What is the initial evaluation and treatment approach for a patient presenting with a cough?

Initial Evaluation and Treatment Approach for Cough

The initial evaluation of a patient with cough should begin with a focused medical history to determine if the patient is taking an ACE inhibitor, is a smoker, or has evidence of serious life-threatening systemic disease. 1

Initial Assessment

• Determine the duration of cough to classify as acute (< 3 weeks), subacute (3-8 weeks), or chronic (> 8 weeks) 2
• Assess for signs of respiratory distress including increased respiratory rate, intercostal retractions, dyspnea, cyanosis, or altered mental status 1
• Evaluate for risk factors for complications including comorbidities, frailty, impaired immunity, or reduced ability to clear secretions 1
• Rule out serious conditions like pneumonia or pulmonary embolism that may present with cough 3

Diagnostic Approach

• Obtain a chest radiograph if pneumonia is suspected based on clinical findings such as tachypnea, tachycardia, dyspnea, or abnormal lung findings 1
• For chronic cough, spirometry should be performed to evaluate for reversible airflow obstruction 3
• If spirometry does not indicate reversible airflow obstruction, consider bronchoprovocation challenge (BPC) to confirm asthma diagnosis 3

Management Based on Duration and Etiology

Acute Cough (< 3 weeks)

• For acute cough associated with common cold:

  • First-generation antihistamine/decongestant combination (brompheniramine and sustained-release pseudoephedrine) is recommended 2
  • Naproxen can be administered to help decrease cough in this setting 2
  • Newer generation non-sedating antihistamines are ineffective and should not be used 2
  • Consider honey for cough suppression in patients over 1 year of age 1
  • Ensure adequate fluid intake to avoid dehydration 1

• For acute exacerbation of chronic bronchitis:

  • A short course (10-15 days) of systemic corticosteroid therapy is recommended 2
  • Central cough suppressants such as codeine and dextromethorphan are recommended for short-term symptomatic relief 2

Chronic Cough (> 8 weeks)

Follow a sequential and additive treatment approach as multiple causes may be present 2:

1. First step: If patient is taking an ACE inhibitor, discontinue and replace with another medication 2
2. Second step: If patient smokes, counsel and assist with smoking cessation 2
3. Third step: Treat Upper Airway Cough Syndrome (UACS) with first-generation antihistamine/decongestant 2
4. Fourth step: If cough persists, evaluate and treat for asthma with inhaled corticosteroids and bronchodilators 2
5. Fifth step: Consider non-asthmatic eosinophilic bronchitis (NAEB) with induced sputum test for eosinophils or empiric trial of corticosteroids 2
6. Sixth step: Consider gastroesophageal reflux disease (GERD) and treat with proton pump inhibitors if suspected 2

Special Considerations

Asthma-Related Cough

• Initial treatment should include inhaled bronchodilators and inhaled corticosteroids 2
• For refractory cases, consider adding a leukotriene receptor antagonist before escalating to systemic corticosteroids 2
• For severe or refractory cough due to asthma, a short course (1-2 weeks) of systemic corticosteroids followed by inhaled corticosteroids is recommended 2

Non-Asthmatic Eosinophilic Bronchitis (NAEB)

• First-line treatment is inhaled corticosteroids 2
• If a causal allergen or occupational sensitizer is identified, avoidance is the best treatment 2
• For persistent symptoms despite high-dose inhaled corticosteroids, oral corticosteroids should be given 2

Common Pitfalls to Avoid

• Do not rely solely on cough characteristics for diagnosis, as they have limited diagnostic value 1
• Do not use newer generation non-sedating antihistamines for cough associated with common cold as they are ineffective 2
• Do not diagnose bacterial sinusitis during the first week of symptoms in patients with acute upper respiratory tract infection 2
• Do not forget to consider uncommon causes when cough persists despite appropriate evaluation and treatment 1
• For chronic cough, avoid treating only one potential cause, as multiple factors often contribute 2