper airway cough syndrome as the cause
❑ Persistent symptoms: begin a topical nasal steroid
Symptoms still persist: sinus imaging for sinusitis
❑ Inhaled corticosteroids and beta agonists
❑ No response or cannot take inhaled medication:consider oral corticosteroids for 5-10 days
❑ Consider adding a leukotriene inhibitor before an oral corticosteroid
❑ Inhaled corticosteroids for 4 weeks
❑ Empirically treated for GERD if there is not response to therapy
❑ Anti-reflux diet, lifestyle modification, proton pump inhibitor
❑ Adding prokinetic therapy if there is NO response to treatment




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