Management of Chronic Cough Lasting More Than 1 Month
The management of chronic cough (>1 month) should follow a systematic, sequential approach targeting the most common causes: upper airway cough syndrome (UACS), asthma, gastroesophageal reflux disease (GERD), and non-asthmatic eosinophilic bronchitis (NAEB). 1, 2
Initial Evaluation
Essential First Steps
- Chest radiography to rule out structural abnormalities 2
- Medication review to identify potential causes (particularly ACE inhibitors) 2
- Smoking assessment with strong recommendation for cessation if applicable 1
- Environmental/occupational exposure evaluation 2
Red Flag Symptoms Requiring Urgent Attention
- Hemoptysis
- Significant dyspnea
- Prolonged fever
- Weight loss
- Recent hospitalization 2
Systematic Treatment Algorithm
Step 1: UACS (Post-nasal Drip)
- First-line treatment: First-generation antihistamine/decongestant combination for 2-4 weeks 1, 2
- Example: Brompheniramine with sustained-release pseudoephedrine
- For persistent nasal symptoms: Add topical nasal steroid or nasal anticholinergic
- If symptoms persist: Consider sinus imaging to evaluate for sinusitis 1
Step 2: Asthma/Bronchial Hyperresponsiveness
- Perform spirometry with bronchodilator response testing
- Consider methacholine challenge test even with normal spirometry 2
- Treatment: Inhaled corticosteroids and bronchodilators for 4 weeks 2
- Consider measuring sputum eosinophils or FeNO to assess eosinophilic inflammation 2
Step 3: GERD
- Treatment: Proton pump inhibitor with lifestyle modifications for 4-8 weeks 2
- Lifestyle modifications: Elevate head of bed, avoid eating before bedtime, weight loss if applicable
Step 4: Non-asthmatic Eosinophilic Bronchitis
- Consider inhaled corticosteroids for 2-4 weeks 2
- Particularly if normal spirometry but elevated FeNO
Important Management Principles
Multiple Causes
- Up to 25% of chronic cough patients have multiple contributing causes 2
- Maintain all partially effective treatments while adding new therapies 1
- Reassess response after each treatment trial before proceeding to next step 2
For Refractory Cough
- Consider neuromodulators (gabapentin, pregabalin, amitriptyline) 2, 3
- Speech pathology therapy for cough suppression techniques 2
- Low-dose morphine may be considered for idiopathic chronic cough 2, 3
Additional Considerations
- For post-infectious cough: Ipratropium to reduce bronchial hyperresponsiveness 2
- For persistent unexplained cough: Consider high-resolution CT chest to evaluate for bronchiectasis or interstitial lung disease 2
- Bronchoscopy may be warranted if CT is abnormal or cough remains unexplained 2
Symptomatic Relief
- Ensure adequate hydration for effective mucus clearance 2
- Honey and lemon mixture, acetaminophen or ibuprofen for symptom relief 2
- Menthol lozenges or vapor may provide temporary relief 2
Cautions
- Avoid overreliance on opioid antitussives due to risk of dependence 2
- Be aware that chronic cough significantly impacts quality of life and requires thorough evaluation 3
- Remember that in most cases, an accurate diagnosis and therapeutic success can be achieved with a systematic approach 1
By following this algorithmic approach and addressing the most common causes of chronic cough in sequence, most patients will experience significant improvement or resolution of their symptoms.