Chronic cough

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karina Zavaleta, MD [2], Anmol Pitliya, M.B.B.S. M.D.[3]

Chronic Cough Differential Diagnosis

Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
			Symptoms							Physical exam
			Onset	Duration	Productive cough	Hemoptysis	Weight lost	Fever	Dyspnea	Ascultation	Lab findings	Imaging	PFT	Gold standard
Respiratory	Upper airway diseases	Laryngopharyngeal reflux	Chronic	Variable	+	−	−	−	+	Hoarseness Stridor	Decreased levels of salivary epidermal growth factor (EGF) Increased levels of NKTR Biopsy may be helpful	X−Ray may be helpful Endoscopy examination may be helpful as well	Normal function	24 hour−dual sensor pH probe	Throat clearing Globus sensation
		Rhinosinusitis	Acute, subacute, chronic, recurrent	Acute: Less than 4 weeks Subacute: 4−12 weeks Chronic: More than 12 weeks Recurrent: 4 or more episodes or acute rhinosinusitis per year	+	−	−	+	+	Clear chest	In complicated acute bacterial rhinosinusitis, endoscopic cultures or sinus aspirate is indicated Nasal culture may also be helpful	Air−fluid level, mucosal edema and bony erosion of sinus on CT MRI for distinguish the etiology	Normal function	Clinical diagnosis: Nasal congestion, obstruction, and purulent rhinorrhea	Erythema in periorbital area
Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
			Symptoms							Physical exam
			Onset	Duration	Productive cough	Hemoptysis	Weight lost	Fever	Dyspnea	Ascultation	Lab findings	Imaging	PFT	Gold standard
Respiratory	Lower airway	Asthma	Chronic	Years	+ Clear mucoid or yellow sputum	−	−	−	+	Wheezing (expiratory) Rales Rhonchi	Eosinophilia Total serum IgE in test for allergy may be helpful	Normal airways in chest X−ray CT if there any abnormality in chest X−Ray	FEV1/FVC ratio <70% and FEV1 >15% increase after 15 minutes of 2 puffs of beta 2 sympathomimetic drug After physical active FEV1 decreases by >15% After inhaled corticosteroid (ICS)FEV1 increased by >15%	Airflow limitation on spirometry	Family history Seasonal variation
		Chronic Bronchitis	Chronic	Most of the days for three months in the las two years.	+ Clear sputum	−	−	+	+	Wheezing Rhonchi	CBC and ABG may be helpful	Chest X−Ray to exclude other diseases CT may also be helpful	FEV1/FVC ratio < 70% Post bronchodilatador FEV1 > 80% Reduced FVC after bronchodilatador administration Decread vital capacity Increased total lung capacity	Demostration of airflow limitation on spirometry	Smoker's cough Cigarette smoking Pollution
		Non−asthmatic eosinophilic bronchitis	Chronic	More than 8 weeks	+ Eosinophilic sputum	−	−	−	+	Wheezing Shortness of breath	High levels of IgE Airway eosinophilia in sputum induction or bronchial wash fluid from bronchoscopy (bronchoalveolar lavage)	Normal chest X−Ray	FEV1/FVC >70% No response of short acting bronchodilator	Bronchial biopsy Eosinophilia	Exposure to an occupational cause
		Bronchiectasis	Chronic	Months to years	+ Mucopurulent sputum	+	−	−	+	Crackles Wheezing Shortness of breath	Complete blood count (CBC) IgG, IgM and IgA Sputum culture for fungi, bacteria and mycobacteria	Linear atelectasis and dilated airways in chest X−Ray	FEV1/FVC <70% Normal FVC Low levels of FEV1	CT of chest	Digital clubbing Recurrent pleurisy
		Emphysema	Chronic	Months to years	+ Mucoid or purulent sputum	−	−	+	+	Shortness of breath Wheezing Prolonged expiration Crackles	Testing for alpha 1−antitrypsin may be helpful	Chest X−Ray to exclude other diseases CT may also be helpful	FEV1/FVC <70% Post bronchodilator FEV1 >80	Detection of early emphysema in CT of chest	Exposure of tobacco and air pollution
Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
			Symptoms							Physical exam
			Onset	Duration	Productive cough	Hemoptysis	Weight lost	Fever	Dyspnea	Ascultation	Lab findings	Imaging	PFT	Gold standard
Respiratory	Parenchyma	Pneumoconioses	Acute, Chronic	Years	−	−	+	+	+	Wheezing Rhonchi Crackles	CBC and ABG may be helpful	Small oppacities and fibrosis observed in chest X−ray CT and FDG−PET may be helpful	FEV1/FVC <70% FEV1 <80%	Exposure history and chest radiograph	Fibrogenic: Silica, asbestos Inert: Iron, barium Granulomatous: Beryllium Giant cell pneumonia: Cobalt
		Lung cancer	Chronic	Years	+	+	+	+/−	+	Hoarseness	The following investigations may be helpful: Complete blood count (CBC) ALT, AST Calcium Alkaline phosphatase LDH Creatinine	Contrast−enhanced CT of chest and upper abdomen	Not specific	Tissue biopsy (sample should be sufficient for molecular testing)	Risk factor: Cigarette smoking Types Small cell lung cancer (SCLC) Non−small cell lung cancer (NSCLC)
		Interstitial lung disease	Chronic	Variable	−	+	+	−	+	Wheezing Crackles or velcro rales Inspiratory high−pitched rhonchi	The following investigations may be helpful: Hepatic function test Renal function test CBC Serological testing	Nodular, reticular or both pattern in chest X−ray CT in patients with diffuse pulmonary lung disease	Reduction in FVC, RV, FRC, TLC and FEV1 on spirometry FEV1/FVC normal or increase Lung volumes Diffusion capacity (DLCO reduced)	Lung biopsy when lab, imaging, and PFT has indeterminate result	Clubbing is common in asbestosis and idiopathic pulmonary fibrosis
		Tuberculosis (TB)	Chronic	More than 2 or 3 weeks	+	+	+	+	+	Pleural effusion Crackles Whispered pectoriloquy Decreased fremitus Rhonchi	Sputum acid−fast bacilli (AFB) smear may be positive Mycobacterial culture may be positive Molecular testing may be helpful	Reactivation of TB is observed as infiltration in the upper lobe in chest X−Ray In patients with HIV, Tb is observed as lobar infiltration, adenopathy, lung mass named tuberculoma, small fibronodular lesions, and/or pleural effusion on chest X−Ray CT can detect early nodal process	Decreased FEV1 Reduced FVC	Isolation of Mycobacterium tuberculosis from some secretion	Etiology: Mycobacterium tuberculosis Complications: Pneumothorax, bronchiectasis, pulmonary destruction and chronic pulmonary aspergillosis
		Cystic fibrosis (CF)	Chronic	Variable	+	−	+	+/−	+	Barrel−shaped chest Wheezing Tachypnea	Respiratory tract culture may be helpful for diagnosing secondary bacterial infection Bronchoalveolar lavage for cytology may be helpful ≥ 60 mmol/L Sweat chloride test CFTR mutation in molecular testing may be positive	Hyperinflation, atelectasis, and infiltrates on chest X−Ray Severe patients present bronchietasis, "tram tracks" peribronchial cuffing in chest X−Ray The extension of bronchietasis can be defined by CT	RV/TLC ratio increased FEV1/FVC ratio <70% Low levels of FEV1 High levels of TLC RV increased	Sweat chloride test	Evidence of CFTR dysfunction
Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
			Symptoms							Physical exam
			Onset	Duration	Productive cough	Hemoptysis	Weight lost	Fever	Dyspnea	Ascultation	Lab findings	Imaging	PFT	Gold standard
[[[Heart|Cardiac]]		Mitral Stenosis	Chronic	Variable	+ Pink frothy	+	−	−	+	Crackles Hoarseness	Not specifc	Electrocardiogram may be helpful Enlargement of left atrium and appendage in chest radiograph	FVC reduced	Resting transthoracic echocardiography	Stress testing Cardiac catheterization
