Treatment Options for Continuous Cough
The most effective management of continuous cough requires identifying and treating the underlying cause through a systematic approach combining diagnostic testing and targeted treatment trials based on the most probable aggravating factors.
Initial Assessment and Diagnostic Approach
- Chest radiograph and spirometry are mandatory initial tests for all patients with chronic cough 1
- Evaluate for common causes including asthma, gastroesophageal reflux disease (GORD), upper airway pathology, and medication side effects 1
- Assess for smoking history, as smoking is one of the commonest causes of persistent cough and appears to be dose-related 1
- Review current medications, particularly ACE inhibitors, which should be discontinued in all patients with troublesome cough 1
Treatment Based on Underlying Cause
Asthma and Eosinophilic Airway Inflammation
- Consider a two-week oral steroid trial to rule out eosinophilic airway inflammation 1
- For patients with normal spirometry but suspected asthma, bronchial provocation testing should be performed 1
- Note that a negative bronchial provocation test excludes asthma but does not rule out a steroid-responsive cough 1
Gastroesophageal Reflux Disease (GORD)
- Intensive acid suppression with proton pump inhibitors and alginates should be undertaken for a minimum of 3 months 1
- For patients with typical reflux symptoms, empirical treatment should be offered before oesophageal testing 1
- Consider antireflux therapy in carefully selected cases 1
- GORD-related cough may occur without gastrointestinal symptoms 1
Upper Airway Cough Syndrome/Rhinosinusitis
- In patients with prominent upper airway symptoms, a trial of topical corticosteroid is recommended 1
- Examination of ear, nose, and throat should be performed in preference to sinus imaging 1
Smoking-Related Cough
- Smoking cessation should be strongly encouraged as it is accompanied by significant remission in cough symptoms 1
Management of Acute Viral Cough
- Most short-term coughs are due to viral infections and don't require antibiotics, even if producing phlegm 1
- Home remedies such as honey and lemon may provide symptomatic relief 1
- Over-the-counter cough remedies containing dextromethorphan may be effective 1
- Menthol lozenges or vapor may also provide relief 1
Refractory Chronic Cough
- For patients with interstitial lung disease (ILD) and refractory chronic cough, consider therapies such as gabapentin and multimodality speech pathology therapy 1
- In palliative settings when alternative treatments have failed, opiates may be considered for symptom control with reassessment of benefits and risks at 1 week and monthly thereafter 1
Red Flags Requiring Urgent Medical Attention
- Coughing up blood 1
- Breathlessness 1
- Prolonged fever and feeling unwell 1
- Underlying medical conditions such as COPD, heart disease, diabetes, or asthma 1
- Recent hospitalization 1
- Symptoms persisting for more than three weeks 1
Special Considerations
- Cough suppression may be contraindicated when cough clearance is important, such as in pneumonia or bronchiectasis 1
- Bronchoscopy should be undertaken in patients with chronic cough where inhalation of a foreign body is suspected 1
- High-resolution computed tomography may be useful in patients with chronic cough when other targeted investigations are normal 1
- Chronic cough should only be considered idiopathic following thorough assessment at a specialist cough clinic 1