Cough resident survival guide

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

• Allergic Rhinitis
• Asthma
• Bronchiectasis
• Gastroesophageal Reflux Disease (GERD)
• Post-nasal drip
• Medications' side effect
  • ACE inhibitors
• Bronchitis
• Laryngopharyngeal reflux
• Respiratory tract infection
• Lung cancer
• Nonasthmatic eosinophilic bronchitis

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.

Acute Cough < 3 weeks

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 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.

Subacute Cough ,(3-8 weeks)

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

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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 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.

Chronic Cough> 8 weeks

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, Sitagliptin

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:

• 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, Echocardiography)
• 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.

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 ❑ Pulmonary embolism ❑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

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 inhaledmedication: 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

• 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