What to ask when evaluating a patient with chronic cough?

Evaluating Chronic Cough: What to Ask

When evaluating chronic cough, begin by establishing duration (≥8 weeks defines chronic cough), then systematically inquire about the three most common causes: upper airway cough syndrome, asthma, and gastroesophageal reflux disease, while screening for red flags and medication-induced cough. 1, 2

Essential History Components

Duration and Characteristics

• Ask specifically about cough duration - chronic cough is defined as lasting ≥8 weeks in adults 3
• Inquire about cough quality: dry versus productive, timing (nocturnal, postprandial), and whether it occurs in paroxysms 1
• Assess progression: sudden onset versus gradual, worsening versus stable 1

Medication History

• Directly ask about ACE inhibitor use - this is a critical question that must not be missed, as these medications are a common reversible cause 3, 2
• Ask about other cough-inducing medications including sitagliptin 4

Symptoms Suggesting Upper Airway Cough Syndrome (UACS)

• Postnasal drip sensation - patients may describe throat clearing or sensation of mucus dripping down the back of throat 1, 2
• Nasal discharge, congestion, or rhinorrhea 1
• Frequent throat clearing 1

Symptoms Suggesting Asthma

• Wheezing or chest tightness - even without classic asthma history 1, 2
• Dyspnea or shortness of breath 1
• Nocturnal symptoms - cough or breathlessness waking patient from sleep 1
• Exercise-induced symptoms 1

Symptoms Suggesting GERD

• Heartburn or acid regurgitation - though notably, reflux-associated cough may occur WITHOUT these typical symptoms 1, 2
• Dysphagia or difficulty swallowing 1
• Worse after meals or when lying down 1

Smoking and Environmental Exposures

• Current and past tobacco use - smoking is responsible for 85-90% of chronic bronchitis cases and is dose-related 3, 5
• Detailed occupational history - exposure to dust, chemicals, fumes, or other respiratory irritants 3
• Passive smoke exposure at home or workplace 3, 5
• Environmental irritants in the home 3

Chronic Bronchitis Criteria

• Ask about daily productive cough: Does the patient have cough with sputum production occurring most days for at least 3 months per year for 2 consecutive years? 3, 5
• Inquire about sputum color changes and volume 3

Red Flag Symptoms Requiring Urgent Investigation

• Hemoptysis - any blood in sputum warrants immediate further workup 3, 6
• Unintentional weight loss 6
• Fever or prominent systemic illness 3
• Recurrent pneumonia 6
• Suspicion of inhaled foreign body 3

Sputum Production

• Presence of significant sputum usually indicates primary lung pathology and requires different diagnostic approach 3
• Ask about sputum color, consistency, and volume 3

Impact Assessment

• Quantify cough severity using visual analogue scales or validated cough-specific quality of life questionnaires 3, 2
• Ask about impact on sleep, work, and social activities 3

Common Pitfalls to Avoid

• Don't overlook GERD as a cause even when typical reflux symptoms are absent - reflux-associated cough frequently occurs without heartburn 2
• Don't rely on patient self-diagnosis - many patients incorrectly self-diagnose "bronchitis" without meeting clinical criteria 5
• Don't forget to ask about ALL medications - ACE inhibitors are frequently missed as the culprit 3, 2
• Don't assume normal spirometry rules out asthma - cough-variant asthma commonly presents with normal baseline spirometry 2