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]

Cough
Resident Survival Guide
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

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.

Causes

Common Causes

Diagnosis

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

disease
 
 
 
 
 
Infections
 
 
 
 
 
 
 
 
 
Exacerbation of pre-existing condition
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lower respiratory tract infection
 
 
Upper respiratory tract infection
 
 
 
Asthma
 
Bronchiectasis
 
Upper airway cough syndrome
 
COPD
 
Evaluate and treat first
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute Bronchitis
 
 
 
Pertussis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pertussis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
COPD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Upper airway cough syndrome
 
Asthma
 
Bronchitis
 
Gastroesophageal reflux disease
 
Bronchiectasis
 
 
 
 
 
 
 
 
 
 
Condition
 
 
 
 
Postinfectious
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tuberculosis
 
 
 
 
 
 
 
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
HRCT
Bronchoscopy
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.


Treatment

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:
Pneumonia
❑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
Ipratropium
❑ 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
UPPER AIRWAY COUGH SYNDROME–INDUCED 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
 
 
 
ASTHMA-INDUCED CHRONIC COUGH
❑ 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
 
 
 
 
NON-ASTHMATIC EOSINOPHILIC BRONCHITIS-INDUCED CHRONIC COUGH
❑ Inhaled corticosteroids for 4 weeks
 
 
GERD-INDUCED CHRONIC COUGH
❑ 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
 
 
 
 
 



Do's

Don'ts

References

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