Cough resident survival guide: Difference between revisions

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__NOTOC__
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{{CMG}}; {{AE}} {{SaraH}}
{{CMG}}; {{AE}} {{SaraH}} {{Sara.Zand}}


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==Overview==
==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]].
[[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==
==Causes==


===Common Causes===
===Common Causes===
* [[Allergic Rhinitis]]
* [[Allergic Rhinitis]]
* [[Asthma]]
* [[Asthma]]<ref name="pmid11716169">{{cite journal |vauthors=Janson C, Chinn S, Jarvis D, Burney P |title=Determinants of cough in young adults participating in the European Community Respiratory Health Survey |journal=Eur Respir J |volume=18 |issue=4 |pages=647–54 |date=October 2001 |pmid=11716169 |doi=10.1183/09031936.01.00098701 |url=}}</ref>
* [[Bronchiectasis]]
* [[Bronchitis]]<ref name="pmid23204254">{{cite journal |vauthors=Kim V, Criner GJ |title=Chronic bronchitis and chronic obstructive pulmonary disease |journal=Am J Respir Crit Care Med |volume=187 |issue=3 |pages=228–37 |date=February 2013 |pmid=23204254 |pmc=4951627 |doi=10.1164/rccm.201210-1843CI |url=}}</ref>
* [[Gastroesophageal Reflux Disease]] ([[GERD]])
* [[Gastroesophageal Reflux Disease]] ([[GERD]])
* [[Post-nasal drip]]
* [[Post-nasal drip]]<ref name="pmid22577385">{{cite journal |vauthors=Sylvester DC, Karkos PD, Vaughan C, Johnston J, Dwivedi RC, Atkinson H, Kortequee S |title=Chronic cough, reflux, postnasal drip syndrome, and the otolaryngologist |journal=Int J Otolaryngol |volume=2012 |issue= |pages=564852 |date=2012 |pmid=22577385 |pmc=3332192 |doi=10.1155/2012/564852 |url=}}</ref>
* Medications' side effect
* [[Foreign body aspiration]]<ref name="AkelmaCizmeci2013">{{cite journal|last1=Akelma|first1=Ahmet Zulfikar|last2=Cizmeci|first2=Mehmet Nevzat|last3=Kanburoglu|first3=Mehmet Kenan|last4=Mete|first4=Emin|title=An Overlooked Cause of Cough in Children: Foreign Body Aspiration|journal=The Journal of Pediatrics|volume=163|issue=1|year=2013|pages=292–293|issn=00223476|doi=10.1016/j.jpeds.2012.12.089}}</ref>
**[[ACE inhibitor|ACE inhibitors]]
*[[ACE inhibitor|ACE inhibitors]]<ref name="pmid30664425">{{cite journal |vauthors=Yılmaz İ |title=Angiotensin-Converting Enzyme Inhibitors Induce Cough |journal=Turk Thorac J |volume=20 |issue=1 |pages=36–42 |date=January 2019 |pmid=30664425 |pmc=6340691 |doi=10.5152/TurkThoracJ.2018.18014 |url=}}</ref>
*[[Bronchitis]]
*[[Bronchiectasis]]<ref name="pmid31176801">{{cite journal |vauthors=Mac Aogáin M, Chotirmall SH |title=Bronchiectasis and cough: An old relationship in need of renewed attention |journal=Pulm Pharmacol Ther |volume=57 |issue= |pages=101812 |date=August 2019 |pmid=31176801 |pmc=7110869 |doi=10.1016/j.pupt.2019.101812 |url=}}</ref>
*[[Laryngopharyngeal reflux disease|Laryngopharyngeal reflux]]
*[[Laryngopharyngeal reflux disease|Laryngopharyngeal reflux]]<ref name="pmid30364386">{{cite journal |vauthors=Patel DA, Blanco M, Vaezi MF |title=Laryngopharyngeal Reflux and Functional Laryngeal Disorder: Perspective and Common Practice of the General Gastroenterologist |journal=Gastroenterol Hepatol (N Y) |volume=14 |issue=9 |pages=512–520 |date=September 2018 |pmid=30364386 |pmc=6194652 |doi= |url=}}</ref>
*[[Respiratory tract infection]]
*[[Respiratory tract infection]]<ref name="pmid25383204">{{cite journal |vauthors=Dicpinigaitis PV |title=Effect of viral upper respiratory tract infection on cough reflex sensitivity |journal=J Thorac Dis |volume=6 |issue=Suppl 7 |pages=S708–11 |date=October 2014 |pmid=25383204 |pmc=4222932 |doi=10.3978/j.issn.2072-1439.2013.12.02 |url=}}</ref>
*[[Lung cancer]]
*[[Lung cancer]]<ref name="HarleMolassiotis2020">{{cite journal|last1=Harle|first1=Amélie|last2=Molassiotis|first2=Alex|last3=Buffin|first3=Oliver|last4=Burnham|first4=Jack|last5=Smith|first5=Jaclyn|last6=Yorke|first6=Janelle|last7=Blackhall|first7=Fiona H.|title=A cross sectional study to determine the prevalence of cough and its impact in patients with lung cancer: a patient unmet need|journal=BMC Cancer|volume=20|issue=1|year=2020|issn=1471-2407|doi=10.1186/s12885-019-6451-1}}</ref>
* Nonasthmatic eosinophilic bronchitis
*Non-[[asthmatic]] [[eosinophilic]] [[bronchitis]]<ref name="pmid29404185">{{cite journal |vauthors=Yıldız T, Dülger S |title=Non-astmatic Eosinophilic Bronchitis |journal=Turk Thorac J |volume=19 |issue=1 |pages=41–45 |date=January 2018 |pmid=29404185 |pmc=5783052 |doi=10.5152/TurkThoracJ.2017.17017 |url=}}</ref>
*Non-[[acid reflux disease]]<ref name="QiuXu2015">{{cite journal|last1=Qiu|first1=Zhongmin|last2=Xu|first2=Xianghuai|last3=Yu|first3=Li|last4=Chen|first4=Qiang|last5=Lv|first5=Hanjing|title=Diagnosis and treatment of patients with nonacid gastroesophageal reflux-induced chronic cough|journal=Journal of Research in Medical Sciences|volume=20|issue=9|year=2015|pages=885|issn=1735-1995|doi=10.4103/1735-1995.170625}}</ref>
*[[Swallowing]] disorder<ref name="pmid25991980">{{cite journal |vauthors=Drozdz DR, Costa CC, Jesus PR, Trindade MS, Weiss G, Neto AB, da Silva AM, Mancopes R |title=Pharyngeal swallowing phase and chronic cough |journal=Int Arch Otorhinolaryngol |volume=16 |issue=4 |pages=502–8 |date=October 2012 |pmid=25991980 |pmc=4399588 |doi=10.7162/S1809-97772012000400012 |url=}}</ref>
*[[Congestive heart failure]]<ref name="FerasinLinney2019">{{cite journal|last1=Ferasin|first1=L.|last2=Linney|first2=C.|title=Coughing in dogs: what is the evidence for and against a cardiac cough?|journal=Journal of Small Animal Practice|volume=60|issue=3|year=2019|pages=139–145|issn=00224510|doi=10.1111/jsap.12976}}</ref>
* Habit [[cough]]<ref name="WeinbergerLockshin2017">{{cite journal|last1=Weinberger|first1=Miles|last2=Lockshin|first2=Boris|title=When is cough functional, and how should it be treated?|journal=Breathe|volume=13|issue=1|year=2017|pages=22–30|issn=1810-6838|doi=10.1183/20734735.015216}}</ref>


