Cough resident survival guide
Resident Survival Guide
Cough is a common presentation of different diseases that can be acute, subacute, or chronic depending on the cause. Different organs may be involved such as the lung, heart, or gastrointestinal tract. There are some life-threatening conditions that may present with cough such as pulmonary embolism and it is of significant importance to differentiate them from other causes that can induce cough. Therefore assessment of cough requires detailed knowledge and attention to the time of onset and etiologies. We discuss a concise overview of an approach to diagnosis and management of cough based on the American College of Chest Physicians (CHEST) methodological guidelines.
- Allergic Rhinitis
- Gastroesophageal Reflux Disease (GERD)
- Post-nasal drip
- Medications' side effect
- Laryngopharyngeal reflux
- Respiratory tract infection
- Lung cancer
- Nonasthmatic eosinophilic bronchitis
Acute cough is considered cough that lasts less than three weeks. Shown below is an algorithm summarizing the evaluation of acute cough according to the American College of Chest Physicians guidelines.
|History and physical
examination, ask about environmental and occupational factors and travel exposures± investigations
|Life-threatening diagnosis||Non-life-threatening diagnosis|
exacerbation of asthma or COPD, PE, heart failure, other seriousdisease
|Infections||Exacerbation of pre-existing condition|
|Evaluate and treat first|
|Consider TB in
endemic areasor high risk
- Subacute cough is considered 3 to 8 weeks. Shown below is an algorithm describing the evaluation of subacute cough in adults according to the American College of Chest Physicians guidelines.
|History and Physical Exam Ask about red flags,
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, PE, heart failure, other serious disease|
- Not postinfectious: Work up same as chronic cough
- Chronic cough is defined as cough that lasts more than 8 weeks. Shown below is an algorithm describing the evaluation of chronic cough in adults according to the American College of Chest Physicians guidelines.
|History, Physical exam and CXR|
|Life-threatening condition||Consider 4 most common causes: 1)Upper Airway Cough Syndrome (UACS), secondary to rhinosinus diseases, 2)Asthma, 3)Non-asthmatic Eosinophilic Bronchitis 4)Gastroesophageal Reflux Disease (GERD)||Smoking, ACEI, Sitagliptin|
|Treat based on the cause||Discontinue for at least 4week|
|Follow up 4-6 weeks if inadequate response||Initial treatments for each condition||Further investigation if No response to treatment*||Consider 4 most common causes of cough if No response at4-6 week follow up|
|Follow up 4-6 weeks if inadequate response to optimal treatment|
Consider the following further investigations if no response to treatment*:
- 24h esophageal pH / Impedance monitoring
- Endoscopic and/or videofluoroscopic swallow evaluation
- Barium esophagram / Modified barium swallow
- Sinus Imaging• HRCT
- Bronchoscopy• Cardiac Work-up (ECG, Holter Monitoring, Echo)
- Environmental / Occupational Assessment
- Consider uncommon causes
|determine if the cause of the cough is one of the life-threatening conditions below and treat accordingly |
❑severe exacerbation of asthma or COPD
❑ other serious condittons
|Cough due to the common cold: a first-generation antihistamine plus a decongestant|
❑ naproxen (Naprosyn) favorably affects cough
❑ Newer-generation nonsedating antihistamines are not effective
|confirmed whooping cough by culture positive nasopharyngeal swab:|
macrolide antibiotics plus isolation for 5 days beginning first day of treatment
|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)
Uncommon Causes of Cough:
- nonacid reflux disease
- a swallowing disorder
- congestive heart failure
- habit cough.
If a complete workup fails to find a cause for the cough, the remaining diagnosis is an unexplained cough. and referral to cough specialist should be considered
- Always first determine if the cause of the cough is one of the life-threatening conditions especially in the management of acute cough such as pulmonary embolism.
- Always ask about environmental and occupational factors and travel exposures in the management of acute cough
- Routinely assess cough quality of life or cough severity with a validated tool
- Routinely follow up with the patient with subacute cough in 4-6 weeks
- naproxen (Naprosyn) favorably affects the acute cough due to common cold.
- Due to the side effects of oral corticosteroids if inhaled corticosteroid fails to treat asthma induced chronic cough consider adding a leukotriene inhibitor before an oral corticosteroid.
- GERD should be considered as a cause of chronic cough if treatments for the other causes of chronic cough fail.
- This guideline is intended for general information only and is not medical advice. It does not replace professional medical care and physician advice.
- Do not continue ACE inhibitors in patients presenting with chronic cough.
- Do not miss the following red flags during an assessment of cough:
- Smoker > 45 years of age with a
- new cough, change in cough, or
- coexisting voice disturbance
- Systemic symptoms including [[Fever, Weight loss, and Peripheral edema with weight gain
- Weight gain
- Recurrent pneumonia
- History Abnormal respiratory
- Exam and/or abnormal chest
- Radiograph coinciding with the duration of cough
- Adults aged 55-80 years who
- Have a 30 pack-year smoking
- History and currently smoke or who have quit within the past 15 years
- Prominent dyspnea, especially at rest or at night
- Trouble swallowing when eating or drinking
- Irwin RS, French CL, Chang AB, Altman KW, CHEST Expert Cough Panel* (2018). "Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report". Chest. 153 (1): 196–209. doi:10.1016/j.chest.2017.10.016. PMC 6689094 Check
|pmc=value (help). PMID 29080708.