What are the management options for chronic cough?

Management of Chronic Cough

The management of chronic cough should follow a systematic, algorithmic approach targeting the most common causes sequentially, with empiric treatment trials of defined duration for each suspected etiology. 1, 2

Definition and Initial Evaluation

• Adults: Chronic cough defined as cough lasting >8 weeks 3
• Children: Chronic cough defined as cough lasting >4 weeks 1

Initial Assessment Should Include:

• Detailed history for specific cough pointers
• Physical examination
• Chest radiograph
• Spirometry (pre- and post-β2 agonist) when age appropriate 1, 2

Common Causes of Chronic Cough

In Adults:

1. Upper Airway Cough Syndrome (UACS)
2. Asthma/bronchial hyperresponsiveness
3. Gastroesophageal Reflux Disease (GERD)
4. Nonasthmatic eosinophilic bronchitis (NAEB)
5. ACE inhibitor use 1, 2, 4

In Children:

1. Protracted bacterial bronchitis (PBB)
2. Asthma
3. Upper airway cough syndrome 1

Systematic Management Algorithm

Step 1: Rule Out Red Flags

• Hemoptysis
• Prominent dyspnea
• Persistent fever
• Weight loss
• Abnormal respiratory findings
• Recurrent pneumonia 2, 5

Step 2: Address Modifiable Factors

• Discontinue ACE inhibitors
• Smoking cessation
• Avoid environmental irritants 1, 2

Step 3: Sequential Empiric Treatment Trials

For Upper Airway Cough Syndrome:

• First-generation antihistamine/decongestant combination for 2-4 weeks (e.g., brompheniramine with sustained-release pseudoephedrine) 2

For Asthma/Bronchial Hyperresponsiveness:

• Inhaled corticosteroids and bronchodilators for 4 weeks 2
• Consider testing for airway hyperresponsiveness in children >6 years 1

For GERD:

• Proton pump inhibitor with lifestyle modifications for 4-8 weeks 2
• Important: Do not treat for GERD in children without GI symptoms 1

For Nonasthmatic Eosinophilic Bronchitis:

• Inhaled corticosteroids 1

For Post-infectious Cough:

• Inhaled ipratropium bromide as first-line therapy 2
• Antibiotics only if bacterial infection confirmed 2

Step 4: Additional Investigations for Refractory Cough

If cough persists despite appropriate empiric treatment:

• Consider bronchoscopy for occult airway disease 1
• Consider CT imaging if red flags present 5
• In children with wet/productive cough, investigate for underlying disease (e.g., bronchiectasis) 1

Step 5: Management of Refractory Chronic Cough

For cough that remains unexplained or unresponsive to treatment:

• Neuromodulators: gabapentin or pregabalin 2, 4, 5
• Speech pathology therapy for cough suppression techniques 2, 6
• Low-dose morphine in selected cases 4
• Consider referral to cough specialist 1

Special Considerations

For Children:

• Use pediatric-specific cough management protocols 1
• Base management on cough characteristics (wet vs. dry) 1
• Do not use empiric treatment for GERD, asthma, or UACS unless other features of these conditions are present 1
• Consider tic cough (formerly habit cough) in unexplained cases 1

For Pertussis:

• Macrolide antibiotics if suspected (within first few weeks) 2
• Isolation for 5 days from start of treatment 2

Pitfalls to Avoid

• Treating empirically without systematic approach
• Failing to recognize multiple causes contributing to chronic cough
• Continuing ineffective treatments beyond recommended trial periods
• Overlooking medication side effects (especially ACE inhibitors)
• Inappropriate use of antibiotics for non-bacterial causes
• Neglecting to follow up to confirm resolution or need for further investigation

By following this systematic approach, most cases of chronic cough can be effectively diagnosed and managed, improving quality of life and reducing unnecessary healthcare utilization.