Cough

Background

• Cough is the most common symptom for which patients seek medical attention.
  • It may be acute (< 3 weeks), subacute (3-8 weeks), or chronic (> 8 weeks).
  • The estimated incidence is 9%-33% of population.
• Common causes of cough include:
  • for acute cough
    • viral upper respiratory tract infection (common cold)
    • exacerbation of underlying lung disorder, such as asthma and chronic obstructive pulmonary disease (COPD)
  • for subacute cough
    • postinfectious cough
    • exacerbation of underlying lung disorder
    • beginning stage of chronic cough
  • for chronic cough
    • use of angiotensin-converting enzyme (ACE) inhibitors
    • smoking
    • gastroesophageal reflux disorder (GERD)
    • upper airway cough syndrome
    • bronchitis (acute, chronic, or nonasthmatic eosinophilic)
    • COPD
    • asthma, including cough variant asthma
  • There are many uncommon causes.

Evaluation

• When taking the history, ask about:
  • onset, duration, and characteristics of cough and associated symptoms
  • use of medications, particularly angiotensin-converting enzyme (ACE) inhibitors
  • known conditions that cause cough and prior upper respiratory infection
  • smoking history, triggers, and possible exposures
• The physical may be unremarkable, but patients may have signs of viral upper respiratory tract infection or underlying pulmonary disease.
• Diagnostic algorithms and testing may help determine underlying cause.

Management

• Acute cough
  • For common cold symptoms, medications not recommended include over-the-counter cough and cold medicines, nonsteroidal anti-inflammatory drugs, and codeine-containing medications.
  • For acute bronchitis, consider peripheral cough suppressants (such as levodropropizine and moguisteine) for short-term relief of coughing.
  • For acute cough requiring symptom relief, medications affecting efferent limb of cough reflex (such as baclofen) are NOT recommended.
  • For acute cough NOT due to asthma, albuterol is NOT recommended.
  • Opiate antitussives (codeine, hydrocodone) generally are not recommended due to adverse effects, and should be particularly avoided in children < 18 years old due to serious adverse effects including respiratory depression.
• Subacute cough
  • Antibiotics are not recommended for patients with postinfectious cough that is not due to bacterial sinusitis or for patients with early Bordetella pertussis infection, while it is unknown what optimal therapy will be.
  • For confirmed or probable B. pertussis infection, prescribe macrolide antibiotics and isolate patient for 5 days from start of treatment to prevent disease spread (Strong recommendation).
• Chronic cough
  • Empiric treatment systematically directed at common causes of cough is recommended.