==Diagnosis==
Shown below is an algorithm summarizing the evaluation of acute, subacute, chronic [[cough]].<ref name="pmid29080708">{{cite journal| author=Irwin RS, French CL, Chang AB, Altman KW, CHEST Expert Cough Panel*| title=Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report. | journal=Chest | year= 2018 | volume= 153 | issue= 1 | pages= 196-209 | pmid=29080708 | doi=10.1016/j.chest.2017.10.016 | pmc=6689094 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29080708  }} </ref><ref name="BoujaoudePratter2009">{{cite journal|last1=Boujaoude|first1=Ziad C.|last2=Pratter|first2=Melvin R.|title=Clinical Approach to Acute Cough|journal=Lung|volume=188|issue=S1|year=2009|pages=41–46|issn=0341-2040|doi=10.1007/s00408-009-9170-6}}</ref><ref name="pmid27029594">{{cite journal |vauthors=Kilgore PE, Salim AM, Zervos MJ, Schmitt HJ |title=Pertussis: Microbiology, Disease, Treatment, and Prevention |journal=Clin Microbiol Rev |volume=29 |issue=3 |pages=449–86 |date=July 2016 |pmid=27029594 |pmc=4861987 |doi=10.1128/CMR.00083-15 |url=}}</ref><ref name="pmid32026427">{{cite journal |vauthors=Kaplan AG |title=Chronic Cough in Adults: Make the Diagnosis and Make a Difference |journal=Pulm Ther |volume=5 |issue=1 |pages=11–21 |date=June 2019 |pmid=32026427 |pmc=6966942 |doi=10.1007/s41030-019-0089-7 |url=}}</ref>


upper airway cough syndrome (UACS).
AECOPD (acute exacerbation of COPD)
tuberculosis TB
URI = upper respiratory tract infection.
LRTI = lower respiratory tract infection; PE = pulmonary embolism;
ACEI = angiotensin-converting enzyme inhibitor;
NAEB = nonasthmatic eosinophilic bronchitis;
PI = postinfectious; PNDS = postnasal drip syndrome;
RTI = respiratory tract infection.
AECB = acute exacerbation of chronic bronchitis;
GERD = gastroesophageal reflux disease;
NAEB = nonasthmatic eosinophilic bronchitis
==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.<ref name="pmid29080708">{{cite journal| author=Irwin RS, French CL, Chang AB, Altman KW, CHEST Expert Cough Panel*| title=Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report. | journal=Chest | year= 2018 | volume= 153 | issue= 1 | pages= 196-209 | pmid=29080708 | doi=10.1016/j.chest.2017.10.016 | pmc=6689094 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29080708  }} </ref>


