Chronic Cough – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

  • Chronic cough persists >8 weeks in adults.
  • Subacute cough describes cough lasting 3–8 weeks.
  • In children, chronic cough is defined as cough for >4 weeks in duration.
  • Patients present because of fear of the causative illness (e.g., cancer), as well as annoyance, self-consciousness, and hoarseness.
  • Patients with stress urinary incontinence may find cough particularly troubling.
  • At the primary care level, COPD and smoking-related cough are most common causes.
  • System(s) affected: Gastrointestinal; Pulmonary

Epidemiology

  • Predominant age: All age groups
  • Predominant sex: Male = Female

Incidence

Recurrent cough has been reported at 3–40% by various population estimates.

Prevalence

Chronic cough is one of the most common reasons for primary care visits.

Risk Factors

Although various conditions may contribute to chronic cough, the main causes include smoking and pulmonary diseases.

Pathophysiology

Varies with findings and disorders implicated

Etiology

  • Often multiple etiologies, but most are related to bronchial irritation. Most frequent etiologies (account for >90% of cases) in nonsmokers include:
    • Upper airway cough syndrome (UACS) (postnasal drip syndrome)
    • Asthma
    • Nonasthmatic eosinophilic bronchitis (NAEB)
    • GERD
  • Other causes:
    • Chronic smoking or exposure to smoke or pollutants
    • Aspiration
    • Bronchiectasis
    • ACE inhibitor therapy
    • Pertussis
    • Tuberculosis
    • Cystic fibrosis
    • Chronic interstitial lung disease
    • Restrictive lung disease
    • Neoplasms: lung or laryngeal cancer, other
    • Psychogenic (habit cough)

Commonly Associated Conditions

Patients with UACS, asthma, and GERD may present with chronic cough as the only symptom and not the usual symptoms associated with the diagnoses.

Gastroesophageal reflux disease, Post-viral cough, Cough, stress urinary incontinence, chronic cough, eosinophilic bronchitis, pulmonary diseases, cystic fibrosis,

Diagnosis

History

  • The age of the patient, presence of associated signs/symptoms, medical history, medication history (ACE inhibitor), environmental 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.
  • Various ambulatory systems for recording cough are under development.

Physical Exam

  • 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
  • Absence of additional signs/symptoms of a particular condition not necessarily helpful (75% of GERD patients have no other signs or symptoms)

Diagnostic Tests & Interpretation

Extensive testing only if indicated by the history and physical. Simple testing (CXR, sinus CT) is followed by empiric therapy directed at likely underlying etiology.

Pediatric Considerations

Children with chronic cough should undergo, at a minimum, spirometry and chest radiograph (if age-appropriate).

Lab

Initial lab tests

As indicated by history and physical

Follow-Up & Special Considerations

If clinically indicated:

  • Sweat chloride testing
  • Sputum for eosinophils and cytology

Imaging

Initial approach

If clinically indicated: CXR

Follow-Up & Special Considerations

If clinically indicated:

  • Chest CT
  • Endoscopy

Diagnostic Procedures/Surgery

If diagnosis suspected and inadequate response to initial measures, procedures can be considered:

  • Pulmonary function testing
  • Purified protein derivative (PPD) skin testing
  • 24-hour esophageal pH monitor
  • Bronchoscopy if necessary
  • Endoscopic or video fluoroscopic swallow evaluation or barium esophagram
  • Sinus CT
  • Ambulatory cough monitoring and cough challenge with citric acid or capsaicin (at specialized cough clinic)
  • Echocardiogram

Pathological Findings

Specific to underlying cause

Treatment

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  • With chronic cough, empiric treatment should be directed at the most common causes (UACS, asthma, GERD, NAEB) (1)[C].
  • Oral antihistamine/decongestant therapy with a 1st-generation antihistamine should be initial empiric treatment (1)[C].
  • In patients with cough associated with the common cold, nonsedating antihistamines were not found to be effective in reducing cough (1)[C].
  • In stable patients with chronic bronchitis, therapy with ipratropium bromide may reduce chronic cough (2)[C].
  • Centrally-acting antitussive drugs (codeine, dextromethorphan) are recommended for short-term symptomatic relief of coughing in patients with chronic bronchitis (2)[C]:
    • These agents have limited efficacy in cough due to upper respiratory infections (2)[C].
  • For cough associated with lung cancer, the use of narcotic cough suppressants is recommended (2)[C].

Pediatric Considerations

  • In 2008, 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.
  • The American Academy of Pediatrics does not recommend central cough suppressants for treating any kind of cough (1)[B].
  • In children <14 years old, when pediatric recommendations are not available, adult recommendations should be used with caution (1)[C].
  • Some children with recurrent cough and no evidence of airway obstruction may benefit from an inhaled β-agonist (3)[C].

