What are the recommended management strategies for chronic cough?

Chronic Cough Management

Manage chronic cough through a systematic approach combining targeted diagnostic testing with sequential empiric treatment trials for the most common causes: upper airway cough syndrome (UACS), asthma/eosinophilic bronchitis, gastroesophageal reflux disease (GERD), and medication-induced cough. 1

Initial Evaluation

Mandatory baseline investigations include chest radiograph and spirometry in all patients. 1

Key historical elements to identify:

• ACE inhibitor use - discontinue immediately if present, as no patient with troublesome cough should continue these medications 1
• Smoking status - one of the most common causes, dose-related 1
• Reflux symptoms - though cough may occur without gastrointestinal symptoms 1
• Upper airway symptoms - rhinosinusitis, post-nasal drip 1, 2
• Respiratory symptoms - wheezing, shortness of breath suggesting asthma 2

Sequential Treatment Algorithm

First-Line Empiric Therapy

Address the most probable aggravants sequentially and additively, as multiple causes frequently coexist. 1

1. ACE Inhibitor-Induced Cough

• Discontinue ACE inhibitor immediately 1
• Switch to alternative antihypertensive class 2

2. Smoking-Related Cough

• Smoking cessation is mandatory - accompanied by significant symptom remission 1

3. Upper Airway Cough Syndrome

• Trial of topical corticosteroid nasal spray for prominent upper airway symptoms 1
• First-generation antihistamine-decongestant combination as alternative 2
• ENT examination preferred over sinus imaging initially 1

4. Asthma/Eosinophilic Bronchitis

• Two-week oral corticosteroid trial - lack of response effectively excludes eosinophilic airway inflammation 1, 3
• No current airway function test reliably excludes corticosteroid-responsive cough 1
• Bronchial provocation testing indicated in patients with normal spirometry and no obvious etiology 1
• Negative provocation test excludes asthma but does not rule out steroid-responsive cough 1

5. Gastroesophageal Reflux Disease

• Intensive acid suppression with proton pump inhibitors and alginates for minimum 3 months 1, 2
• Failure to consider GERD is a common reason for treatment failure 1
• Empirical treatment should precede oesophageal testing 1
• No current oesophageal function test predicts treatment response 1

Advanced Investigations

When initial empiric therapy fails:

• High-resolution CT may be useful when other targeted investigations are normal 1
• Bronchoscopy mandatory if foreign body inhalation suspected 1
• Fibreoptic laryngoscopy for persistent upper airway symptoms 1

Treatment Monitoring

Formally quantify treatment effects using validated cough-specific quality of life questionnaires or visual analog scales. 1, 3

Refractory Chronic Cough

Consider chronic cough idiopathic only after thorough assessment at a specialist cough clinic. 1

For unexplained chronic cough after complete evaluation:

• Referral to specialist cough clinic strongly encouraged 1
• Consider multimodality speech pathology therapy 2
• Neuromodulatory treatment (gabapentin, pregabalin) may be considered 2, 4

Critical Pitfalls to Avoid

• Never continue ACE inhibitors in patients with troublesome cough 1
• Do not undertreated GERD - requires full 3-month trial of intensive acid suppression 1, 2
• Avoid premature diagnosis of idiopathic cough - ensure adequate treatment duration and specialist evaluation first 1, 3
• Recognize multiple simultaneous causes - use additive sequential therapy rather than stopping after first intervention 1, 2
• Cough suppression may be contraindicated when cough clearance is important for secretion management 1, 3

Cost-Effective Approach

Optimal management combines selected diagnostic testing with empirical treatment trials based on most probable aggravants, rather than exhaustive upfront testing. 1