{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | '''Acute Cough''' | | | | | |'''Acute Cough'''='''Acute Cough'''}}
{{familytree | | | | | | | | | '''Acute Cough''' | | | | | |'''Acute Cough'''='''Acute [[Cough]]''' ≤ 3 [[weeks]] duration}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | History and physical
{{familytree | | | | | | | | | History and physical
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{{familytree/end}}
{{familytree/end}}


*[[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.
.


{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | '''Subacute Cough''' | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |'''Subacute Cough'''='''Subacute [[Cough]]'''}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | '''Subacute Cough''' | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |'''Subacute Cough'''='''Subacute [[Cough]]''' ,(3-8 weeks duration)}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | History and Physical Exam Ask about red flags,
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | History and Physical Exam Ask about red flags,
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environmental and
environmental and
occupational factors,
occupational factors,
travel exposures=[[History]] and [[Physical Exam]], Ask about red flags,
travel exposures=[[History]] and [[Physical Exam]], Ask about red flags ''( [[hemoptysis]], [[smoking ]], [[dyspnea]], [[hoarseness]], abnormal [[CXR]] findings)''
[[environmental]] and
[[environmental]] and
[[occupational]] factors,
[[occupational]] factors,
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{{familytree | | | | | | | |,|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |,|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | |Postinfectious or life-threatening diagnosis
{{familytree | | | | | | |Postinfectious or life-threatening diagnosis
| | | | | | | | | | | | | | | | | | | | | New onset or exacerbation of pre-existing condition| | | | | Not postinfectious* |Postinfectious or life-threatening diagnosis
| | | | | | | | | | | | | | | | | | | | | New onset or exacerbation of pre-existing condition| | | | | Not postinfectious |Postinfectious or life-threatening diagnosis
=Postinfectious or [[life-threatening]] diagnosis
=Postinfectious or [[life-threatening]] diagnosis
|New onset or exacerbation of pre-existing condition=New onset or exacerbation of pre-existing [[condition]]|Not postinfectious*=Not [[postinfectious]]*}}
|New onset or exacerbation of pre-existing condition=New onset or exacerbation of pre-existing [[condition]]|Not postinfectious=Not [[postinfectious]]}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |!| | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |!| | }}
{{familytree | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | | |!| | | | | | | | }}
{{familytree | | |Pneumonia, severe exacerbation of asthma or COPD, pulmonary embolism, heart failure, other serious disease
{{familytree | | |Pneumonia, severe exacerbation of asthma or COPD, pulmonary embolism, heart failure, other serious disease
   | | | | | | |!| | | | | | | | | | | | | | | | | | |!| | | | | | |Pneumonia, severe exacerbation of asthma or COPD, pulmonary embolism, heart failure, other serious [[disease]]
   | | | | | | |!| | | | | | | | | | | | | | | | | | |!| | | | | | |Pneumonia, severe exacerbation of asthma or COPD, pulmonary embolism, heart failure, other serious disease=[[Pneumonia]], severe exacerbation of [[asthma]] or [[COPD]],[[ pulmonary embolism]], [[heart failure]], other serious [[disease]]
=[[Pneumonia]], severe exacerbation of [[asthma]] or [[COPD]],[[ pulmonary embolism]], [[heart failure]], other serious [[disease]]
|}}
|}}
{{familytree | | | | | | | | | | | |!| | |,|-| Pertusis | | | | | | | | | | | |!| | | | | | | |Pertusis=[[Pertusis]]}}
{{familytree | | | | | | | | | | | |!| | |,|-| Pertussis | | | | | | | | | | | |!| | | | | | | |Pertussis=[[Pertussis]]}}
{{familytree | | | | | | | | | | | |!| | |!| | | | | | | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.}}
{{familytree | | | | | | | | | | | |!| | |!| | | | | | | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.}}
{{familytree | | | | | | | | | | | |!| | |)|-| COPD | | | |!| | | |!| | | |!| | | |!| | | |!| |COPD=[[COPD]]}}
{{familytree | | | | | | | | | | | |!| | |)|-| COPD | | | |!| | | |!| | | |!| | | |!| | | |!| |COPD=[[COPD]]}}
{{familytree | | | | | | | | | | | |!| | |!| | | | | | | UACS | | Asthma | | Bronchitis | | GERD | | Bronchiectasis|UACS=[[Upper airway]] [[cough]] syndrome|Asthma=[[Asthma]]|Bronchitis=[[Bronchitis]]|GERD=[[Gastroesophageal reflux disease]]|Bronchiectasis=[[Bronchiectasis]]}}
{{familytree | | | | | | | | | | | |!| | |!| | | | | | | UACS | | Asthma | | Bronchitis | | GERD | | Bronchiectasis|UACS=[[Upper airway]] [[cough]] syndrome|Asthma=[[Asthma]]|Bronchitis=[[Bronchitis]]|GERD=[[Gastroesophageal reflux disease]]|Bronchiectasis=[[Bronchiectasis]]}}
{{familytree | | | | | | | | | | |     |-|+|-| Postinfectious | | | | | | | | | | | |!| | | |Postinfectious=[[Postinfectious]]}}
{{familytree | | | | | | | | | | | |-|+|-| Postinfectious | | | | | | | | | | | |!| | | |Postinfectious=[[Postinfectious]]|k=[[ Condition]]}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | |,|-|-|^|-|-|.| | | |}}  
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | |,|-|-|^|-|-|.| | | |}}  
{{familytree | | | | | | | | | | | | | | |`|-| TB| | | | | | | |  NAEB | | | | AECB
{{familytree | | | | | | | | | | | | | | |`|-| TB| | | | | | | |  NAEB | | | | AECB
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{{familytree/end}}
{{familytree/end}}
<span style="font-size:85%">'''Abbreviations:'''
<span style="font-size:85%">'''Abbreviations:'''
'''TB:''' [[Tuberculosis]];
'''[[TB]]:''' [[Tuberculosis]];
'''NAEB:''' [[Nonasthmatic eosinophilic bronchitis;]];
'''[[COPD]]:''' [[Chronic obstructive pulmonary disease]];
'''AECB:''' [[ Acute exacerbation of chronic bronchitis]];
'''[[GERD]]:'''[[Gastroesophageal reflux disease]]
'''COPD''' [[Chronic obstructive pulmonary disease]];
'''GERD'''[[gastroesophageal reflux disease]];
'''UACS'''[[Upper airway cough syndrome]].


