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]

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

Overview

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.

Causes

Common Causes

Diagnosis

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.[1]

 
 
 
 
 
 
 
 
Acute Cough
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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, PE, heart failure, other serious

disease
 
 
 
 
 
Infections
 
 
 
 
 
 
 
 
 
Exacerbation of pre-existing condition
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
LRTI
 
 
URTI
 
 
 
Asthma
 
Bronchiectasis
 
UACS
 
COPD
 
Evaluate and treat first
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute Bronchitis
 
 
 
Pertussis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider TB in

endemic areas

or high risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Subacute Cough
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pertusis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
COPD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
UACS
 
Asthma
 
Bronchitis
 
GERD
 
Bronchiectasis
 
 
 
 
 
 
 
 
 
 
{{{ }}}
 
 
 
 
Postinfectious
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TB
 
 
 
 
 
 
 
NAEB
 
 
 
AECB/COPD
 
 
 
 
 
  • Not postinfectious: Work up same as chronic cough


 
 
 
 
 
 
 
 
Chronic Cough
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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

Treatment

Shown below is an algorithm summarizing the treatment of Cough according to the American College of Chest Physicians guidelines.

 
 
 
Cough image.jpg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute Cough
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
determine if the cause of the cough is one of the life-threatening conditions below and treat accordingly
Pneumonia
❑severe exacerbation of asthma or COPD
PE
heart failure
❑ 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





 
 
 
Pertussis.jpg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Subacute Cough
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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)




 
 
 
 
 
 
 
 
 
 
 
 
 
 
COPD.jpg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chronic Cough
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1-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
 
 
 
2-ASTHMA-INDUCED CHRONIC COUGH
inhaled corticosteroids and beta agonists
❑No response or cannot take inhaled medication: Oral consideration corticosteroids for five to 10 days*
❑Consider adding a leukotriene inhibitor before an oral corticosteroid
 
 
 
 
3-NONASTHMATIC EOSINOPHILIC BRONCHITIS-INDUCED CHRONIC COUGH
inhaled corticosteroids for 4 weeks
 
 
4-GERD-INDUCED CHRONIC COUGH
Any patient who responds only partially or not at all to the therapies discussed in 1-3 should be empirically treated for GERD.
❑antireflux diet and other lifestyle modification and a proton pump inhibitor
❑No response to therapy: Consider prokinetic therapy
 
 
 
 
 



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

Do's

  • 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.

Don'ts

  • 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:
    • Hemoptysis
    • Smoker > 45 years of age with a
    • new cough, change in cough, or
    • coexisting voice disturbance
    • Hoarseness
    • Systemic symptoms including [[Fever, Weight loss, and Peripheral edema with weight gain
    • Weight gain
    • Vomiting
    • 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

References

  1. 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.