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Chronic Cough: Evaluation and Management CHARLIE MICHAUDET, MD, and JOHN MALATY, MD, University of Florida College of Medicine, Gainesville, Florida

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Chronic Cough: Evaluation and Management CHARLIE MICHAUDET, MD, and JOHN MALATY, MD, University of Florida College of Medicine, Gainesville, Florida Chronic Cough: Evaluation and Management CHARLIE MICHAUDET, MD, and JOHN MALATY, MD, University of Florida College of Medicine, Gainesville, Florida Although chronic cough in adults (cough lasting longer than eight weeks) can be caused by many etiologies, four conditions account for most cases: upper airway cough syndrome, gastroesophageal reflux disease/laryngopharyn- geal reflux disease, asthma, and nonasthmatic eosinophilic bronchitis. Patients should be evaluated clinically (with spirometry, if indicated), and empiric treatment should be initi- ated. Other potential causes include angiotensin-converting enzyme inhibitor use, environmental triggers, tobacco use, chronic obstruc- tive pulmonary disease, and obstructive sleep apnea. Chest radiogra- phy can rule out concerning infectious, inflammatory, and malignant thoracic conditions. Patients with refractory chronic cough may warrant referral to a pulmonologist or otolaryngologist in addi- tion to a trial of gabapentin, pregabalin, and/or speech therapy. In children, cough is considered chronic if present for more than four weeks. In children six to 14 years of age, it is most commonly caused by asthma, protracted bacterial bronchitis, and upper airway cough syndrome. Evaluation should focus initially on these etiologies, with targeted treatment and monitoring for resolution. (Am Fam Physi- cian. 2017;96(9):575-580. Copyright © 2017 American Academy of Family Physicians.) ILLUSTRATION JONATHAN BY DIMES CME This clinical content ough caused by the common cold less than three weeks and subacute cough conforms to AAFP criteria typically lasts one to three weeks from three to eight weeks.2 When persistent for continuing medical education (CME). See and is self-limited. However, per- and excessive, cough can seriously impair CME Quiz on page 567. sistent chronic cough can be the quality of life and lead to vomiting, muscle Author disclosure: No rel- Cfirst sign of a more serious disease process. pain, rib fractures, urinary incontinence, evant financial affiliations. According to the Centers for Disease Control tiredness, syncope, and depression. It also has ▲ Patient information: and Prevention, cough of undifferentiated psychosocial effects, such as embarrassment A handout on this topic is duration is the most common presenting and negative impact on social interactions.3 available at http://www. symptom in patients of all ages in the primary This article presents a systematic approach aafp.org/afp/2011/1015/ 1 p894.html. care ambulatory setting. In adults, chronic to the evaluation of chronic cough, derived cough is defined as symptoms lasting longer from the results of prospective studies and an than eight weeks, whereas acute cough lasts evidence-based practice guideline.4,5 Assessment of Chronic Cough BEST PRACTICES IN PULMONARY MEDICINE: RECOMMENDATIONS The initial evaluation should focus on iden- FROM THE CHOOSING WISELY CAMPAIGN tifying potential triggers, such as the use of an angiotensin-converting enzyme (ACE) Recommendation Sponsoring organization inhibitor, environmental exposures, smok- Do not diagnose or manage asthma without American Academy of Allergy, ing status, and chronic obstructive pulmo- spirometry. Asthma and Immunology nary disease (COPD). It should also rule out Cough and cold medicines should not be American Academy of red flags (e.g., fever, weight loss, hemoptysis, prescribed or recommended for respiratory Pediatrics illnesses in children younger than four years. hoarseness, excessive dyspnea or sputum production, recurrent pneumonia, smok- Source: For more information on the Choosing Wisely Campaign, see http://www. ing history of 20 pack-years, or smoker older choosingwisely.org. For supporting citations and to search Choosing Wisely recom- than 45 years) that suggest a serious underly- mendations relevant to primary care, see http://www.aafp.org/afp/recommendations/ 6 search.htm. ing cause of cough. The patient’s description of the cough (character, timing, presence or NovemberDownloaded 1, from 2017 the ◆ American Volume Family96, Number Physician 9 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2017 American Academy of FamilyAmerican Physicians. Family For the Physician private, noncom 575- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Chronic Cough SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References In adults with chronic cough, initial evaluation