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chronic cough

Cough lasting >3 weeks (>8 weeks [4,14,17]) without an obvious cause. Etiology: 1) allergic rhinitis*, postnasal drip (most common cause) 2) bronchospasm, asthma* 3) gastroesophageal reflux* 4) COPD [4] 5) postinfectious cough (generally viral infection or Mycoplasma) 6) pharmaceutical agents: a) ACE inhibitors (20% of patients given ACE inhibitor) [14] b) beta-blockers [4] 7) connective tissue diseases a) temporal arteritis b) rheumatoid bronchiolitis c) Sjogren's syndrome 8) infectious: Bordetella pertussis (whooping cough) [2] 9) eosinophilic bronchitis [4,7] 10) habit cough [3] 11) unlikely etiologies - obstructive sleep apnea - tonsillar enlargement & recurrent tonsillitis - external ear disease mediated through auricular branch of the vagus nerve - parenchymal lung disease not visible on chest X-ray - pulmonary fibrosis - bronchiectasis - sarcoidosis - tracheobronchial disease - tracheobronchomalacia - chronic bronchitis - tracheopathia osteochondroplastica - foreign body inhalation [15,16] (may be radiolucent) - Whipple's disease (rare) [12] * 3 most common causes (90%); 99% in non-smokers with normal chest X-ray, not taking an ACE inhibitor [4] Epidemiology: - 12% of general population [14] - more common in women than men [14] - most common in 5th & 6th decade of life [14] Pathology: - cough reflex hyperresponsiveness [17] Clinical manifestations: - cough & other symptoms associated with etiology - cough with exercise or colde exposure suggests cough-variant asthma - presence of other symptoms (edema, arthralgias, myalgias, night sweats, diarrhea, headache) suggest a systemic etiology [12] - can persist for years [14] Laboratory: - sputum eosinophils to rule out eosinophilic bronchitis [4,7] - after spirometry & failed treatment for asthma [4] Special laboratory: 1) ear, nose & throat examination 2) spirometry if obstructive lung disease (asthma, COPD) suspected [4] or failure of intranasal glucocorticoids [4] - even if GERD more likely diagnosis (GRS11) [20] 3) Bernstein test or ambulatory esophageal pH testing - trial of proton pump ihibitor indicated prior to testing [4] 4) methacholine inhalation challenge to exclude asthma 5) bronchoscopy in the absence of chest X-ray abnormalities is of low diagnostic yield with exceptions - case of Christmas tree needle inhalation in child apparent only with laryngoscopy [16] - eosinophils on bronchial wash for non-asthmatic eosinophilic bronchitis [4] Radiology: - chest X-ray, especially for smokers [4] - high-resolution CT of thorax for refractory cases Complications: - physical, social, & psychological effects [14] Management: 1) empiric therapy recommended prior to extensive workup [4] - gabapentin may be useful [4,5] 2) for postnasal drip a) antihistamines b) decongestants c) glucocorticoid nasal spay, flunisolide, fluticasone ... 3) post-infection not caused by postnasal drip: ipratropium nasal spray 4) for cough variant asthma & post viral infection, treat as asthma 5) for GERD, use proton pump inhibitor for at least 8-12 weeks [6] - acid suppression with proton-pump inhibitors not effective in treating chronic cough due to GERD [18] 6) for non-asthmatic eosinophilic bronchitis, treat empirically with inhaled glucocorticoid [4,7] 7) referral for diagnostic testing only after failure of empiric therapy [8] 8) idiopathic chronic cough [17] - antitussive: dextromethorphan [4] - topical anesthetic: benzonatate - low-dose morphine - gabapentin or pregabalin [4] - multimodal speech therapy [4] (treatment of choice)

