What are the recommendations for managing a chronic cough?

From the Guidelines

Chronic cough management should prioritize identifying and treating the underlying cause, with a focus on common causes such as upper airway secretions, asthma, and gastroesophageal reflux disease (GERD), as recommended by the most recent guidelines 1. When managing a chronic cough, it is essential to first consult a healthcare provider for proper diagnosis, as chronic cough (lasting more than 8 weeks) can stem from various conditions like postnasal drip, asthma, GERD, or medication side effects.

Key Recommendations

• For symptomatic relief, over-the-counter options include dextromethorphan (15-30mg every 6-8 hours) for suppressing cough or guaifenesin (200-400mg every 4 hours) to thin mucus, as suggested by previous studies 1.
• Lifestyle modifications are crucial: staying hydrated with 8-10 glasses of water daily, using a humidifier to moisten air, avoiding irritants like smoke and strong fragrances, and elevating the head while sleeping.
• For specific conditions, treatments may include antihistamines or nasal steroids for allergies, proton pump inhibitors for GERD, or inhalers for asthma, as outlined in guidelines for managing chronic cough due to GERD 1.
• In cases of unexplained chronic cough, a therapeutic trial of multimodality speech pathology therapy or gabapentin may be considered, as suggested by recent guidelines 1.

Diagnostic Approach

• The diagnostic approach should focus on detecting and treating upper airway secretions, asthma, and GERD, alone or in combination, as these are the most common causes of chronic cough 1.
• In patients with chronic cough, objective testing for bronchial hyperresponsiveness and eosinophilic bronchitis, or a therapeutic corticosteroid trial, may be necessary to determine the underlying cause 1.

Treatment

• Treatment should be given in sequential and additive steps, as more than one cause of cough may be present, as recommended by guidelines for managing chronic cough 1.
• In patients with chronic cough due to GERD, an empiric trial of medical antireflux therapy, including dietary and lifestyle modifications, acid suppression therapy, and prokinetic therapy, may be effective 1.
• For patients with unexplained chronic cough, referral to a cough specialist may be indicated if the cough persists after all other treatments have been tried 1.

From the Research

Chronic Cough Recommendations

The management of chronic cough involves a stepwise evaluation to minimize invasiveness and expense of the work-up 2. The following are key recommendations:

• Initial screening should search for smoking, occupational exposure to an airway irritant, cough-inducing medications, airway hyperresponsiveness following upper respiratory infection, chronic bronchitis, or any systemic symptoms suspicious for serious disease 2.
• Patients who are not diagnosed after an initial screening are evaluated or empirically treated in a stepwise fashion for postnasal drip, asthma, and reflux 2.
• The most common causes of chronic cough in adults are upper airway cough syndrome, gastroesophageal reflux disease/laryngopharyngeal reflux disease, asthma, and nonasthmatic eosinophilic bronchitis 3.
• Evaluation should focus initially on these etiologies, with targeted treatment and monitoring for resolution 3.
• Chest radiography can rule out concerning infectious, inflammatory, and malignant thoracic conditions 3, 4.
• Patients with refractory chronic cough may warrant referral to a pulmonologist or otolaryngologist in addition to a trial of gabapentin, pregabalin, and/or speech therapy 3.

Diagnostic Approach

A thorough initial patient assessment with adherence to diagnostic guidelines is critical to accurately identify the cause of chronic cough 5. The diagnostic approach should include:

• A focused history and physical examination 4.
• Chest radiography in most patients 4.
• Pulmonary function tests, such as spirometry, if indicated 6, 4.
• Further testing, such as high-resolution computed tomography, may be indicated if the cause of chronic cough is not identified 4.

Treatment

Treatment of chronic cough should be targeted at the underlying cause 6, 3. The following are key treatment recommendations:

• Empiric treatment for gastroesophageal reflux disease should be initiated in lieu of testing for patients with chronic cough and reflux symptoms 4.
• A trial of a decongestant and a first-generation antihistamine is warranted if upper airway cough syndrome is suspected 4.
• The diagnosis of asthma should be confirmed based on clinical response to empiric therapy with inhaled bronchodilators or corticosteroids 4.
• Patients should avoid exposure to cough-evoking irritants, such as cigarette smoke 4.