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

Management of Cough

Classify cough by duration—acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks)—as this determines your diagnostic and therapeutic pathway. 1

Immediate Actions

• Discontinue ACE inhibitors immediately if the patient is taking them, as they are a common reversible cause of chronic cough 1, 2
• Counsel smokers on cessation, as 90-94% experience cough resolution within the first year of quitting 1
• Assess for life-threatening conditions including pneumonia, pulmonary embolism, or systemic illness requiring urgent intervention 1, 2
• Obtain a chest radiograph if pneumonia is suspected based on tachypnea, tachycardia, dyspnea, or abnormal lung findings 1, 2

Acute Cough (<3 Weeks)

For common cold: Prescribe a first-generation antihistamine/decongestant combination plus naproxen to decrease cough severity and hasten resolution 3, 1, 2

• Do not use newer non-sedating antihistamines as they are ineffective for cough 2

For acute exacerbation of chronic bronchitis: Administer a short course (10-15 days) of systemic corticosteroids 1, 2

Critical distinction: Determine if this represents a serious condition (pneumonia, pulmonary embolism) versus self-limited viral illness, acute bronchitis, or asthma 3

Subacute Cough (3-8 Weeks)

First, determine if the cough is postinfectious (following an obvious respiratory infection) or non-infectious 3, 1

For postinfectious cough:

• Trial of inhaled ipratropium as it may attenuate the cough 3
• If cough persists and adversely affects quality of life, consider inhaled corticosteroids 3
• Antibiotics have no role unless bacterial sinusitis or early Bordetella pertussis infection is present 3

For non-infectious subacute cough: Evaluate and manage as chronic cough 3, 1

Chronic Cough (>8 Weeks)

Use a sequential and additive treatment approach targeting the three most common causes, which frequently coexist: upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD) 3, 1

Initial Evaluation

• Perform spirometry as part of the basic evaluation, though its utility is not clearly established 1
• Obtain chest radiograph to rule out malignancy, pneumonia, or structural lung disease 1

Sequential Treatment Protocol

Step 1: Treat Upper Airway Cough Syndrome (UACS)

• Prescribe an oral first-generation antihistamine/decongestant combination 1, 2
• Add a topical corticosteroid if prominent upper airway symptoms are present 1

Step 2: Evaluate and Treat for Asthma

• If spirometry shows reversible airflow obstruction: Treat with inhaled bronchodilators and inhaled corticosteroids 1, 2
• If spirometry is normal but asthma suspected: Consider bronchoprovocation challenge or empiric trial of inhaled corticosteroids and bronchodilators 1
• For refractory cases: Add a leukotriene receptor antagonist before escalating to systemic corticosteroids 2

Step 3: Treat Non-Asthmatic Eosinophilic Bronchitis (NAEB)

• Perform induced sputum test for eosinophils if available 1
• Use empiric treatment with inhaled corticosteroids if testing is unavailable 1
• If a causal allergen or occupational sensitizer is identified, avoidance is the best treatment 2

Step 4: Treat Gastroesophageal Reflux Disease (GERD)

• For patients with prominent upper GI symptoms: Initiate proton pump inhibitor (PPI) therapy plus antireflux diet and lifestyle modifications 3, 1
• For patients without GERD symptoms: Consider empiric PPI trial, as response may take 2 weeks to several months 3
• If no response to PPI: Add prokinetic agent (metoclopramide) and ensure rigorous adherence to dietary measures 3
• Consider 24-hour esophageal pH monitoring if cough persists, though interpretation criteria vary 3

Advanced Evaluation for Persistent Cough

If cough persists after 4-6 weeks of empiric treatment:

• In tuberculosis-endemic countries: Obtain expectorated or induced sputum with acid-fast staining or bronchoscopy 3
• In the United States: Perform high-resolution CT scan to evaluate for bronchiectasis or occult interstitial disease 3, 1
• Perform bronchoscopy to look for occult airway disease (endobronchial tumor, sarcoidosis, suppurative infection, eosinophilic or lymphocytic bronchitis) 3, 1
• Consider uncommon causes: Non-acid reflux disease, swallowing disorder, congestive heart failure, or habit cough 3
• Consider referral to a specialist cough clinic when diagnosis remains unclear 1, 4

Management of Refractory Chronic Cough

For cough that persists despite thorough evaluation:

• Multimodality speech pathology therapy including cough suppression techniques, vocal hygiene, and psychoeducational counseling 4
• Trial of gabapentin for refractory chronic cough 4, 5
• Low-dose opiates (codeine or dextromethorphan) for symptom control when all alternative treatments have failed, particularly in palliative care settings 4, 6

Critical Pitfalls to Avoid

• Do not rely on cough characteristics alone (productive vs. dry, timing, quality) as they have little diagnostic value 3, 1
• Do not treat only one cause—multiple factors often contribute simultaneously, requiring additive therapy that maintains all partially effective treatments 3, 1, 2
• Do not label as idiopathic until thorough assessment at a specialist clinic excludes uncommon causes 1, 4
• Do not use routine cough suppressants when cough clearance is important for secretion management 1
• Do not prescribe antibiotics for postinfectious cough unless there is evidence of bacterial infection 4

Special Populations

Immunocompromised patients:

• Use the same initial algorithm but expand the differential diagnosis based on immune defect type and severity 1, 2
• 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 to identify appropriate treatment 4
• Manage with organized multidisciplinary teams 4