</span>
</span>
<br>
<br>
*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.




{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | |'''Chronic Cough'''| | | | | | | | | |'''Chronic Cough'''='''Chronic Cough'''}}
{{familytree | | | | | | | | |'''Chronic Cough'''| | | | | | | | | |'''Chronic Cough'''='''Chronic Cough'''> 8 weeks duration }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | History, Physical exam and CXR | | | | | |History, Physical exam and CXR=History, Physical exam and CXR}}
{{familytree | | | | | | | | | History, Physical exam and CXR | | | | | |History, Physical exam and CXR=[[History]], [[Physical exam]] and [[CXR]]}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | 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]] |Life-threatening condition=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)=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]]=[[Smoking]], [[ACEI]], [[Sitagliptin]]}}
{{familytree | | Life-threatening condition | | | | | Consider four most common causes | | | | | [[Smoking]], [[ACEI]]|Life-threatening condition=Life-threatening [[condition]]|Consider four most common causes =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]]=[[Smoking]], [[ACEI]]}}
{{familytree | | |!| | | | | | |!| | | | | | |!| }}
{{familytree | | |!| | | | | | |!| | | | | | |!| }}
{{familytree | | Treat based on the cause | | |,|-|-|^|-|-|-|.| | Discontinue for at least 4week | | | ||Treat based on the cause=Treat based on the cause|Discontinue for at least 4week=Discontinue for at least 4week}}
{{familytree | | Treat based on the cause | | |,|-|-|^|-|-|-|.| | Discontinue for at least four weeks | | | ||Treat based on the cause=[[Treat]] based on the cause|Discontinue for at least four weeks=Discontinue for at least four [[weeks]]}}
{{familytree | | |!| | | |!| | | | | | |!| | |!| | | | | }}
{{familytree | | |!| | | |!| | | | | | |!| | |!| | | | | }}
{{familytree | | 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=Follow up 4-6 weeks if inadequate response|Further investigation if No response to treatment*=Further investigation if No response to treatment*|Initial treatments for each condition=Initial treatments for each condition|Follow up 4-6 weeks if inadequate response to optimal treatment=Follow up 4-6 weeks if inadequate response to optimal treatment|Consider 4 most common causes of cough if No response at4-6 week follow up=Consider 4 most common causes of cough if No response at4-6 week follow up}}
{{familytree | | 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=[[Follow up]] 4-6 weeks if inadequate response|Further investigation if No response to treatment=Further investigation if No response to [[treatment]]|Initial treatments for each condition=Initial [[treatments]] for each [[condition]]|Follow up 4-6 weeks if inadequate response to optimal treatment=Follow up 4-6 weeks if inadequate response to optimal [[treatment]]|Consider four most common causes of cough if No response at 4-6 weeks follow up=Consider four most common causes of [[cough]] if No response at 4-6 weeks [[follow up]]}}
{{familytree | | | | | | |!| | | | | | | | | | | | | }}
{{familytree | | | | | | |!| | | | | | |!| | | | | }}
{{familytree | | | | | | Follow up 4-6 weeks if inadequate response to optimal treatment | | | | | | | | | | |Follow up 4-6 weeks if inadequate response to optimal treatment=Follow up 4-6 weeks if inadequate response to optimal treatment}}
{{familytree | | | | | | Follow up 4-6 weeks if inadequate response to optimal treatment | | | | C1 | | | |Follow up 4-6 weeks if inadequate response to optimal treatment=[[Follow up]] 4-6 weeks if inadequate response to optimal [[treatment]]| C1=<div style="float: left; text-align: left; height: 20em; width: 17em; padding:1em;"> '''The investigation:'''<br>
{{familytree | |`| | | | | | | | | | | | | | | | | | }}
----
❑  24h [[esophageal]] [[pH]] monitoring<br> ❑ [[Endoscopic]], [[videofluoroscopic]] [[swallow]] evaluation  <br> ❑  [[Barium esophagram]] <br> ❑ [[Sinus Imaging]]  <br> ❑ [[HRCT]] <br>❑[[Bronchoscopy]]<br>❑ [[ECG]],[[ Holter]] Monitoring, [[Echocardiography]] <br>❑[[Environmental]] / [[Occupational]] Assessment<br></div>}}
{{familytree | | | | | | | | | | | | | | | | | | | }}
{{familytree/end}}
{{familytree/end}}
{{familytree/end}}
Consider the following further investigations if no response to treatment*:
 
