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Subject: Chronic Cough
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Chronic cough is defined as a cough that persists for >8 weeks in adults.
In children, chronic cough is often defined as a cough of >4 weeks in duration.
Subacute cough describes a cough lasting 3 to 8 weeks.
Patients present because of fear of the causative illness (e.g., cancer) as well as annoyance, self-consciousness, and hoarseness.
System(s) affected: gastrointestinal (GI), pulmonary
Predominant age: all age groups
Predominant sex: male = female, with females more likely to seek out medical attention
Often multiple etiologies, but most are related to bronchial irritation. Most frequent etiologies (account for >90% of cases) in nonsmokers include the following:
Cough reflex hypersensitivity or cough hypersensitivity syndrome define a syndrome of cough with characteristic trigger symptoms not adequately explained by other medical conditions 1.
Patient age, associated signs/symptoms, medical history, medication history (i.e., ACE inhibitors), environmental and occupational exposures, potential for aspiration, and smoking history may make some causes more likely.
The character of cough or description of sputum quality is rarely helpful in predicting the underlying cause.
Cough diaries have not correlated well with objective measures.
Hemoptysis or signs of systemic illness preclude empiric therapy.
Signs and symptoms are variable and related to the underlying cause; usually, a nonproductive cough with no other signs or symptoms.
Possible signs and symptoms of UACS, sinusitis, GERD, congestive heart failure, chronic stressors
Absence of additional signs/symptoms of a particular condition not necessarily helpful
Evaluation often starts with empiric therapy directed at likely underlying etiology and/or simple testing such as a chest x-ray (CXR).
Extensive testing only if indicated by the history and physical
Evaluation will be dictated by findings in the comprehensive history and physical.
Evaluation of peak flow may be indicated.
If considering neoplasm, heart failure, or infectious etiologies, CXR or B-type natriuretic peptide (BNP) may be indicated.
In cases of failure to respond to initial trial of empiric therapy, CXR may also be beneficial.
If abnormal CXR, suspected neoplasm, or underlying pulmonary disorder, consider a chest CT.
Consider pulmonary consultation.
Refer to gastroenterologist for endoscopy.
Pulmonary function testing
Purified protein derivative (PPD) skin testing
24-hour esophageal pH monitor
Bronchoscopy, if history of hemoptysis or smoking with normal CXR
Endoscopic or video fluoroscopic swallow evaluation or barium esophagram
Ambulatory cough monitoring and cough challenge with citric acid, capsaicin, or other bronchodilator (at specialized cough clinic)
With chronic cough, empiric treatment should be directed at the most common causes as clinically indicated (UACS, asthma, GERD) 2[C].
Oral antihistamine/decongestant therapy with a 1st-generation antihistamine or nasal steroid spray can be used as initial empiric treatment 2[C].
In patients with cough associated with the common cold, nonsedating antihistamines were not found to be effective in reducing cough 2[C].
In stable patients with chronic bronchitis, therapy with ipratropium bromide may reduce chronic cough 3[C].
Centrally acting antitussive drugs (dextromethorphan, hydrocodone) may be used for short-term symptomatic relief of coughing in patients with chronic bronchitis but have limited efficacy in cough due to upper respiratory infections 3[C].
For cough associated with lung cancer, narcotic cough suppressants are recommended 3[C].
The American Academy of Pediatrics does not recommend central cough suppressants for treating any kind of cough 2[B].
In children ≪14 years, when pediatric recommendations are not available, adult recommendations should be used with caution 2[C].
Some children with recurrent cough and no evidence of airway obstruction may benefit from an inhaled β-agonist 4[C].
In infants and children with nonspecific chronic cough, trials of empiric PPI therapy were not effective 5[C].
In patients with chronic cough, considerations for potential etiology should include asthma 2[B] or UACS 2[C].
With concomitant complaints of heartburn and regurgitation, GERD should be considered as a potential etiology 2[C].
90% of patients will have resolution of cough after smoking cessation 2[A].
