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cough

see chronic cough if > 2 months duration Etiology: 1) generally a reflex response to stimuli that irritate the larynx, trachea or large bronchi a) external stimuli* including asthma - dust - foreign body - hot or cold air - smoke b) internal stimuli - inflammation of the respiratory mucosa - bronchitis (acute bronchitis, chronic bronchitis) - pneumonia - upper respiratory tract infection - compression of the airway - tumor - enlarged peribronchial lymph node - post-nasal drip* - gastroesophageal reflux disease* 2) left-sided heart failure 3) pharmacologic agents: a) ACE inhibitors* b) inhaled drugs c) mycophenolate d) propofol e) aspirin, NSAIDs f) beta-blockers g) antibiotics - amphotericin B - erythromycin - sulfonamides - aminoglyocosides h) chemotherapeutic agents [5] 4) respiratory tract infection - pertussis (coughing spasms) 5) elderly - oropharyngeal dysphagia with meal-time cough in elderly may be due to stroke [19] - pocketing of food in severe dementia [19] 6) cough may be intentional action to illicit a vagal maneuver * common causes of chronic cough Epidemiology: - most common complaint in outpatient medicine Pathology: 1) afferent arm of cough reflex a) trigeminal nerve b) glossopharyngeal nerve c) superior laryngeal nerve d) vagus nerve 2) efferent arm of cough reflex a) recurrent laryngeal nerve b) spinal nerves 3) lesions in the nose, ears, pharynx, larynx, bronchi, lungs, pleura & abdominal viscera may cause cough History: - duration, rate of onset, fever/chills, sputum (quality), dyspnea, pleuritic chest pain, orthopnea, sore throat, rhinorrhea, headache, stiff neck, ear pain, nausea/vomiting, diarrhea, arthralgia, myalgia, smoking, recent antibiotics, exposure to tuberculosis or asbestos, travel, ill contacts, pneumococcal & influenza vaccination Clinical manifestations: - cough due to upper respiratory tract infection may persist from weeks to several months - generally resolves within 10 days in 50% of children & within 25 days in 90% [15] - persistent severe, paroxysmal coughing suggests pertussis - cough with exposure to cold air suggests asthma - see chronic cough for cough > 2 months duration Laboratory: - sputum examination for eosinophilia - Bordetella pertussis antigen in body fluid (if indicated) Special laboratory: - provocation inhalation testing with methacholine for suspected asthma - see chronic cough for cough > 2 months duration Radiology: - chest X-ray - generally of low yield - indications: - fever, constitutional symptoms, - abnormal physical examination - altered mental status [5] Complications: 1) cough syncope a) increased intrathoracic pressure b) decreased cardiac output & cerebral perfusion 2) rib fractures 3) pneumothorax Management: 1) antihistamine (1st generation)/decongestants, i.e. (brompheniramine/pseudoephedrine) 1st line agent for cough due to common cold [8] - may be useful for cough due to post-nasal drip [8] 2) intranasal glucocorticoids for cough due to allergic rhinitis & post-nasal drip (upper airway cough syndrome) [5] 3) opiates (i.e. codeine) have proven antitussive effects - codeine not recommended for children with cough due to upper respiratory tract infection [16] 4) inhaled ipratropium for cough with wheezing that persists > 1 week after upper respiratory tract infection 5) inhaled glucocorticoids if ipratropium fails 6) dextromethorphan has mild antitussive effects (avoid coadministration with SSRI) 7) sugar, honey, cough drops can relieve cough by increasing saliva which coats the larynx & relieves irritation [10,11,12] 8) haloperidol is an effective antitussive agent [5] 9) cough due to GERD may respond to omeprazole 10) NSAIDs may be useful by reducing inflammation [8] 11) little evidence that other agents have antitussive effects - guaifenesin, terpin hypdrate, benzonatate, cough drops 12) placebo before bedtime of benefit in treatment of cough, congestion, & rhinorrhea due to common cold in children [17] 13) treatment of asthma 14) antibiotics - not recommended without a clear bacterial cause [5] - azithromycin if pertussis suspected - persistent severe, paroxysmal coughing suggests pertussis 15) unexplained chronic cough [5] - speech therapy may be benefit - antitussives may be of benefit - gabapentin may be effective [5]

