What is the appropriate management approach for a patient presenting with a cough?

Management Approach for Cough

The management of cough should follow a systematic, step-wise approach based on cough duration, with initial focus on identifying and treating the most common causes including upper airway cough syndrome, asthma, and gastroesophageal reflux disease. 1, 2

Initial Assessment

• Categorize cough by duration:

  • Acute: < 3 weeks
  • Subacute: 3-8 weeks
  • Chronic: > 8 weeks 1

• Key history elements:

  • ACE inhibitor use (stop medication if present)
  • Smoking status (counsel cessation)
  • "Red flags" requiring urgent evaluation:
    • Hemoptysis
    • Significant dyspnea
    • Fever
    • Weight loss
    • Abnormal respiratory findings
    • Suspicion of lung cancer
    • Possible foreign body inhalation 2

• Basic diagnostic testing:

  • Chest radiograph (essential)
  • Spirometry if chronic cough 1, 2

Management Algorithm by Cough Duration

1. Acute Cough (<3 weeks)

• First, rule out serious conditions:

  • Pneumonia
  • Pulmonary embolism 1

• For viral upper respiratory infections:

  • Symptomatic treatment:
    • Honey and lemon mixtures
    • Dextromethorphan for cough suppression
    • First-generation antihistamines for nocturnal cough 2
  • Guaifenesin may help loosen phlegm and thin bronchial secretions 3
  • Avoid antibiotics for viral infections 2

2. Subacute Cough (3-8 weeks)

• Determine if postinfectious:

  • If yes, evaluate for:
    • Upper airway cough syndrome (UACS)
    • Transient bronchial hyperresponsiveness
    • Asthma
    • Pertussis
    • Acute exacerbation of chronic bronchitis 1

• For postinfectious cough:

  • Consider short course of inhaled corticosteroids if quality of life affected
  • Inhaled ipratropium bromide as first-line therapy 2

• For suspected pertussis:

  • Macrolide antibiotics if confirmed/strongly suspected
  • Isolation for 5 days from treatment start 2

3. Chronic Cough (>8 weeks)

• Sequential empiric treatment approach:

  1. First step: Upper Airway Cough Syndrome (UACS)

     • First-generation antihistamine/decongestant for 2-4 weeks
     • Example: brompheniramine with sustained-release pseudoephedrine 1, 2

  2. If cough persists: Asthma

     • Ideally perform bronchoprovocation challenge (BPC)
     • If unavailable or positive, treat with:
       • Inhaled corticosteroids
       • Inhaled β-agonists
       • Consider oral leukotriene inhibitors 1, 2

  3. If cough persists: Non-asthmatic Eosinophilic Bronchitis (NAEB)

     • Perform induced sputum test for eosinophils if available
     • If unavailable, empiric trial of corticosteroids 1

  4. If cough persists: Gastroesophageal Reflux Disease (GERD)

     • Proton pump inhibitor with lifestyle modifications for 4-8 weeks 2

• For refractory chronic cough:

  • Consider neuromodulators (gabapentin)
  • Speech pathology therapy for cough suppression techniques
  • Low-dose morphine in selected cases 2, 4

Special Considerations

• Medication-induced cough:

  • Stop ACE inhibitors and replace with alternative agent 1, 2
  • Allow 4 weeks to determine if cough resolves 2

• Smoking-related cough:

  • Strong smoking cessation counseling and assistance 1

• Uncommon causes:

  • Consider if cough persists after standard evaluation
  • Perform chest CT scan and possibly bronchoscopy 1

Follow-up and Referral

• Re-evaluate if cough persists beyond expected timeframe (4-6 weeks)
• Consider specialist referral for:
  • Cough persisting despite appropriate treatment
  • Suspected serious underlying pathology
  • Significant impact on quality of life 2

Common Pitfalls to Avoid

• Premature diagnosis closure
• Unnecessary antibiotic use for viral infections
• Overlooking medication causes (especially ACE inhibitors)
• Delayed diagnosis of serious conditions
• Inadequate follow-up 2
• Using codeine-containing medications (potential for serious side effects) 2

By following this systematic approach to cough management, clinicians can effectively diagnose and treat most cases while ensuring serious conditions are not missed.