What is the current guideline for managing chronic cough?

Current Guidelines for Managing Chronic Cough

The management of chronic cough should be based on a systematic, etiology-directed approach rather than empirical treatment of common causes without supporting evidence. 1

Definition and Classification

• Chronic cough is defined as daily cough lasting more than 4 weeks in children 1, 2
• In adults, chronic cough is defined as cough lasting longer than 8 weeks 3

Initial Evaluation

Required Initial Testing

• Chest radiograph for all patients with chronic cough 1, 2
• Spirometry (pre and post β2-agonist) when age appropriate 1, 2

Clinical Assessment

• Determine if cough is wet/productive or dry 1, 2
• Evaluate for specific cough pointers:
  • Chest pain
  • Digital clubbing
  • Failure to thrive
  • Hemoptysis
  • Hypoxia/cyanosis
  • Immunodeficiency
  • Feeding difficulties
  • Recurrent pneumonia
  • Abnormal voice/cry
  • Wheeze/stridor 2

Management Algorithm

Step 1: Identify and Address Exacerbating Factors

• Environmental tobacco smoke exposure 1
• Occupational irritants 4
• Cough-inducing medications (e.g., ACE inhibitors) 4, 5

Step 2: Evaluate and Treat Based on Specific Characteristics

For Wet/Productive Cough

1. Protracted Bacterial Bronchitis (PBB) Protocol:
   • Prescribe 2 weeks of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) 1, 2
   • If cough resolves within 2 weeks, diagnose as PBB 1
   • If cough persists after 2 weeks, extend antibiotics for additional 2 weeks 1, 2
   • If cough persists after 4 weeks of appropriate antibiotics, conduct further investigations (e.g., flexible bronchoscopy with quantitative cultures, chest CT) 1

For Dry Cough or Cough with Specific Features

1. Suspected Asthma:

   • For patients with clinical features of asthma, consider airway hyperresponsiveness testing 1
   • Time-limited trial of asthma therapy (2-4 weeks of inhaled corticosteroids at 400 μg/day beclomethasone equivalent) 2
   • Do not increase doses if unresponsive to initial treatment 2

2. Suspected Upper Airway Cough Syndrome (UACS):

   • Evaluate for post-nasal drip 4, 6
   • Trial of treatment based on specific findings

3. Suspected Gastroesophageal Reflux Disease (GERD):

   • Only treat for GERD when GI symptoms are present 1
   • Do not use acid suppressive therapy solely for chronic cough 1
   • Follow evidence-based GERD-specific guidelines for treatment 1
   • If treating, evaluate response after 4-8 weeks 1

4. Suspected Pertussis:

   • Consider testing for Bordetella pertussis when clinically suspected (post-tussive vomiting, paroxysmal cough, inspiratory whoop) 1

5. Tic Cough/Somatic Cough Disorder:

   • Consider when cough has remained medically unexplained after comprehensive evaluation 1
   • Look for core clinical features: suppressibility, distractibility, suggestibility, variability, and premonitory sensation 1
   • For somatic cough disorder, consider non-pharmacological approaches (hypnosis, suggestion therapy, counseling, psychological referral) 1

Step 3: Additional Investigations When Initial Management Fails

• Do not routinely perform additional tests (skin prick test, Mantoux, bronchoscopy, chest CT) unless clinically indicated 1
• Consider referral to specialist (pulmonologist) if cough persists despite appropriate management 2

Important Caveats

• Avoid empirical treatment for common adult causes (UACS, asthma, GERD) unless other features consistent with these conditions are present 1
• Do not assume adult causes apply to children, as etiologies differ significantly 1, 2
• Set time limits for therapeutic trials to confirm or refute hypothesized diagnoses 1
• Multiple causes may contribute to chronic cough in up to 25% of patients 4
• Missing serious underlying conditions (bronchiectasis, aspiration lung disease, cystic fibrosis) can occur in up to 18% of children with chronic cough 2

Follow-up and Monitoring

• Reassess in 2 weeks to evaluate response to treatment 2
• Review within 48-72 hours if symptoms worsen or new concerning symptoms develop 2
• Consider complications if patient remains febrile or unwell 48 hours after treatment 2