should focus on the most common causes: upper C 2, 4-6, 10, 14, 20- airway cough syndrome, gastroesophageal or laryngopharyngeal reflux disease, asthma, and 22, 24, 26, 30, 35 nonasthmatic eosinophilic bronchitis. Other causes to consider include angiotensin-converting enzyme inhibitor use, environmental triggers, tobacco use, and chronic obstructive pulmonary disease. In patients with refractory chronic cough, referral to a pulmonologist or otolaryngologist should be C 4, 5, 36, 38-41 considered, as well as a trial of gabapentin (Neurontin), pregabalin (Lyrica), or speech therapy. In children six to 14 years of age with chronic cough, initial evaluation should focus on the most C 4, 6, 42-44 common causes: asthma, protracted bacterial bronchitis, and upper airway cough syndrome. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort. absence of sputum production) should not Table 1. Etiologies of Chronic Cough in Adults and Children determine the clinical approach; sequen- tial or concomitant treatment of common 4 Adults Children causes is still recommended. Unless a likely cause is identified, chest radiography should Most common Most common Angiotensin-converting enzyme Asthma be obtained to rule out most infectious, inhibitor use Protracted bacterial inflammatory, and malignant thoracic con- Asthma bronchitis ditions. When physical examination find- Environmental triggers Upper airway cough ings are normal and no red flags are present, Gastroesophageal/laryngopharyngeal syndrome (in children older routine computed tomography of the chest reflux disease than six years) and sinuses is not necessary, nor is initial Nonasthmatic eosinophilic bronchitis Less common bronchoscopy.2 Tobacco use Environmental triggers The diagnostic approach should focus on Upper airway cough syndrome Foreign body (in younger detection and treatment of the four most children) Less common common causes of chronic cough in adults: Gastroesophageal reflux Bronchiectasis disease upper airway cough syndrome (UACS), Chronic obstructive pulmonary disease Pertussis asthma, nonasthmatic eosinophilic bron- Obstructive sleep apnea Postinfectious bronchospasm chitis, and gastroesophageal reflux disease Pertussis (GERD)/laryngopharyngeal reflux disease.4,5 Least common Postinfectious bronchospasm After evaluation and empiric management of Chronic aspiration Least common Congenital abnormality these etiologies, less common causes should Arteriovenous malformation 7 8 Cystic fibrosis be considered (Tables 1 and 2 ). A suggested Bronchiolitis Immunodeficiency primary care approach to the evaluation of Bronchogenic carcinoma Primary ciliary dyskinesia chronic cough for immunocompetent adults Chronic aspiration 9 Psychogenic cough is shown in Figure 1. Chronic interstitial lung disease Tourette syndrome/tic Irritation of external auditory canal Common Causes of Chronic Cough Persistent pneumonia UPPER AIRWAY COUGH SYNDROME Psychogenic cough The term UACS, previously referred to as Sarcoidosis postnasal drip syndrome, was coined in Tuberculosis the 2006 American College of Chest Phy- 4 Adapted with permission from Benich JJ III, Carek PJ. Evaluation of the patient with sicians guideline in recognition of the chronic cough. Am Fam Physician. 2011;84(8):888. fact that multiple etiologies, including chronic rhinosinusitis, allergic rhinitis, and 576 American Family Physician www.aafp.org/afp Volume 96, Number 9 ◆ November 1, 2017 Chronic Cough nonallergic rhinitis, were difficult to differentiate solely ASTHMA AND COPD by clinical presentation. UACS is the most common The prevalence of asthma in patients with chronic cough cause of chronic cough.10 Rhinorrhea, nasal stuffiness, ranges from 24% to 29%.13 It should be suspected in sneezing, itching, and postnasal drainage suggest the patients with shortness of breath, wheezing, and chest diagnosis, but their absence does not rule out UACS.11 tightness, but cough can be the only manifestation in Physical findings may include swollen turbinates and cough variant asthma. If the physical examination and direct visualization of postnasal drainage and cobble- spirometry findings are nondiagnostic, bronchial chal- stoning of the posterior pharynx. If a specific cause is lenge testing (methacholine inhalation test) should be identified, therapy should be started; otherwise, initial considered.14 Resolution of the cough after asthma treat- treatment includes a decongestant combined with a ment is also diagnostic. After counseling the patient about first-generation antihistamine. Intranasal corticoste- potential triggers, treatment usually includes an inhaled roids, saline nasal rinses, nasal anticholinergics, and bronchodilator and high-dose inhaled corticosteroid. A antihistamines are also reasonable
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