* 24h esophageal pH / Impedance monitoring
<span style="font-size:85%">'''Abbreviations:'''
* Endoscopic and/or videofluoroscopic swallow evaluation
'''[[CXR]]:''' [[Chest-X-ray]];
* Barium esophagram / Modified barium swallow
'''[[ACEI]]:''' [[Angiotensin converting enzyme inhibitor]];
* Sinus Imaging• HRCT
'''[[GERD]]:''' [[Gastroesophageal reflux disease]];
* Bronchoscopy• Cardiac Work-up (ECG, Holter Monitoring, Echo)
'''[[HRCT]] scan:'''[[High-resolution computed tomography]].
* Environmental / Occupational Assessment
 
* Consider uncommon causes
</span>
<br>


==Treatment==
==Treatment==
Shown below is an algorithm summarizing the treatment of [[Cough]] according to the [[American College of Chest Physicians]] guidelines.
Shown below is an algorithm summarizing the treatment of [[Cough]].<ref name="BoujaoudePratter2009">{{cite journal|last1=Boujaoude|first1=Ziad C.|last2=Pratter|first2=Melvin R.|title=Clinical Approach to Acute Cough|journal=Lung|volume=188|issue=S1|year=2009|pages=41–46|issn=0341-2040|doi=10.1007/s00408-009-9170-6}}</ref><ref name="YildizDulger2018">{{cite journal|last1=Yildiz|first1=Tekin|last2=Dulger|first2=Seyhan|title=Non-astmatic Eosinophilic Bronchitis|journal=Turkish Thoracic Journal|volume=19|issue=1|year=2018|pages=41–45|issn=21492530|doi=10.5152/TurkThoracJ.2017.17017}}</ref><ref name="pmid31478634">{{cite journal |vauthors=DeGeorge KC, Ring DJ, Dalrymple SN |title=Treatment of the Common Cold |journal=Am Fam Physician |volume=100 |issue=5 |pages=281–289 |date=September 2019 |pmid=31478634 |doi= |url=}}</ref><ref name="pmid26394802">{{cite journal |vauthors=Scanlon KM, Skerry C, Carbonetti NH |title=Novel therapies for the treatment of pertussis disease |journal=Pathog Dis |volume=73 |issue=8 |pages=ftv074 |date=November 2015 |pmid=26394802 |pmc=4626598 |doi=10.1093/femspd/ftv074 |url=}}</ref><ref name="pmid30201828">{{cite journal |vauthors=Speich B, Thomer A, Aghlmandi S, Ewald H, Zeller A, Hemkens LG |title=Treatments for subacute cough in primary care: systematic review and meta-analyses of randomised clinical trials |journal=Br J Gen Pract |volume=68 |issue=675 |pages=e694–e702 |date=October 2018 |pmid=30201828 |pmc=6145999 |doi=10.3399/bjgp18X698885 |url=}}</ref><ref name="Morice2004">{{cite journal|last1=Morice|first1=A.H.|title=The diagnosis and management of chronic cough|journal=European Respiratory Journal|volume=24|issue=3|year=2004|pages=481–492|issn=0903-1936|doi=10.1183/09031936.04.00027804}}</ref>
 
