II. Definition

  1. Cough duration longer than 8 weeks

III. Causes

  1. See Chronic Cough Causes
  2. Pertussis is responsible for 20% of severe cough in adults and teens >2 weeks presenting to emergency departments
    1. Senzilet (2001) Clin Infect Dis 32:1691-7

IV. History

  1. Tobacco Smoking
    1. Packs per day
    2. Morning cough
  2. Post-nasal drainage (typically presents with Globus sensation)
    1. Allergic Rhinitis
    2. Sinusitis
  3. Asthma
    1. Night cough
    2. Environmental irritants
    3. Atopic Family History
  4. Gastroesophageal Reflux
    1. Cough Worse supine (exception in Reflux Laryngitis which is worse in upright position)
    2. Cough relieved with Antacids?
    3. Frequent throat clearing
  5. Chronic Bronchitis
    1. Productive cough
    2. Tobacco Smoker
  6. Medications
    1. ACE Inhibitors
  7. Airway Hyperresponsive
    1. Recent Upper Respiratory Infection or Bronchitis
      1. Bordatella Pertussis
      2. Chlamydia pneumoniae
      3. Mycoplasma pneumoniae
      4. Influenza
      5. RSV
      6. Parainfluenza
    2. Non-productive cough
  8. Cancer or Tuberculosis Symptoms
    1. Night Sweats
    2. Hemoptysis
    3. Weight loss

V. Imaging

  1. Chest XRay
    1. Indicated in most cases of Chronic Cough
    2. Conditions resulting in abnormal findings
      1. Bronchiectasis
      2. Bronchogenic Carcinoma
      3. Tuberculosis
      4. Sarcoidosis
      5. Peristant Pneumonia
  2. Chest CT Indications
    1. Elucidate abnormal Chest XRay

VI. Management: Initial Interventions

  1. General
    1. Consider Chest XRay unless cause is obvious
    2. Algorithm applies to non-urgent cough evaluation
    3. Immunocompromised patients require urgent evaluation
  2. Avoid Lung toxins
    1. Tobacco Cessation
    2. See Occupational Asthma
  3. Discontinue ACE Inhibitor if using
    1. Convert to Angiotensin Receptor Blocker
    2. Reassess after 4 weeks
  4. If suspect post-Bronchitis airway hyper-responsiveness
    1. Consider Pertussis
    2. Consider Inhaled Corticosteroids
    3. Consider inhaled Ipratropium Bromide (Atrovent)
  5. If Suspect Chronic Bronchitis
    1. Tobacco Cessation
    2. Bronchodilators
  6. Consider infectious cause evaluation
    1. Purified Protein Derivative (PPD) for Tuberculosis
    2. Nasopharyngeal swab PCR for Bordetella pertussis

VII. Management: Step 1 - Treat empirically for postnasal drip

VIII. Management: Step 2 - Evaluate for Asthma

  1. Consider cough-variant Asthma empiric trial
    1. Trial Bronchodilator with or without Inhaled Corticosteroid (e.g. Albuterol, Advair)
    2. Trial Leukotriene Receptor Antagonist (e.g. Singulair)
    3. Consider Prednisone 40 mg orally daily for 7-10 days
  2. Perform Pulmonary Function Tests
    1. FEV1 before and after Bronchodilator
    2. Consider Methacholine Challenge test
      1. High False Positive Rate (25%)
      2. Near 100% Negative Predictive Value
  3. Treat Asthma if present
    1. See Allergen Control
    2. Inhaled Corticosteroids or Cromolyn Sodium
    3. Inhaled Beta Agonist

IX. Management: Step 3 - Evaluate Pulmonary and Sinus Disease

  1. Chest XRay (if not already done)
  2. CT Sinuses

X. Management: Step 4 - Treat for Gastroesophageal Reflux

  1. High Dose Proton-Pump Inhibitor
    1. Omeprazole (Prilosec) 20 to 80 mg PO qd
    2. Requires 2-3 months of therapy to eliminate cough
  2. Anti-Reflux Esophagitis measures
  3. Consider diagnostic testing
    1. Upper GI
    2. Upper Endoscopy
    3. 24 hour esophageal pH monitoring

XI. Management: Step 5 - Advanced lung diagnostics

  1. Consider Eosinophilic Bronchitis evaluation
    1. Obtain 3 induced Sputum samples
    2. Negative if Eosinophils <3% in Sputum
    3. Responds to oral or Inhaled Corticosteroids
  2. Pulmonology Consultation
    1. Bronchoscopy may be considered
  3. If pulmonary evaluation negative
    1. Repeat Asthma medications
    2. Repeat Antihistamine and Decongestant combinations
  4. Evaluate for less common etiologies
    1. See Chronic Cough Causes

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Ontology: Chronic cough (C0010201)

Concepts Sign or Symptom (T184)
SnomedCT 161930005, 139187006, 68154008
Dutch chronisch hoesten, chronisch; hoesten, hoesten; chronisch
French Toux chronique
German chronischer Husten
Italian Tosse cronica
Portuguese Tosse crónica
Spanish Tos crónica, tos crónica (hallazgo), tos crónica
Japanese 慢性咳嗽, マンセイガイソウ
English chronic cough (symptom), chronic cough, chronic coughing, cough chronic, chronic coughs, Chronic cough (disorder), Chronic cough, Chronic cough (finding), chronic; cough, cough; chronic
Czech Chronický kašel
Hungarian Chronikus köhögés