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Learning outcome:
o List causes for acute & chronic cough
o Outline Ix and Rx of patients with chronic cough

General Cough
History

Onset gradually or suddenly

Characteristic of cough dry, sputum, blood
Associated features nocturnal, with eating or talking, hours after eating
food, positional,
recent infection
Timing duration, frequency, diurnal variation
Exacerbating factors exercise, temperature, aerosols, dust History of
atopy
PMH asthma, COPD, bronchiectasis, lung cancer, atopic disease,
cardiovascular disease, etc
DH ACEi
SH smoking, occupation, pets

Red flag symptoms

Copius production of sputum bronchiectasis, COPD

Weight loss, fever, haemoptysis TB, lymphoma, lung cancer
Considerable breathlessness acute bronchitis, obstructive airway
disease, fibrotic lung disease, heart failure

Common serious conditions presenting with isolated cough just to keep in the
back of your mind

Neoplasm
Infection TB
Foreign body inhalation
Acute allergy anaphylaxis
Interstitial lung disease

Acute Cough

Defined as cough lasting less than 3 weeks

Majority of cases unlikely to need any investigations
Most self-limiting, but keep in mind the serious conditions as noted above.
Look out for red flag symptoms and investigate their potential causes, e.g.
increasing breathlessness investigate asthma.
o All patients with red flag symptoms need a CXR

Causes of acute cough with normal CXR

Commonly
o Viral respiratory tract infection e.g. influenza, rhinovirus,
adenovirus
o Bacterial infection acute bronchitis, whooping cough(pertussis)
o COPD
o Smoking
o ACEi
o Asthma
N.B. also common causes of
o Post-nasal drip
chronic cough
o GORD
Less commonly
o PE
o TB
o Heart failure
o Malignancy
o Inhaled foreign body
o Inhaled toxic fumes

Treatment

Almost always benign and prescribed treatment may be unnecessary

Simple advice
o Home remedies honey and lemon preparations
o OTC medications e.g. linctuses, lozenges
Possible medication
o Dextromethorphan non-sedating opiate shown to supress acute
cough. Component in many OTC cough remedies
o Menthol cough suppression acute and short lived
o Sedative antihistamines n.b. causes drowsiness
o Codeine or pholcodine n.b. no greater efficacy than
dextromethorphan, but greater side-effects

Chronic Cough

Defined as a cough last 8 weeks

Causes

Simply for student level

o Asthma
o GORD
o Post-nasal drip
o Smoking
o ACEi
Most commonly bit more depth
o Asthma syndromes cough variant asthma, eosinophillic bronchitis
o Reflux disease GORD, laryngopharyngeal reflux, oesophageal
dysmotility
o Post-nasal drip
o Smoking
o Drug induced i.e. ACEi
Other less common causes
o Cardiovascular LVF, PE
o Chronic infection bronchiectasis, TB, CF, lung abscess
o Post-infectious cough following M.Pneumoniae, whooping cough
o Parenchymal lung diseases interstitial lung fibrosis, emphysema,
sarcoidosis
o Tumours lung cancer, benign, metastatic
o Upper airway conditions chronic tonsil enlargement, obstructive
sleep apnoea
o Foreign body in large airways
o Idiopathic/ psychogenic diagnosis of exclusion

Red flag symptoms

Copius production of sputum bronchiectasis, COPD

Weight loss, fever, haemoptysis TB, lymphoma, lung cancer
Considerable breathlessness obstructive airway disease, fibrotic lung
disease, heart failure

Trial of Treatment

Trial of treatment can be used to challenge a diagnosis to see if there is a

response.
If there is a response on treatment, relapse on stopping and then response
again on restarting this strengthens your diagnosis.

Management

This is an example of a management pathway which can be adopted

(from BMJ and is similar to BTS guidelines).

Stop smoking
o Stopping smoking leads to a reduction in cough within 2 month.
o Usually doesnt resolve the cough though.
o Smokers also higher risk for COPD and cancer, which can cause the
cough, so need further Ix
CXR
Spirometry

Stop offending drugs

o Most commonly ACEi.
o ACEi induced cough can start years after treatment
o After stopping, cough usually resolves after 1-4 weeks, but may take
up to 3 months

Trial of treatment for asthma and variants

o Asthma may manifest solely as a cough
There are different variants that may produce a cough, most
commonly
Cough variant asthma
Non asthma eosinophillic bronchitis
o Other things pointing to asthma include
Hx atopy, nocturnal cough, wheeze
Peak flow variability >20%

Spirometry showing >20% reversibility pre and post

bronchodilators

Both variants should respond to trial of inhaled or oral

corticosteroids
E.g. Prednisolone 30mg OD, for 8 weeks
Should respond within 2 weeks, but may take up to 8 weeks
If diagnosed with cough variant asthma, follow national asthma
guidelines. But note, no need for LABA in step 3, use leukotrienes
instead.

Trial of treatment for GORD

o Cough may manifest solely as a cough
o Other things pointing to GORD
No coughing at night coughing at night is rare with GORD
Hoarse voice
Cough when eating/ talking
Retrosternal burning
Cough occurs in certain position or hours after food
o Trial with high dose PPI
E.g. Omeprazole 20/40mg BD
May take 1-3 months for cough to resolve

Trial of treatment for post-nasal drip

o Things pointing to post-nasal drip
Persistent nasal obstruction or discharge
Feeling of something dripping in the back of their throat
Recurrent desire to clear their throat
o Trial of antihistamines, decongestants or nasal corticosteroids
Usually trial of topical corticosteroids first for 1 month

If initial management is unsuccessful refer onto secondary care

respiratory, gastro, ENT

Investigations

Basic investigation
o CXR
For all those with red flag symptoms
o Spirometry
Consider in all patients with chronic cough
If suggestive of asthma syndromes then offer trial of
prednisolone
Basic investigations secondary care
o Bronchoscopy
For all patients who foreign body inhalation is suspected
For patients where other more targeted investigations are
normal.
o High resolution CT of thorax

Considered in patients with persistent atypical cough where

more targeted investigations have been normal.
More sensitive and specific than CXR in diagnosing
bronchiectasis and diffuse pulmonary diseases.
Specialised investigations
o Bronchial provocation test measuring airway hyperresponsiveness
o 24-hr ambulatory oesophageal monitoring
o Radiological scanning of the sinuses
o Fibreoptic laryngoscopy
o Measurement and monitoring cough
o Induced sputum