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 defense mechanism for preventation of irritation and aspiration by clearing 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 increases mortality based o underlying disorder. Assessment of life threatening causes of cough such as obstructive airway disease or pulmonary embolism is of important.

Causes

Common Causes

[1]

Diagnosis

Acute cough is considered cough that lasts less than three weeks. Shown below is an algorithm summarizing the evaluation of acute cough.[3][4][5]


 
 
 
 
 
 
 
 
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,

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
 
 
 
 
 
 
 
 
 
 
{{{ }}}
 
 
 
 
Postinfectious
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tuberculosis
 
 
 
 
 
 
 
Non-asthmatic eosinophilic bronchitis
 
 
 
Acute exacerbation of chronic bronchitis/COPD
 
 
 
 
 

Abbreviations: TB: Tuberculosis; NAEB: Nonasthmatic eosinophilic bronchitis;; AECB: Acute exacerbation of chronic bronchitis; COPD Chronic obstructive pulmonary disease; GERDgastroesophageal reflux disease; UACSUpper airway cough syndrome.


  • Not postinfectious: Work up same as chronic cough


 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  • Consider the following further investigations if no response to treatment:

Treatment

Shown below is an algorithm summarizing the treatment of Cough.[4]


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
Naproxen (Naprosyn) favorably affects cough
❑ 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
 
 
 
 
 



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

Don'ts

References

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  2. Qiu, Zhongmin; Xu, Xianghuai; Yu, Li; Chen, Qiang; Lv, Hanjing (2015). "Diagnosis and treatment of patients with nonacid gastroesophageal reflux-induced chronic cough". Journal of Research in Medical Sciences. 20 (9): 885. doi:10.4103/1735-1995.170625. ISSN 1735-1995.
  3. 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.
  4. 4.0 4.1 Boujaoude, Ziad C.; Pratter, Melvin R. (2009). "Clinical Approach to Acute Cough". Lung. 188 (S1): 41–46. doi:10.1007/s00408-009-9170-6. ISSN 0341-2040.
  5. Kilgore PE, Salim AM, Zervos MJ, Schmitt HJ (July 2016). "Pertussis: Microbiology, Disease, Treatment, and Prevention". Clin Microbiol Rev. 29 (3): 449–86. doi:10.1128/CMR.00083-15. PMC 4861987. PMID 27029594.
  6. Jo, Eun-Jung; Song, Woo-Jung (2019). "Environmental triggers for chronic cough". Asia Pacific Allergy. 9 (2). doi:10.5415/apallergy.2019.9.e16. ISSN 2233-8276.
  7. Benich JJ, Carek PJ (October 2011). "Evaluation of the patient with chronic cough". Am Fam Physician. 84 (8): 887–92. PMID 22010767.
  8. Mello CJ, Irwin RS, Curley FJ (May 1996). "Predictive values of the character, timing, and complications of chronic cough in diagnosing its cause". Arch Intern Med. 156 (9): 997–1003. PMID 8624180.
  9. Rudolph, Colin D.; Mazur, Lynnette J.; Liptak, Gregory S.; Baker, Robert D.; Boyle, John T.; Colletti, Richard B.; Gerson, William T.; Werlin, Steven L. (2001). "Guidelines for Evaluation and Treatment of Gastroesophageal Reflux in Infants and Children". Journal of Pediatric Gastroenterology and Nutrition. 32: S1–S31. doi:10.1097/00005176-200100002-00001. ISSN 0277-2116.
  10. Pratter, Melvin R. (2006). "Chronic Upper Airway Cough Syndrome Secondary to Rhinosinus Diseases (Previously Referred to as Postnasal Drip Syndrome )". Chest. 129 (1): 63S–71S. doi:10.1378/chest.129.1_suppl.63S. ISSN 0012-3692.
  11. Turner, Richard D.; Bothamley, Graham H. (2015). "Cough and the Transmission of Tuberculosis". The Journal of Infectious Diseases. 211 (9): 1367–1372. doi:10.1093/infdis/jiu625. ISSN 0022-1899.
  12. MacIntyre, C Raina; Bourouiba, Lydia; Chughtai, Abrar Ahmad; de Silva, Charitha; Doolan, Con; Bahl, Prateek (2020). "Airborne or Droplet Precautions for Health Workers Treating Coronavirus Disease 2019?". The Journal of Infectious Diseases. doi:10.1093/infdis/jiaa189. ISSN 0022-1899.
  13. McEwan, J. R.; Choudry, N.; Street, R.; Fuller, R. W. (1989). "Change in cough reflex after treatment with enalapril and ramipril". BMJ. 299 (6690): 13–16. doi:10.1136/bmj.299.6690.13. ISSN 0959-8138.