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Chapter 11. Cough
Symptoms of deep vein thrombosis (leg swelling and pain)
may be present. Pulmonary embolism should always be
included in the differential diagnosis in patients with risk factors but these patients tend to be sicker, and, therefore, more
often visit emergency rooms rather than the outpatient office.
241
Subacute Cough
The severity of postinfectious cough is quite variable and can
be disabling in some cases (e.g., sleep disturbance, stress
incontinence, and posttussive vomiting). In most cases, the
patient may recall a preceding episode of fever and upper
respiratory symptoms. Some report persistent nasal symptoms indicating postnasal drip as a mechanism of cough. In
adults, paroxysmal whooping cough spells and posttussive
vomiting have a low sensitivity (32.5% [95% CI, 24.5–41.6]
and 29.8% [95% CI, 18.0–45.2]) but high specificity (77.7%
[95% CI, 73.1–81.7] and 79.5% [95% CI, 69.4–86.9]) in the
clinical diagnosis of pertussis. Fever and absence of cough
paroxysms suggest pertussis is unlikely the cause [6]. Pertussis
can be diagnosed by nasopharyngeal culture, polymerase
chain reaction (PCR), and serology [19]. It is important to
determine the vaccination status and whether there is a possible exposure to young children to identify pertussis, where
early treatment may be potentially helpful.
Chronic Cough
Chronic cough is more prevalent in middle-aged females.
Women have more frequent cough than men and have
heightened cough reflex sensitivity [20]. The first step is to
rule out the serious and common causes by history, physical
examination, chest X-ray, and spirometry. The presence of
weight loss, fever, night sweats, chest pain, and hemoptysis
suggests life-threatening diseases, e.g., lung cancer and tuberculosis [8]. Further work-up including sputum testing and
chest computed tomography (CT) should be considered.
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I. Soghier and K. Kinjo
Drug-induced cough, especially due to angiotensinconverting enzyme (ACE) inhibitors, is common (about
16%) [21] and tends to be dry. It starts within 1–2weeks after
the initiation of ACE inhibitors but can be delayed up to
6months. The cough subsides when the drug is discontinued
usually within 4weeks [22].
Bronchiectasis, COPD, and various parenchymal lung diseases can be identified by chest imaging and spirometry.
Patients often have exertional dyspnea which can go unnoticed because they attribute that to their smoking. It is helpful
to ask the family about the patient’s exercise capacity.
Localized or unilateral wheezing may suggest an endobronchial lesion (cancer or foreign body). Chest CT should be
ordered. The patient should be referred to a pulmonologist
for bronchoscopy.
Once the serious causes are excluded, the four most frequent etiologies of chronic cough are asthma, non-asthmatic
eosinophilic bronchitis, GERD, and upper airway cough syndrome [8, 23, 24] (Fig. 11.2). These conditions may present
with cough and typical symptoms but many patients have
only cough. Thus, empirical (diagnostic) treatment is tried in
many cases before an extensive work-up is undertaken.
Asthma usually presents with episodic dyspnea and wheezing in addition to cough. Occasionally, cough can be the only
symptom, an entity known as “cough variant asthma.” A personal or family history of atopy or recent initiation of a beta
blocker can be helpful. Spirometry showing reversible airway
obstruction is often seen in asthma. If the pulmonary function
test is normal, a methacholine challenge test, sputum eosinophils, or elevated exhaled nitric oxide may assist in diagnosis.
Non-asthmatic eosinophilic bronchitis is difficult to distinguish from asthma clinically. Sputum eosinophilia without
bronchial hyperresponsiveness is diagnostic.
Patients with upper airway cough syndrome have nasal
discharge, a sense of postnasal drip or the urge to clear their
throat leading to cough. Cobblestone appearance and secretions may be seen in the nasopharynx. Treatment with nasal
steroids or antihistamines is recommended, especially for
patients with a history of allergic rhinitis or chronic sinusitis.
function test
• COPD
Abnormal chest imaging or pulmonary
No improvement
• Bronchiectasis
GERDUpper airway cough syndrome
Chapter 11. Cough
• Interstitial lung disease
Lifestyle modification
PPI (proton pump inhibitor)
243
Chronic Cough
Sitagliptin
Discontinue ACE inhibitor/
Normal chest Imaging
Improvement
ACE inhibitor/ Sitagliptin induced
Allergen avoidance
ICS (inhaled corticosteroid)
cough
bronchitis
Spirometry
Asthma/ Non-asthmatic eosinophilic
Bronchoprovocation challenge
If no improvement in 4-6 weeks consider
• 24 hour pH/ impedance monitoring
• Endoscopic/ videofluoroscopicevaluation
Trigger avoidance
Sputum eosinophils
ICS +/-LTRA (leukotriene agonist)
• Modified barium swallow
• Bronchoscopy
• Sinus imaging
• Echocardiogram
• Environmental assessment
F . Management of chronic cough
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I. Soghier and K. Kinjo
Treatment
Once the etiology is found, a specific treatment can be instituted. This should be followed by an evaluation in 4–6weeks.
