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Management of cough.

Cough is a common symptom that leads to a large number of visits to primary care physicians every year. It is the chief complaint of over 2.5 million patients presenting to their doctors with acute bronchitis each year, but it is also associated with an extensive list of other illnesses. Both alone and in conjunction with illnesses such as asthma, gastroesophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), or heart failure (HF), cough and its etiology present a diagnostic dilemma that requires a systematic approach in order to have appropriate diagnosis and management. The guidelines of the American College of Chest Physicians describe recommendations based on the duration of cough (Chest 2006;129(suppl. 1):222S-31S).

Acute cough typically lasts fewer than three weeks, and although it can be associated with life-threatening illnesses--such as pneumonia, HE or pulmonary embolism--it is typically caused by one of four main disease processes: upper airway cough syndrome (UACS), asthma, GERD, or nonasthmatic eosinophilic bronchitis (NAEB). Exacerbations of an underlying illness, such as COPD, or infection with influenza, Bordetella pertussis, acute bronchitis, or the common cold may also trigger acute, cough.

Subacute cough is defined as lasting 3-8 weeks, and chronic cough is defined as lasting longer than 8 weeks. Subacute cough is often caused by a postinfectious upper respiratory irritation, increased mucus production, or postnasal drip. A chronic cough is often linked to more than one condition's being present simultaneously. In addition to the common causes of acute cough, possible causes of chronic cough include tobacco use; ACE-inhibitor use; COPD; infectious etiologies such as tuberculosis; HF; interstitial lung disease; and lung cancer, among others.

Acute/Subacute Cough

A careful medical history and examination are important in ruling out potential causes of cough, including smoking, medication effect, or life-threatening illness such as HF or pneumonia. An important early goal is to determine whether cough is a manifestation of a life-threatening illness, an exacerbation of underlying illness, an environmental exposure, or a new non-life-threatening process. Good evidence supports the cessation of cough-inducing medicines such as ACE-inhibitors, even if symptoms began prior to medicine initiation, and the cessation of smoking.

The next goal is to determine if a cough is postinfectious in etiology. If it is postinfectious, the next goal is to determine if it is from UACS, transient bronchial hypersensitivity, asthma exacerbation, acute bronchitis, or pertussis. If the subacute cough is not postinfectious, it should be managed like a chronic cough.

For cough caused by asthma, there is good evidence to support the use of inhaled corticosteroids, inhaled [beta]-agonists, or oral leukotriene inhibitors, ideally after a bronchoprovocation challenge test--such as a methacholine challenge--is administered to confirm the diagnosis.

Chronic Cough

For chronic cough, there is good evidence supporting empirical, additive, sequential steps of therapy, given the frequency of multifactorial etiology. Empirical treatment should include ad vice about smoking cessation if the patient smokes. The next step addresses UACS with the addition of an oral first-generation antihistamine and decongestant combination. If symptoms persist, the diagnosis of asthma should be pursued, using office spirometry and bronchoprovocation challenge if needed. If the latter is not available, empirical treatment of asthma is the next step. If treatment of UACS and asthma do not improve the cough, one should rule out NAEB with an induced sputum test for eosinophils. If this is not possible, consideration can be given to empirical treatment with corticosteroids.

For patients with chronic cough who have not responded to interventions for UACS, asthma, and NAEB, the treatment of GERD is the next step. Initial treatment for GERD includes an antireflux diet and a proton pump inhibitor. If symptoms persist beyond several months, further evaluation with endoscopy, esophageal pH monitoring, or a barium swallow study may be necessary Ultimately, if all treatment options and diagnostic studies have been completed and there is still no identifiable cause of cough symptoms, patients should be referred to a cough specialist.

The Bottom Line

Cough is common, and the list of causes is formidable. A sequential, systematic approach is recommended whereby clinicians can identify dangerous sources when present, and target the more common causes in most cases. A search for common reversible causes--such as tobacco use, ACE-inhibitor use, and environmental irritants--is always the first step. The next step is a systematic approach advocating a combination of limited diagnostic testing and empirical treatment. Treat UACS with an antihistamine/ decongestant combination; treat asthma with inhaled corticosteroids or [beta]-agonists; and treat GERD with proton pump inhibitors and diet modification.

Guidelines are most useful when they are available at the point of care. A concise yet complete handheld computer version of this guideline is available for download, compliments of FAMILY PRACTICE NEWS, at


DR. SKOLNIK is an associate director of the Family Medicine Residency Program at Abington (Pa.) Memorial Hospital and a coauthor of "Redi-Reference Clinical Guidelines." DR. WILSON is a third-year family medicine resident at Abington.
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Title Annotation:Clinical Guidelines For Family Physicians
Author:Skolnik, Neil S.; Wilson, Adrian
Publication:Family Practice News
Date:Feb 15, 2007
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