Medication

Treatments (antacids, bronchodilators, inhaled corticosteroids, proton pump inhibitors, antibiotics) should be directed at the specific cause of cough.

First Line

  • In adults, oral antihistamine/decongestant therapy should be empiric treatment. Multiple formulations are available OTC in combination with other ingredients. Advise patients to review labels carefully or consult pharmacist.
    • Chlorpheniramine 2 mg/phenylephrine 5 mg/Acetaminophen 325 mg (Tylenol Allergy Multi-Symptom) 2 caplets or gelcaps PO q12h (Maximum 12 caplets or gelcaps in 24 hours: Age >12 years.
  • Central cough suppressants for short-term symptomatic relief of nonproductive cough:
    • Dextromethorphan 10–20 mg PO q4h: Age >12 years. Use 5–10 mg PO q4h for age 6–12 years.
    • Narcotics: Codeine 15–30 mg PO q6h; hydrocodone (Vicodin) 5 mg PO q6h; hydrocodone (Tussionex Pennkinetic) 10 mg (5 mL) PO q12h for age 12 or over

Second Line

  • A peripherally acting antitussive agent has been used.
    • Benzonatate (Tessalon Perles) 100–200 mg PO three times daily as needed (Maximum 600 mg daily): Age >10
  • 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 (4)[C].
    • Morphine was administered 5–10 mg PO twice daily.
  • For patients with cystic fibrosis, amiloride may increase cough clearance.

Additional Treatment

General Measures

  • In patients with chronic cough, considerations for potential etiology should include asthma (1)[B] or UACS (1)[C].
  • With concomitant complaints of heartburn and regurgitation, GERD should be considered as a potential etiology (1)[C].
  • 90% of patients will have resolution of cough after smoking cessation (1)[A].
  • When indicated, ACE inhibitor therapy should be switched in patients in whom intolerable cough occurs (1)[A].
  • Empiric treatment of postnasal drip and GERD.
  • Consider nonpharmacological options such as warm fluids, hard candy, or nasal drops. In infants and children, can try clearing secretions with a bulb syringe.
  • Attempt maximal therapy for single most likely cause for several weeks, then search for coexistent etiologies.

Issues for Referral

Refer based on specific diagnosis for cough.

Surgery/Other Procedures

Fundoplication may be effective for cough secondary to refractory GERD.

Ongoing Care

Follow-Up Recommendations

Consider stepwise withdrawal of medications after resolution of cough.

Patient Monitoring

Frequent follow-up is necessary to assess the effectiveness of the treatment and the addition of other medications as needed.

Diet

Patients with GERD may benefit by avoiding ethanol, caffeine, nicotine, citrus, tomatoes, chocolate, and fatty foods.

Patient Education

  • Reassure patient that most cases do not have life-threatening causes and that the condition can usually be managed effectively.
  • Counsel that several weeks to a month may be needed for significant reduction or total elimination of cough.
  • Prepare the patient for the possibility of multiple diagnostic tests and therapeutic regimens, because the treatment is very often empiric.

Prognosis

  • >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.

Complications

  • 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

References

1. Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006;129:1S–23S.

2. Bolser DC. Cough suppressant and pharmacologic protussive therapy: ACCP evidence-based clinical practice guidelines. Chest.2006;129:238S–249S.

3. Gupta A, et al. Management of chronic non-specific cough in childhood: An evidence-based review. Arch Dis Child Educ Pract Ed. 2007;92:ep33–ep39.

4. Morice AH, Menon MS, Mulrennan SA et al. Opiate therapy in chronic cough. Am J Respir Crit Care Med. 2007;175:312–5.

Additional Reading

Pavord ID, Chung KF. Management of chronic cough. Lancet.2008;371:1375–84.

See Also (Topic, Algorithm, Electronic Media Element)

Asthma; Bronchiectasis; Congestive Heart Failure; Eosinophilic Pneumonias; Gastroesophageal Reflux Disease (GERD); Laryngeal Cancer; Lung, Primary Malignancies; Pertussis; Pulmonary Edema; Rhinitis, Allergic; Sinusitis; Tuberculosis

Algorithm: Cough, Chronic

Codes

ICD9

786.2 Cough

Snomed

68154008 Chronic cough (finding)

Clinical Pearls

  • Chronic cough is defined as a cough that persists for >8 weeks in adults.
  • In patients with chronic cough, most frequent etiologies include a history of smoking, asthma, UACS, and GERD.
  • In 2008, the FDA issued a public health advisory stating that OTC cough and cold medicines should not be given to children <2 years.
  • Consumer Healthcare Products Association (CHPA) members are voluntarily changing OTC product labels to state “do not use” in children <4 years old. New child-resistant packaging and measuring devices are being developed.

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