Any unresolved cough should be referred to a specialist or
preferably a cough clinic if available.
Acute cough is usually self-limited and requires only reassurance [10]. Patients have reported relief from the use of
over-the-counter medications, e.g., dextromethorphan, menthol, and first-generation antihistamines. There is no role for
antibiotics except in the treatment of cough due to bacterial
pneumonia, pertussis, and severe COPD exacerbations.
In pertussis, macrolides for 5–7days decrease the spread of
the disease. The CDC recommends early antibiotic initiation
within the first 2weeks to decrease the duration of symptoms
[25, 26] but a Cochrane review found it does not alter the
clinical course of the disease [27]. When suspected, treatment
should be started without waiting for laboratory confirmation. There is insufficient evidence to recommend other interventions, e.g., corticosteroids, antihistamines, beta2-adrenergic
agonists, leukotriene receptor antagonists, or pertussisspecific immunoglobulin in the symptomatic management of
pertussis-related cough [28].
For influenza-related cough, antivirals should be initiated
preferably within 48h in patients who are very ill or at high
risk for serious influenza-associated complications. Antiviral
drugs have proven to reduce the duration of illness, ameliorate symptoms and prevent hospitalizations and death [29,
30]. The mainstays of treatment for acute exacerbations of
COPD and asthma are steroids and bronchodilators.
Patients with cough caused by asthma and non-asthmatic
eosinophilic bronchitis should be given inhaled corticosteroids as first-line treatment [31, 32]. If the response is inadequate, clinicians should consider increasing the dose of the
inhaled steroid and trial of a leukotriene inhibitor [33, 34].
Some patients with asthma may require oral glucocorticoids
for 1–2weeks [3]. Alternative causes of cough should also be
Chapter 11. Cough
245
sought. It is important to try to identify possible triggers/
allergens and encourage avoidance.
When GERD is suspected, lifestyle modification measures
are recommended. These include diet modification, elevation
of the head of the bed, avoidance of food 3h before bedtime,
and weight loss in obese patients [35]. For patients who have
symptoms of reflux (heartburn and regurgitation), pharmacologic therapy can be initiated. Proton pump inhibitors should
not be prescribed alone without lifestyle modification in
cough reflux syndrome if there are no reflux symptoms
because they are unlikely to be effective [36]. Improvement
in symptoms may take up to 3months. If there is no response
after therapeutic trial, referral for pH monitoring study and
esophageal manometry should be considered if there is a
strong clinical suspicion warranting diagnostic confirmation,
e.g., those undergoing surgery for reflux [37].
Patients suffering from cough due to stable COPD should
be treated according to the GOLD guidelines [38]. Smoking
cessation and avoidance of environmental triggers help alleviate the severity of cough. There is insufficient evidence to
recommend other treatments, e.g., antibiotics, cough suppressants, or mucolytics to specifically target cough [39].
In addition, avoidance of occupational and other toxic
substances is a key aspect in controlling cough when an
external inhalational trigger is suspected. Treatment will
depend on the disease manifestation, e.g., prescribing oral
corticosteroids for hypersensitivity pneumonitis. Referral to a
pulmonologist is usually required for specialist testing.
Unexplained chronic cough is usually managed with the
aid of a pulmonologist. These patients may benefit from
speech therapy [40] or a trial of gabapentin with reevaluation
of the risk-benefit profile [41].
Clinical Pearls
• Cough should be approached based on the duration of the
symptom.
• A thorough history and physical exam should give clues to
the correct diagnosis in many cases.
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I. Soghier and K. Kinjo
• When patients present with chronic cough and no other
obvious symptoms, asthma, GERD, and upper airway
cough syndrome should be considered.
Do Not Miss This!
• Many serious diseases such as COPD, lung cancer, intersti-
tial pneumonia, and tuberculosis present with cough.
These should be excluded by history, physical examination,
chest X-ray, and spirometry, before thinking about asthma,
GERD, and upper airway cough syndrome.
• Weight loss, fever, night sweats, and hemoptysis suggest a
serious disease like tuberculosis or cancer. You should get
a chest X-ray/CT and sputum for acid-fast bacilli.
• Unilateral wheezing suggests an endobronchial lesion, e.g.,
cancer or a foreign body. Get a chest CT and refer to a
pulmonologist for bronchoscopy.
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