 
 


{{familytree/start |summary=Sample 12}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=Sample 12}}{{familytree/start |summary=PE diagnosis Algorithm.}}
Line 207: Line 199:
{{Family tree | | | | A01 | | | |A01= [[File:Cough image.jpg|300px]]}}
{{Family tree | | | | A01 | | | |A01= [[File:Cough image.jpg|300px]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= '''Acute Cough'''}}
{{Family tree | | | | B01 | | | |B01= '''Acute [[Cough]]'''}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= determine if the cause of the [[cough]] is one of the life-threatening conditions below and treat accordingly <br> ❑[[Pneumonia]] <br> ❑severe exacerbation of [[asthma]] or [[COPD]]<br> ❑ [[PE]] <br> ❑[[heart failure]]<br> ❑ other serious condittons
{{Family tree | C01 | | | | C02 |C01= ❑''Determine if the cause of the [[cough]] is one of the [[life-threatening]] [[conditions]]'': <br> ❑[[Pneumonia]] <br> ❑Severe exacerbation of [[asthma]] or [[COPD]]<br> ❑ [[Pulmonary embolism]] <br> ❑[[Heart failure]]<br> ❑ Other serious condittons
| C02= Cough due to the common cold: a first-generation antihistamine plus a decongestant<br> ❑ [[naproxen]] (Naprosyn) favorably affects cough <br> ❑ Newer-generation nonsedating [[antihistamines]] are not effective  <br> </div>}}
| C02= ❑''[[Cough]] due to the [[common cold]]'':<br>❑ First-generation [[antihistamine]] plus a [[decongestant]]<br> ❑[[Ipratropium]] <br> ❑ Newer-generation [[nonsedating]] [[antihistamines]] are not effective  <br> </div>}}
{{familytree/end}}
{{familytree/end}}
<br>
<br>
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{{Family tree | | | | A01 | | | |A01= [[File:Pertussis.jpg|300px]]}}
{{Family tree | | | | A01 | | | |A01= [[File:Pertussis.jpg|300px]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= '''Subacute Cough'''}}
{{Family tree | | | | B01 | | | |B01= '''Subacute [[Cough]]'''}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= confirmed whooping cough by culture positive nasopharyngeal swab:<br>[[macrolide]] [[antibiotics]] plus [[isolation]] for 5 days beginning first day of treatment| C02= Cough not caused by Bordetella pertussis:<br>[[inhaled ipratropium]] ([[Atrovent]])<br> ❑if [[cough]] persists: inhaled corticosteroids<br> ❑severe cough:30 to 40 mg of [[prednisone]] per day for a brief period)<br> ❑When other treatments fail: [[codeine]] or [[dextromethorphan]] ([[Delsym]]) }}
{{Family tree | C01 | | | | C02 |C01= confirmed [[whooping]] [[cough]] by [[culture]] positive [[nasopharyngeal]] swab:<br>[[macrolide]] [[antibiotics]] plus [[isolation]] for 5 days| C02= [[Cough]] not caused by [[bordetella pertussis]]:<br>❑ [[Inhaled]] [[ipratropium]] ([[Atrovent]])<br> ❑ If [[cough]] persists: inhaled [[corticosteroids]]<br> ❑ Severe [[cough]]:30 to 40 mg of [[prednisone]] per day for a brief period)<br> ❑ When other [[treatments]] fail: [[codeine]] or [[dextromethorphan]] ([[Delsym]])<br> }}
{{familytree/end}}
{{familytree/end}}
<br>
<br>
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{{Family tree | | | | | | | | | | | | | | | A01 | | | |A01= [[File:COPD.jpg|300px]]}}
{{Family tree | | | | | | | | | | | | | | | A01 | | | |A01= [[File:COPD.jpg|300px]]}}
{{Family tree | | | | | | | | | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | | | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | |B01= '''Chronic Cough'''}}
{{Family tree | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | |B01= '''Chronic [[Cough]]'''}}
{{Family tree | | | | | | |,|-|-|-|-|-|v|-|-|^|-|-|-|v|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | }}
{{Family tree | | | | | | |,|-|-|-|-|-|v|-|-|^|-|-|-|v|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | }}
{{Family tree | | | | | | C01 | | | | C02 | | | | | C03 | | | C04 | | | | | |C01=1-'''UPPER AIRWAY COUGH SYNDROME–INDUCED CHRONIC COUGH'''<br>first-generation antihistamine/decongestant<br> ❑Partial or complete resolution of cough after one to two weeks shows '''upper airway cough syndrome''' as the cause<br> ❑persistent symptoms: begin a topical nasal steroid<br> ❑symptoms still persist: sinus imaging for sinusitis| C02= 2-'''ASTHMA-INDUCED CHRONIC COUGH'''<br> inhaled corticosteroids and beta agonists<br> ❑No response or cannot take inhaled medication: Oral consideration corticosteroids for five to 10 days*<br> ❑Consider adding a leukotriene inhibitor before an oral corticosteroid|C03= 3-'''NONASTHMATIC EOSINOPHILIC BRONCHITIS-INDUCED CHRONIC COUGH'''<br>inhaled corticosteroids for 4 weeks|C04= 4-'''GERD-INDUCED CHRONIC COUGH'''<br> Any patient who responds only partially or not at all to the therapies discussed in 1-3 should be empirically treated for GERD.<br> ❑antireflux diet and other lifestyle modification and a proton pump inhibitor<br> ❑No response to therapy: Consider prokinetic therapy}}
