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

Management of Cough

Classify cough by duration and systematically treat the most common causes using sequential, additive therapy—most patients have multiple simultaneous etiologies requiring combined treatment. 1

Initial Classification and Assessment

Cough must be categorized by duration to guide your diagnostic and therapeutic approach:

• Acute cough (<3 weeks): Most commonly viral upper respiratory infection, acute bronchitis, or environmental exposure 2, 1
• Subacute cough (3-8 weeks): Typically postinfectious, but consider upper airway cough syndrome (UACS), transient bronchial hyperresponsiveness, asthma, or pertussis 2, 1
• Chronic cough (>8 weeks): Usually due to UACS, asthma, non-asthmatic eosinophilic bronchitis (NAEB), or gastroesophageal reflux disease (GERD)—often multiple causes coexist 2, 1

Immediately discontinue ACE inhibitors if the patient is taking one, as this is a common reversible cause that resolves within weeks of cessation 1, 3. Counsel all smokers on cessation, as 90-94% experience cough resolution within the first year of quitting 1.

Critical Initial Evaluation

Assess for life-threatening conditions requiring urgent intervention:

• Signs of respiratory distress: Markedly elevated respiratory rate, intercostal retractions, cyanosis, altered mental status, or severe dyspnea 1, 4
• Pneumonia indicators: Tachypnea, tachycardia, dyspnea, or abnormal lung findings warrant chest radiography 1, 4
• Risk factors for complications: Comorbidities, frailty, immunosuppression, or impaired cough clearance 1, 4

Obtain a chest radiograph if pneumonia is suspected based on clinical findings 1, 4. Perform spirometry as part of the basic evaluation for chronic cough 1.

Management by Duration

Acute Cough (<3 weeks)

For common cold symptoms, use first-generation antihistamine/decongestant combination plus naproxen to decrease cough severity and hasten resolution 2, 1, 4. Newer non-sedating antihistamines are ineffective and should not be used 4.

For acute exacerbation of chronic bronchitis, prescribe a short course (10-15 days) of systemic corticosteroids 1, 4.

Subacute Cough (3-8 Weeks)

First, determine if the cough is postinfectious (following an obvious respiratory infection) or non-infectious 2, 1:

• Postinfectious cough: Consider inhaled ipratropium as first-line therapy, as it may attenuate cough 2. If cough persists and adversely affects quality of life despite ipratropium, add inhaled corticosteroids 2. Antibiotics have no role unless bacterial sinusitis or early pertussis is confirmed 2.
• Non-infectious subacute cough: Evaluate and manage as chronic cough using the algorithm below 2, 1

Chronic Cough (>8 Weeks)

Use a sequential and additive treatment approach targeting the three most common causes, as they frequently coexist and require simultaneous treatment 1, 4:

Step 1: Treat Upper Airway Cough Syndrome (UACS)

• Start with oral first-generation antihistamine/decongestant combination 1, 3
• Add a topical nasal corticosteroid if prominent upper airway symptoms are present 1
• Continue treatment for at least 2-4 weeks before assessing response 2

Step 2: Evaluate and Treat Asthma/NAEB

• If spirometry shows reversible airflow obstruction, treat with inhaled bronchodilators and inhaled corticosteroids 1, 4
• If spirometry is normal but asthma is suspected, consider bronchoprovocation challenge or empiric trial of inhaled corticosteroids and bronchodilators 1
• For NAEB (diagnosed by induced sputum showing eosinophils), use inhaled corticosteroids as first-line treatment 1, 4
• For refractory asthma-related cough, add a leukotriene receptor antagonist before escalating to systemic corticosteroids 4

Step 3: Address GERD

• For patients with prominent reflux symptoms, initiate empiric treatment with proton pump inhibitor (PPI) plus dietary/lifestyle modifications before performing esophageal pH testing 2, 1
• Response to GERD treatment is more variable than UACS or asthma—some patients respond within 2 weeks, others require several months 2
• If partial or no improvement occurs, add prokinetic agent (metoclopramide) and ensure rigorous adherence to dietary measures 2

Critical principle: Maintain all partially effective treatments while adding new therapies, as multiple causes typically coexist 1, 4. Do not discontinue one treatment when starting another.

Advanced Evaluation for Refractory Cough

If cough persists after 4-6 weeks of empiric treatment for the top three diagnoses, pursue advanced testing 1, 3:

• 24-hour esophageal pH monitoring if GERD is suspected but not responding to empiric therapy 2
• High-resolution CT scan to evaluate for bronchiectasis, interstitial lung disease, or occult airway disease 2, 1
• Bronchoscopy to look for endobronchial tumor, sarcoidosis, suppurative infection, eosinophilic or lymphocytic bronchitis 2
• In tuberculosis-endemic areas, obtain sputum samples with acid-fast staining or bronchoscopy 2, 1

Consider uncommon causes based on clinical findings: nonacid reflux disease, swallowing disorder, congestive heart failure, or habit cough 2.

Management of Intractable/Refractory Cough

For cough that persists despite thorough evaluation and treatment:

• Multimodality speech pathology therapy including cough suppression techniques, vocal hygiene, and psychoeducational counseling 3
• Gabapentin trial for refractory chronic cough 3
• Low-dose opiates for symptom control only when all alternative treatments have failed, particularly in palliative care settings 3

Refer to a specialist cough clinic before labeling as unexplained/idiopathic cough 2, 1, 3.

Special Populations

Immunocompromised Patients

Follow the same initial algorithm but expand the differential diagnosis based on immune defect type and severity 1, 4. In HIV patients with CD4+ <200 cells/μL, suspect Pneumocystis pneumonia, tuberculosis, and opportunistic infections 1.

Patients with Dysphagia

Perform videofluoroscopic swallow evaluation or fiberoptic endoscopic evaluation of swallowing to identify appropriate treatment 3. Manage with organized multidisciplinary teams 3.

Critical Pitfalls to Avoid

• Do not rely on cough characteristics alone (timing, quality, productivity)—they have little diagnostic value and lack sensitivity and specificity 2, 1
• Do not treat only one cause—multiple factors contribute simultaneously in most chronic cough cases, requiring additive therapy 1, 4
• Do not use routine cough suppressants when cough clearance is important for secretion management 1
• Do not label as idiopathic until thorough assessment at a specialist clinic excludes uncommon causes 1, 3
• Do not prescribe antibiotics for postinfectious cough unless there is evidence of bacterial infection 3
• Do not use dextromethorphan for chronic cough that lasts more than 7 days, comes back, or occurs with fever, rash, or headache—these could be signs of serious conditions requiring medical evaluation 5