		Pulmonary hypertension	Chronic	More than 2 years	−	+	+	−	+	Hoarseness	The following investigations may be helpful: HIV serology Antinuclear antibody (ANA) Rheumatoid factor (RF) Anti−neutrophil cytoplasmic antibody (ANCA)	Enlargement of the central pulmonary artery and right heart in chest X−Ray Pulmonary artery systolic pressure can be estimated in echocardiography	Low levels of FEV1 Decreased FVC DLCO reduced	Mean pulmonary artery pressure more than 25 mmHg at rest	Chest pain Ascites Syncope Peripherial edema
Gastrointestinal		Gastroesophageal reflux	Chronic	Variable	+	−	+	−	+	Wheezing Hoarseness	Not specific	Upper endoscopy may be helpful Barium esophagram may be helpful	Normal function	PH testing	−−
Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
			Symptoms							Physical exam
			Onset	Duration	Productive cough	Hemoptysis	Weight lost	Fever	Dyspnea	Ascultation	Lab findings	Imaging	PFT	Gold standard
Autoimmune		Goodpasture syndrome	Chronic	Variable	−	+	−	−	+	Shortness of breath	The following investigations may be helpful: Complete blood count (CBC) ANCA positive Anti−GBM in ELISA or western blot	Pulmonary infiltratation in chest X−Ray CT scan for parenchymal involvement	Increased DLCO Decreased TLC Decreased FVC	Renal biopsy	Hematuria Proteinuria
		Wegener's disease (GPA)	Chronic	Months	+	+	+	+	+	Hoarseness Stridor Wheezing	The following investigations may be helpful: ANCA, P−ANCA, C−ANCA BUN Creatinine Complete blood count Urinalysis Lung biopsy	Nodules, pulmonary infiltrates, reticular margins, pleural opacities and cavities in chest X−Ray Nodules, cavities and stellate−shaped peripherial pulmonary in chest CT Bronchoscopy may be helpful	Low levels of DLCO Reduce lung volumes	Tissue biopsy	Nasal crusting, sinus pain, chronic rhinosinusitis, nasal obstruction and discharge in upper airway Saddle nose deformity Purpura in lower extremities
		Sarcoidosis	Chronic	Years	−	−	+	+	+	Wheezing Squeaky sounds	The following investigations may be helpful: Complete blood count (CBC) Urinalysis BUN Liver function test Calcium Alkaline phosphatase levels Electrolytes Histopathologic detection	On chest X−Ray: Stage 1: Bilateral hiliar adenopathy Stage 2: Reticular opacities and hiliar adenopathy Stage 3: Shrink hiliar nodules and reticular opacities Stage 4: Lost of volume	Reduced FVC Decreased of TLC	Clinical diagnosis, histopathologic detection of noncaseating granulomas and exclusion of other diseases	Young adults Skin, joint and eye lesions
		Microscopic polyangitis (MPA)	Chronic	Variable	+	+	+	+	+	Hoarseness Stridor Wheezing	The following investigations may be helpful: ANCA positive BUN Creatinine Complete blood count Urinalysis	Cavitation, nodules, and alveolar opacities in chest X−ray Head and chest CT may be helpful Electromyography/nerve conduction study may also be helpful	Reduced lung volumes	Tissue biopsy	Nerve damage Rhinosinusitis Purpura involving lower extremities
		Churg−Strauss	Chronic	Variable	+	+	+	+	+	Wheezing Rales Rhonchi Expiratory sounds(related to asthma)	Peripherial eosinophilia In active phase CRP and erytrocyte sedimentation rate high Elevated IgE ANCA positive	Infiltrates in chest X−Ray Ground glass opacities, tree−in−bud sign and small nodules in chest CT	Lung volumes decreased FVC reduced FEV1/FVC ratio <70%	Tissue biopsy	Asthma Eosinophilia Rhinosinusitis