{{Family tree | | | | | | C01 | | | | C02 | | | | | C03 | | | C04 | | | | | |C01='''[[UPPER AIRWAY]] [[COUGH]] SYNDROME–INDUCED CHRONIC [[ COUGH]]'''<br>❑[[First-generation]] [[antihistamine]]/[[decongestant]]<br> ❑Partial or complete resolution of [[cough]] after one to two weeks shows '''[[upper airway]] [[cough]] syndrome''' as the cause<br> ❑ Persistent symptoms: begin a topical [[nasal steroid]]<br> ❑ [[Symptoms]] still persist: [[sinus]] imaging for [[sinusitis]]| C02= '''[[ASTHMA]]-INDUCED CHRONIC [[COUGH]]'''<br>❑ Inhaled [[corticosteroids]] and [[beta agonists]]<br> ❑ No response or cannot take [[inhaled]] [[ medication]]:consider oral [[corticosteroids]] for 5-10 days<br> ❑ Consider adding a [[leukotriene inhibitor]] before an oral [[corticosteroid]]|C03= '''NON-[[ASTHMATIC]] [[EOSINOPHILIC]] [[BRONCHITIS]]-INDUCED CHRONIC [[COUGH]]'''<br>❑ Inhaled [[corticosteroids]] for 4 weeks|C04= '''[[GERD]]-INDUCED CHRONIC [[COUGH]]'''<br>❑  Empirically treated for [[GERD]] if there is not response to [[therapy]]<br> ❑ Anti-[[reflux]] [[diet]], [[lifestyle modification]], [[proton pump inhibitor]]<br> ❑ Adding [[prokinetic]] [[therapy]] if there is NO response to [[treatment]]}}
{{familytree/end}}
{{familytree/end}}
<br>
<br>
<br>
<br>
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==
==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 first determine if the cause of the [[cough]] is one of the life-threatening [[conditions]] especially during management of acute [[cough ]] such as [[pulmonary embolism]] or [[obstructive airway disease]].
* Always ask about environmental and occupational factors and travel exposures in the management of acute cough
* Always evaluate [[environmental]] factors such as [[air pollution]] and occupational exposure for management of chronic [[cough]].<ref name="JoSong2019">{{cite journal|last1=Jo|first1=Eun-Jung|last2=Song|first2=Woo-Jung|title=Environmental triggers for chronic cough|journal=Asia Pacific Allergy|volume=9|issue=2|year=2019|issn=2233-8276|doi=10.5415/apallergy.2019.9.e16}}</ref>
* Routinely assess cough quality of life or cough severity with a validated tool
*[[Leukotriene inhibitor]] is prefered  to treat [[asthma]] induced chronic [[cough]] before  begining of oral [[corticosteroid]] agents for prevention of the side effects of [[cotricosteroid]].
* Routinely follow up with the patient with subacute cough in 4-6 weeks
* Three common causes of chronic [[cough]]  include  [[upper aiway]] [[cough]] syndrome, [[asthma]], and [[gastroesophageal reflux disease]].<ref name="pmid22010767">{{cite journal |vauthors=Benich JJ, Carek PJ |title=Evaluation of the patient with chronic cough |journal=Am Fam Physician |volume=84 |issue=8 |pages=887–92 |date=October 2011 |pmid=22010767 |doi= |url=}}</ref><ref name="pmid8624180">{{cite journal |vauthors=Mello CJ, Irwin RS, Curley FJ |title=Predictive values of the character, timing, and complications of chronic cough in diagnosing its cause |journal=Arch Intern Med |volume=156 |issue=9 |pages=997–1003 |date=May 1996 |pmid=8624180 |doi= |url=}}</ref>
* [[naproxen]] (Naprosyn) favorably affects the acute cough due to [[common cold]].
*Notify [[GERD]] in [[pediatric]] presented with [[cough]], [[vomiting]], poor [[weight gain]], [[dysphagia]], [[abdominal]] or [[substernal]] [[pain]].<ref name="RudolphMazur2001">{{cite journal|last1=Rudolph|first1=Colin D.|last2=Mazur|first2=Lynnette J.|last3=Liptak|first3=Gregory S.|last4=Baker|first4=Robert D.|last5=Boyle|first5=John T.|last6=Colletti|first6=Richard B.|last7=Gerson|first7=William T.|last8=Werlin|first8=Steven L.|title=Guidelines for Evaluation and Treatment of Gastroesophageal Reflux in Infants and Children|journal=Journal of Pediatric Gastroenterology and Nutrition|volume=32|year=2001|pages=S1–S31|issn=0277-2116|doi=10.1097/00005176-200100002-00001}}</ref>
* 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.
*The mechanism of [[cough]] in [[upper airway]] [[cough]] syndrome may include [[postnatal drip]], [[ direct irritation]], or [[inflammation]] of the [[cough]] receptors in the [[upper airway]].<ref name="Pratter2006">{{cite journal|last1=Pratter|first1=Melvin R.|title=Chronic Upper Airway Cough Syndrome Secondary to Rhinosinus Diseases (Previously Referred to as Postnasal Drip Syndrome )|journal=Chest|volume=129|issue=1|year=2006|pages=63S–71S|issn=00123692|doi=10.1378/chest.129.1_suppl.63S}}</ref>
* [[GERD]] should be considered as a cause of [[chronic cough]] if treatments for the other causes of chronic cough fail.
* In [[patients]] with [[tuberclusis]] or [[covid-19]], [[cough]] can promote the [[aerosolization]] of [[infectious]] [[particle]].<ref name="TurnerBothamley2015">{{cite journal|last1=Turner|first1=Richard D.|last2=Bothamley|first2=Graham H.|title=Cough and the Transmission of Tuberculosis|journal=The Journal of Infectious Diseases|volume=211|issue=9|year=2015|pages=1367–1372|issn=0022-1899|doi=10.1093/infdis/jiu625}}</ref><ref name="MacIntyreBourouiba2020">{{cite journal|last1=MacIntyre|first1=C Raina|last2=Bourouiba|first2=Lydia|last3=Chughtai|first3=Abrar Ahmad|last4=de Silva|first4=Charitha|last5=Doolan|first5=Con|last6=Bahl|first6=Prateek|title=Airborne or Droplet Precautions for Health Workers Treating Coronavirus Disease 2019?|journal=The Journal of Infectious Diseases|year=2020|issn=0022-1899|doi=10.1093/infdis/jiaa189}}</ref>