Specific

chronic cough coughing spasm; paroxysmal coughing postinfectious cough

General

sign/symptom

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
  2. Guide to Physical Examination & History Taking, 4th edition, Bates B, JB Lippincott, Philadelphia, 1987
  3. Ferri's Clinical Advisor, Instant Diagnosis and Treatment, Ferri FF (ed), Mosby, Philadelphia, 2003
  4. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 719
  5. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2021.
  6. Chang AB et al, Systematic review and meta-analasys of randomized controlled trials of gastroesophageal reflux interventions for chronic cough-associated with gastro-oesophageal reflux. BMJ 2006, 332: 11 PMID: 16330475
  7. Irwin RS; American College of Chest Physicians (ACCP). Assessing cough severity and efficacy of therapy in clinical research: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 Suppl):232S-237S. PMID: 16428716 http://www.chestjournal.org/content/vol129/1_suppl/index.shtml
  8. Prescriber's Letter 13(10): 2006 Pharmacologic Treatment of Cough: Evidence-Based Guidelines Detail-Document#: 221006 (subscription needed) http://www.prescribersletter.com
  9. Prescriber's Letter 14(1): 2007 Pharmacologic treatment of cough: Evidence-based guidelines Detail-Document#: 230109 (subscription needed) http://www.prescribersletter.com
  10. Prescriber's Letter 15(1): 2008 Alternatives to OTC Cough and Cold Medication for Children Detail-Document#: 240111 (subscription needed) http://www.prescribersletter.com
  11. Paul IM et al Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Arch Pediatr Adolesc Med 2007 Dec; 161:1140. PMID: 18056558
  12. Cohen HA et al Effect of Honey on Nocturnal Cough and Sleep Quality: A Double-blind, Randomized, Placebo-Controlled Study Pediatrics, Aug 6, 2012 PMID: 22869830 http://pediatrics.aappublications.org/content/early/2012/08/01/peds.2011-3075.abstract
  13. Irwin RS, Baumann MH, Bolser DC et al Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 Suppl):1S-23S. PMID: 16428686
  14. Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD001831 PMID: 15495019
  15. Thompson M et al Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013;347:f7027 PMID: 24335668 http://www.bmj.com/content/347/bmj.f7027
  16. Kaiser SV et al National Patterns of Codeine Prescriptions for Children in the Emergency Department. Pediatrics. April 21, 2014 PMID: 24753533 http://pediatrics.aappublications.org/content/early/2014/04/16/peds.2013-3171.full.pdf+html - Woolf AD and Greco C Why Can't We Retire Codeine? Pediatrics. April 21, 2014 PMID: 24753529 http://pediatrics.aappublications.org/content/early/2014/04/16/peds.2013-4057.full.pdf+html
  17. Paul IM et al Placebo Effect in the Treatment of Acute Cough in Infants and Toddlers. A Randomized Clinical Trial. JAMA Pediatr. Published online October 27, 2014 PMID: 25347696 http://archpedi.jamanetwork.com/article.aspx?articleid=1913623 - Taylor JA, Opel DJ Using the Placebo Effect to Treat Cold Symptoms in Children. JAMA Pediatr. Published online October 27, 2014 PMID: 25347413 http://archpedi.jamanetwork.com/article.aspx?articleid=1913621
  18. NEJM Question of the Week. May 15, 2018 https://knowledgeplus.nejm.org/question-of-week/545/
  19. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  20. Irwin RS, French CL, Chang AB, et al; CHEST Expert Cough Panel*. Classification of cough as a symptom in adults and management algorithms: CHEST guideline and expert panel report. Chest. 2018;153:196-209. PMID: 29080708