When indicated, ACE inhibitor therapy should be switched in patients in whom intolerable cough occurs 3[A]. It may take several days or weeks for cough to resolve after stopping ACE inhibitor therapy.
Empirically treat postnasal drip and GERD.
Consider nonpharmacologic options, such as warm fluids, hard candy, or nasal drops. In infants and children, try clearing secretions with a bulb syringe.
Attempt maximal therapy for single most likely cause for several weeks, then search for coexistent etiologies.
Treatments (nasal steroids, classic antihistamines, antacids, bronchodilators, inhaled corticosteroids, PPIs, antibiotics) should be directed at the specific cause of cough.
If history and physical exam suggest GERD, may want to trial H2 blocker or PPI therapy prior to further diagnostic testing.
A comparative effectiveness review of 49 studies with common opioid and nonanesthetic antitussives stated there is some efficiency for treating cough in adults, but evidence is limited 6[C].
The FDA issued a public health advisory stating that OTC cough and cold medicines, including antitussives, expectorants, nasal decongestants, antihistamines, or combinations, should not be given to children ≪2 years. Subsequently, manufacturers have changed labeling to state “do not use” in children ≪4 years. National estimates have shown a decline in emergency department visits in children ≪2 years related to adverse events from cough and cold medicine ingestion 7.
Routine empiric treatment of children with chronic cough with leukotriene receptor antagonists lacks evidence and cannot be recommended 8[C]. A small pilot study with montelukast in adults demonstrated some symptom relief after 2 weeks of treatment 9[A].
In adults, oral antihistamine/decongestant therapy can be empiric treatment. Multiple formulations are available OTC in combination with other ingredients. Advise patients to review labels carefully or consult pharmacist:
Central cough suppressants for short-term symptomatic relief of nonproductive cough
A peripherally acting antitussive agent has been used:
Results from a small randomized placebo-controlled trial (n = 27) demonstrated subjective cough score improvement in patients using slow-release morphine sulfate. Patients had failed with other antitussive therapies. Side effects included constipation and drowsiness, and there were no discontinuations due to adverse events 10[A].
An analysis of studies evaluating inhaled corticosteroid use in chronic cough for patients without additional indication such as asthma did not show consistent benefits 11[C].
Reassure patient that most cases of chronic cough are not life-threatening and that the condition can usually be managed effectively.
Counsel that several weeks to a month may be needed for significant reduction or elimination of cough
Prepare the patient for the possibility of multiple diagnostic tests and therapeutic regimens because the treatment is very often empiric.
>80% of patients can be effectively diagnosed and treated using a systematic approach.
Cough from any cause may take weeks to months until resolution, and resolution depends greatly on efficacy of treatment directed at underlying etiology.
Cardiovascular: arrhythmias, syncope
Stress urinary incontinence
Abdominal and intercostal muscle strain
GI: emesis, hemorrhage, herniation
Neurologic: dizziness, headache, seizures
Respiratory: pneumothorax, laryngeal, or tracheobronchial trauma
Skin: petechiae, purpura, disruption of surgical wounds
Medication side effects
Other: negative impact on quality of life
Asthma; Bronchiectasis; Congestive Heart Failure; Eosinophilic Pneumonias; Gastroesophageal Reflux Disease; Laryngeal Cancer; Lung, Primary Malignancies; Pertussis; Pulmonary Edema; Rhinitis, Allergic; Sinusitis; Tuberculosis
Algorithm: Cough, Chronic
J44.9 Chronic obstructive pulmonary disease, unspecified
J41.0 Simple chronic bronchitis
496 Chronic airway obstruction, not elsewhere classified
491.0 Simple chronic bronchitis
68154008 Chronic cough (finding)
13645005 Chronic obstructive lung disease (disorder)
46802002 smokers' cough (disorder)
In patients with chronic cough, most frequent etiologies include a history of smoking, asthma, UACS, and GERD.
The FDA issued a public health advisory stating that OTC cough and cold medicines should not be given to children ≪2 years. OTC cough expectorant and suppressant product labels state “do not use” in children ≪4 years.