==Don'ts==
==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 continue [[ACE inhibitors]] if [[cough]] is associated with the begining of [[ACEI]].<ref name="McEwanChoudry1989">{{cite journal|last1=McEwan|first1=J. R.|last2=Choudry|first2=N.|last3=Street|first3=R.|last4=Fuller|first4=R. W.|title=Change in cough reflex after treatment with enalapril and ramipril.|journal=BMJ|volume=299|issue=6690|year=1989|pages=13–16|issn=0959-8138|doi=10.1136/bmj.299.6690.13}}</ref>
* Do not miss the following red flags during an assessment of cough:
 
**Hemoptysis
* Do not miss the following red flags during an assessment of [[cough]]:<ref name="pmid32026427">{{cite journal |vauthors=Kaplan AG |title=Chronic Cough in Adults: Make the Diagnosis and Make a Difference |journal=Pulm Ther |volume=5 |issue=1 |pages=11–21 |date=June 2019 |pmid=32026427 |pmc=6966942 |doi=10.1007/s41030-019-0089-7 |url=}}</ref>
**[[Smoker]] > 45 years of age with a
**[[Hemoptysis]]
**new [[cough]], change in cough, or
** Changing in [[ cough]] or initiating [[caugh]] in smoker > 45 years old
**coexisting voice disturbance
** Coexisting [[voice]] disturbance
**[[Hoarseness]]
** [[Hoarseness]]
**Systemic symptoms including [[Fever, Weight loss, and Peripheral edema with weight gain <br>
** [[Systemic]] [[symptoms]] including [[fever]], [[weight loss]], [[Peripheral edema]] with [[weight gain]]  
**[[Weight gain]]
** [[Vomiting]]
**[[Vomiting]]
** Recurrent [[pneumonia]]
**[[Recurrent pneumonia]]
** Abnormal [[ chest]] [[radiographic]] findings
**History Abnormal respiratory
** Adults aged 55-80 years with a history of a 30 [[pack-year]] [[smoking]], currently [[smoking]] or history of  quitting within the past 15 years
**Exam and/or abnormal chest
** [[Dyspnea]] at rest, [[orthopnea]]
**Radiograph coinciding with the duration of cough
** [[swallowing]] difficulty during [[eating]] or [[drinking]]
**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==
==References==

Latest revision as of 09:20, 19 March 2021

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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