How should I manage a chronic cough?

Management of Chronic Cough NYD (Not Yet Diagnosed)

A systematic approach using validated cough management protocols is essential for effectively diagnosing and treating chronic cough, with initial evaluation requiring chest radiography and spirometry when age-appropriate. 1

Initial Evaluation

Definition

• Chronic cough is defined as daily cough lasting ≥4 weeks in children or >8 weeks in adults 1, 2

Essential Initial Investigations

• Chest radiograph - mandatory for all patients with chronic cough 1, 3
• Spirometry (pre and post β2 agonist) - when age appropriate (usually reliable in children >6 years) 1

Clinical Assessment

• Assess for specific cough pointers:
  • Wet/productive vs. dry cough
  • Cough timing (nocturnal, exercise-induced)
  • Associated symptoms (hemoptysis, dyspnea, fever, weight loss)
  • Exposure history (tobacco smoke, occupational exposures)
  • Medication review (particularly ACE inhibitors)

Diagnostic Algorithm

Step 1: Identify Cough Characteristics

• Wet/productive cough:

  • Consider protracted bacterial bronchitis (PBB), bronchiectasis, or chronic infection
  • For PBB: 2-week course of antibiotics targeting common respiratory bacteria (S. pneumoniae, H. influenzae, M. catarrhalis) 1
  • If cough persists after 2 weeks of antibiotics, extend treatment for additional 2 weeks 1
  • If cough persists after 4 weeks of appropriate antibiotics, consider further investigations (bronchoscopy, chest CT) 1

• Dry/non-productive cough:

  • Evaluate for specific cough pointers
  • If no specific pointers (non-specific cough), consider "watch, wait, and review" approach 1

Step 2: Evaluate Common Causes

1. Upper Airway Cough Syndrome (UACS)

   • First-generation antihistamine/decongestant combination for 2-4 weeks 3

2. Asthma/Bronchial Hyperresponsiveness

   • Consider if episodic wheezing, nocturnal cough, or exercise-induced symptoms
   • For patients >6 years, consider airway hyperresponsiveness testing 1
   • Trial of inhaled corticosteroids and bronchodilators for 4 weeks 3

3. Gastroesophageal Reflux Disease (GERD)

   • Only treat when GI symptoms of reflux are present 1
   • Proton pump inhibitor with lifestyle modifications for 4-8 weeks 3
   • Do not use acid suppressive therapy solely for chronic cough 1

4. Post-infectious Cough

   • Consider inhaled ipratropium bromide as first-line therapy 3
   • Short course of inhaled corticosteroids if cough affects quality of life 3
   • Test for Bordetella pertussis if clinically suspected (paroxysmal cough, post-tussive vomiting) 1

5. Medication-induced Cough

   • Discontinue ACE inhibitors if suspected cause 3

Step 3: Management of Refractory Cough

• For cough persisting despite appropriate treatment:
  • Consider neuromodulators (gabapentin, pregabalin) 3, 4, 2
  • Speech pathology therapy for cough suppression techniques 3, 5
  • Consider referral to pulmonologist or otolaryngologist 6

Special Considerations

For Children

• Use pediatric-specific cough management protocols 1
• Consider diagnoses specific to children (foreign body aspiration, congenital anomalies) 1
• For children with wet cough, PBB is a common cause requiring antibiotic treatment 1

For Adults

• Consider additional causes like chronic bronchitis, COPD, and obstructive sleep apnea 6, 2
• Non-asthmatic eosinophilic bronchitis may require specific evaluation 2

Symptomatic Relief

• Guaifenesin may help loosen phlegm in productive cough 7
• Dextromethorphan for non-productive cough 3
• First-generation antihistamines for nocturnal cough 3

Follow-up

• Re-evaluate if cough persists beyond 4-6 weeks of appropriate treatment 3
• Assess cough severity before and after treatment using validated tools 3

Common Pitfalls to Avoid

• Premature diagnosis closure without considering multiple contributing factors 3
• Unnecessary antibiotic use for non-bacterial causes 3
• Missing serious underlying conditions (malignancy, tuberculosis) 2
• Empirical treatment without proper diagnostic evaluation 1
• Overlooking medication-induced causes 3

Remember that chronic cough often has multiple contributing factors requiring targeted therapy for each component. A systematic approach using validated algorithms significantly improves outcomes in patients with chronic cough.