Specific

habit cough; somatic cough syndrome; psychogenic cough; cough tic

General

cough chronic respiratory tract disease

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 719
  2. Prescriber's Letter 9(1):3 2002 - Harnden A, Grant C, Harrison T, Perera R, Brueggemann AB, Mayon-White R, Mant D. Whooping cough in school age children with persistent cough: prospective cohort study in primary care. BMJ. 2006 Jul 22;333(7560):174-7. Epub 2006 Jul 7. PMID: 16829538 - Butler C, Francis N, Dinant GJ. Whooping cough in general practice. BMJ. 2006 Jul 22;333(7560):159-60. No abstract available. PMID: 16858020
  3. Journal Watch 24(6):51, 2004 Ambar RD & Hall HR, J Pediatr 144:213, 2004 PMID: 14760264
  4. Medical Knowledge Self Assessment Program (MKSAP) 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  5. Ryan NM et al. Gabapentin for refractory chronic cough: A randomised, double-blind, placebo-controlled trial. Lancet 2012 Aug 28 PMID: 22951084 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60776-4/fulltext
  6. Chang AB, Lasserson TJ, Gaffney J, Connor FL, Garske LA. Gastro-oesophageal reflux treatment for prolonged non-specific cough in children and adults. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD004823 PMID: 21249664
  7. Desai D, Brightling C. Cough due to asthma, cough-variant asthma and non-asthmatic eosinophilic bronchitis. Otolaryngol Clin North Am. 2010 Feb;43(1):123-30 PMID: 20172262
  8. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  9. Dalal B, Geraci SA. Office management of the patient with chronic cough. Am J Med. 2011 Mar;124(3):206-9 PMID: 0932505
  10. Broekhuizen BD, Sachs AP, Hoes AW et al Undetected chronic obstructive pulmonary disease and asthma in people over 50 years with persistent cough. Br J Gen Pract. 2010 Jul;60(576):489-94. PMID: 20594438
  11. Wei W1, Yu L, Wang Y et al Efficacy and safety of modified sequential three-step empirical therapy for chronic cough. Respirology. 2010 Jul;15(5):830-6 PMID: 20546197
  12. Damaraju D et al A Surprising Cause of Chronic Cough. N Engl J Med 2015; 373:561-566. August 6, 2015 PMID: 26244310 http://www.nejm.org/doi/full/10.1056/NEJMcps1303787
  13. Yancy WS Jr, McCrory DC, Coeytaux RR et al Efficacy and tolerability of treatments for chronic cough: a systematic review and meta-analysis. Chest. 2013 Dec;144(6):1827-38. Review. PMID: 23928798
  14. Rothaus C Chronic Cough Now@NEJM. Oct 20, 2016 http://blogs.nejm.org/now/index.php/chronic-cough-2/2016/10/20/
  15. Yilmaz A, Akkaya E, Damadoglu E, Gungor S. Occult bronchial foreign body aspiration in adults: analysis of four cases. Respirology. 2004 Nov;9(4):561-3. PMID: 15612971
  16. Philip J, Bresnihan M, Chambers N. A Christmas tree in the larynx. Paediatr Anaesth. 2004 Dec;14(12):1016-20. PMID: 15601352
  17. Smith JA, Woodcock A Chronic Cough N Engl J Med 2016; 375:1544-1551. October 20, 2016 PMID: 27797316 http://www.nejm.org/doi/full/10.1056/NEJMcp1414215
  18. Herregods TV, Pauwels A, Jafari J et al. Determinants of reflux-induced chronic cough. Gut 2017 Mar 15; PMID: 28298354 http://gut.bmj.com/content/early/2017/03/15/gutjnl-2017-313721
  19. Gibson P, Wang G, McGarvey et al Treatment of Unexplained Chronic Cough: CHEST Guideline and Expert Panel Report. Chest. 2016 Jan;149(1):27-44 PMID: 26426314 PMCID: PMC5831652 Free PMC article
  20. Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  21. Song WJ, Won HK, An J et al Chronic cough in the elderly Pulm Pharmacol Ther. 2019 Jun;56:63-68 PMID: 30914319