What are the recommended management strategies for chronic cough?

From the Guidelines

Chronic cough management should prioritize identifying and treating the underlying cause, with a focus on common causes such as postnasal drip syndrome, asthma, or gastroesophageal reflux disease (GERD), and empiric treatment should be directed at these causes in a sequential and additive manner. The management of chronic cough involves a systematic approach to diagnose and treat the underlying cause, which can be achieved through a medical history, physical examination, and diagnostic tests 1.

Identifying the Underlying Cause

The first step in managing chronic cough is to identify the underlying cause, which can be achieved by:

• Determining whether the patient is receiving an ACE inhibitor, is a smoker, or has evidence of a serious life-threatening or systemic disease 1
• Evaluating the patient's medical history to determine whether the cough is a manifestation of a non-life-threatening disease such as a respiratory tract infection, an exacerbation of a preexisting condition, or an environmental or occupational exposure to some noxious or irritating agent 1

Empiric Treatment

Empiric treatment for chronic cough should be directed at the most common causes of cough, including:

• Postnasal drip syndrome, which can be treated with antihistamines and intranasal corticosteroids
• Asthma, which can be treated with inhaled corticosteroids and bronchodilators
• GERD, which can be treated with proton pump inhibitors and lifestyle modifications, such as weight loss, avoiding late meals, and elevating the head of the bed 1

Treatment Approach

The treatment approach for chronic cough should be sequential and additive, with the following steps:

• Initial empiric treatment with an oral first-generation antihistamine/decongestant (A/D) 1
• If the cough persists, treatment for asthma should be considered, with an empiric trial of antiasthma therapy or a broncho-provocation challenge (BPC) if spirometry does not indicate reversible airflow obstruction 1
• If the cough still persists, treatment for GERD should be considered, with an empiric trial of medical antireflux therapy, including dietary and lifestyle modifications, acid suppression therapy, and prokinetic therapy 1

Additional Considerations

Additional considerations in the management of chronic cough include:

• Counseling and assisting patients who smoke to quit smoking 1
• Stopping and replacing ACE inhibitors in patients who are receiving them 1
• Considering centrally acting neuromodulators, such as gabapentin or amitriptyline, for persistent cough despite targeted therapy 1
• Using speech therapy techniques and avoiding cough triggers to provide additional benefit.

From the FDA Drug Label

Stop use and ask doctor if cough persists for more than 7 days, tends to recur, or is accompanied by fever, rash, or persistent headache. These could be signs of a serious condition. The recommended management strategy for chronic cough is to stop use of the medication and consult a doctor if the cough:

• Persists for more than 7 days
• Tends to recur
• Is accompanied by fever, rash, or persistent headache 2

From the Research

Chronic Cough Management Strategies

Chronic cough management involves a stepwise approach to evaluate and treat the underlying causes. The following are the recommended management strategies:

• Initial assessment: A detailed history, physical examination, chest radiograph, spirometry, exhaled nitric oxide, blood eosinophil count, and measurement of cough severity and quality of life using validated instruments 3.
• Top diagnoses to consider: Asthma, chronic obstructive pulmonary disease, nonasthmatic eosinophilic bronchitis, gastroesophageal reflux disease, and upper airway cough syndrome 4, 3.
• Empiric treatment: Initiate treatment for the most likely respiratory and gastrointestinal diseases, and avoid high-risk factors such as smoking and angiotensin-converting enzyme inhibitors 4, 3.
• Refractory chronic cough: Consider referral to a pulmonologist or otolaryngologist, and trial of gabapentin, pregabalin, and/or speech therapy 4, 3.
• Additional treatment options: Low-dose morphine, non-narcotic purinergic 2×3 (P2×3) receptor antagonists, such as gafapixant and campilixant, are being studied for chronic cough 3.

Diagnostic Approach

The diagnostic approach for chronic cough involves:

• Initial screening: Search for smoking, occupational exposure to airway irritants, cough-inducing medications, airway hyperresponsiveness, and systemic symptoms suspicious for serious disease 5.
• Stepwise evaluation: Evaluate or empirically treat patients in a stepwise fashion for postnasal drip, asthma, and reflux 5.
• Bronchoscopy: Reserved for patients who remain undiagnosed after previous steps have been completed 5.

Treatment Modalities

Treatment modalities for chronic cough include:

• Causal treatment: Successful in the majority of patients, although it may need to be continued over several weeks 6.
• Polypragmatic therapeutic approach: Targeting the three most common causes simultaneously for 7-10 days 6.
• Symptomatic management: Current treatment for refractory cough is limited to symptomatic management 3.