Approach to
Chronic Cough
Andy Sher, MD
PGY-2 Family Medicine
2016-07-27
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Introduction
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Chronic cough – cough lasting
greater than 8 weeks time
Prevalence estimated at 1%
Prevalence higher in urban
populations
Can cause complications in
respiratory, CV, CNS, GI, GU and
MSK systems
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Case
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30 year old woman presenting with a 3
month hx of cough, though her friends
say she’s been coughing for at least the
last year. Cough is dry, worse at night
and can interfere with sleep (can be at
02:00-03:00 but not consistently so). Pt.
has known seasonal allergies which
have been acting up lately. She has
been taking Claritin with some relief.
She is obese but otherwise healthy and
does not smoke. Strong Fhx of atopy.
P/E is unremarkable.
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Approach
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History & Physical (physical is often
normal)
Red flags
Chest X-ray
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Presence of foreign body
Pneumonia
Bronchiectasis
Pulmonary fibrotic disease
Pulmonary neoplasm
TB
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Common Causes of
Chronic Cough
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3 most common causes of chronic
cough in immunocompetent, nonsmoking individuals, not on ACEi
Post-nasal drip syndrome
Asthma
GERD
Note that more than one of these
may be contributing to cough
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Post-nasal drip
syndrome (PNDS)
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Most common cause of chronic
cough
Often nocturnal
Sensation of tickling or constant
drip in back of throat
Throat clearing, hoarseness
Nasal congestion, rhinorrhea
May have no obvious symptoms
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Causes of PNDS
Viral URTI
 Perennial (non-allergic rhinitis)
 Allergic/irritant rhinitis
 Vasomotor rhinitis
 Chronic sinusitis
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Rhinitis - management
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For perennial, vasomotor, post-infectious
rhinitis
Treatment with 1st generation
antihistamine such as
dexbrompheniramine in combination with
a pseudoephedrine decongestant
Cough should improve within 2 days to 2
weeks
Can also use ipratroprium bromide
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Decongestants
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Topical sprays (Otrivin, Dristan) but
beware rebound
Sinutab
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Sudafed
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pseudoephedrine 120 mg +
chlorpheniramine
Drixoral
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pseudoephedrine 60 mg
Chlor-Tripolon (w/ decongestant)
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pseudoephedrine 30 mg + 500 mg
acetominophen
Pseudoephedrine 120 mg +
dexbropheniramine
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Allergic rhinitis management
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Allergen testing to identify
environmental exposures
Nonsedating antihistamines such
as loratadine
Nasal steroids, sodium
cromoglycate, or intranasal
antihistamines
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Chronic sinusitis management
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Sinus X-rays
Air-fluid levels
 Opacifications
 Mucosal thickening (>6mm)
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3 week course of antibiotic therapy
(S. pneumo, S. aureus, H. flu)
Antihistamine and decongestant
for 3 weeks, followed by nasal
steroids for up to 3 months
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Asthma
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Hx: usual symptoms – cough (nocturnal),
wheeze, dyspnea, chest tightness;
triggers; FHx
Up to 57% of cases cough is only
presenting symptom
Reversible airflow obstruction
uncommon in cough variant asthma
(PFTs negative)
Methacholine challenge test
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PPV up to 88%, NPV of 100%
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Asthma - treatment
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B-agonist can provide symptom
relief acutely
Course of inhaled corticosteroids –
6-8 weeks. May require oral
corticosteroid
Can discontinue steroid once
cough stops
Cough can recur if re-exposed to
respiratory irritants or allergens
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GERD
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Transient loss of tone in lower
esophageal sphincter leading to
retrograde movement of acidic
stomach contents into esophagus
Dysphagia, heartburn, waterbrash,
regurgitation, hoarseness/
dysphonia, throat pain
Cough may be only symptom (if
small amount of acid)
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GERD - Management
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Preventive measures
Weight reduction
 Smoking cessation
 Diet low in acidic foods or foods
that reduces LES tone – caffeine,
fatty foods, alcohol
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GERD Management
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Medications
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H2 receptor blocker – 4-6 week trial then
step-up
PPI
Could consider prokinetic agent (ie.
metoclopramide)
Full recovery could take up to 6 months
GERD induced cough can persist even if
other symptoms resolve
Recalcitrant cases – pH probe can be
used to assess efficacy of treatment or
evaluate need for fundoplication
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Approach : summary
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Rule out non-benign pathology –
consider CXR
Empiric trials – start with most likely
etiology based on history & physical +/investigations
Indications for referral
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Abnormal CXR
Immunosuppression
Difficult symptom control
Uncertain etiology
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Case revisited
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CXR? (age, absence of red flags)
Trial Nasonex 2 sprays to each nostril
od, f/u in 6 weeks
Considered trial of puffers but will hold
off for now.
Pt. returns in 6 weeks—rhinitis
symptoms significantly improved but
cough persists (somewhat better?).
hx revisited—on close questioning, pt.
admits to occasional heartburn, 20 lb wt.
gain 1 year ago (coinciding with onset of
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cough), hoarseness in a.m.
Case revisted
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Lifestyle modifications
Zantac 150 mg bid for 8 weeks
Pt. Returns will complete resolution
of sx. Has decided to continue
Nasonex during allergy season.
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Chronic Cough
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Common complaint
The majority of cases can be
attributed to one of PNDS, asthma,
or GERD
Can be more than one etiology for
cough, and may need to treat both
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References
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D’Urzo A, Jugovic P. Chronic cough.
Can. Family Physician. 2002 Aug;48
1311-1316.
Irwin RS, Madison JM. The diagnosis
and treatment of cough. N Engl J Med
2000;343:1715-21.
Currie GP, Gray RD, John M. Chronic
Cough. BMJ 2003;326:261.
Lawler WR. An Office Approach to the
Diagnosis of Chronic Cough. Am Fam
Physician 1998 Dec;58(9):2015-22.
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