• Clinical science

Cough

Abstract

A cough is a forceful expulsion of air from the lungs that helps to clear secretions, foreign bodies, and irritants from the airway. It may be classified as acute (< 3 weeks), subacute (3–8 weeks), or chronic (> 8 weeks), as well as productive (with sputum/mucus expectoration) or dry. Upper respiratory tract infections (URI) and acute bronchitis are the most common causes of acute cough. Subacute cough is often a sequela of a URI (postinfectious cough) but can also be due to chronic bronchitis or pneumonia. Chronic cough is often caused by rhinitis/sinusitis (upper airway cough syndrome), asthma, GERD, and ACE inhibitors. A thorough medical history and physical examination often suffice to diagnose the etiology of cough. Chronic cough or the presence of associated red flag symptoms (dyspnea, fever, hemoptysis, weight loss) are indications for further investigation. Sputum culture, chest x-ray/CT scan, and pulmonary function tests are useful diagnostic tests in the evaluation of cough, but are not routinely indicated. Treatment of cough depends on the underlying etiology.

Pathophysiology

  • Definition: a forceful expulsion of air from the lungs that helps to clear secretions, foreign bodies, and irritants from the airway
  • May be voluntary or a reflex to airway irritants/triggers
    • Mechanical
      • Inhaled/aspirated solid or particulate matter (e.g., smoke, dust)
      • Mucus
    • Chemical
    • Thermal: cold air
  • Cough reflex arc
    1. Irritation of cough receptors in the nose, sinuses, and upper and lower respiratory tracts (see the triggers above)
    2. Transmission along the afferent pathway via the vagus nerve (CN X) to the cough center in the medulla
    3. Generation of efferent signal in the medulla and initiation of cough via the vagus, phrenic, and spinal motor nerves
  • Mechanism of cough reflex

References:[1][2][3][4][5][6][7]

Overview

Differential diagnosis of acute cough

(< 3 weeks)

Subacute cough

(3–8 weeks)

Differential diagnosis of chronic cough

Non-life-threatening causes

Life-threatening causes In children

In adults

(> 8 weeks)

In children

(> 4 weeks)

References:[8][9][10][11]

Approach

History

Clinical examination:

References:[8][6][12][13][14][15]

Diagnostics

  • An acute cough is often a clinical diagnosis (diagnostic tests are not routinely indicated in this case).
  • Patients with chronic cough and/or red flag symptoms (see “Approach” above) require further assessment.

Laboratory tests

Imaging

Pulmonary function tests

Miscellaneous

Close history taking and physical examination are sufficient to diagnose the cause of an acute cough without red flag symptoms! In chronic cough and cough with red flag symptoms, thoracic x-ray and pulmonary function testing should be considered at an early stageReferences:[16][17][18][19][20]

Treatment

Acute cough

Subacute cough

  • Post-infectious cough
    • Often resolves spontaneously (no treatment needed)
    • Cough interfering with sleep/daily activities: antitussives (see below), inhaled bronchodilators, oral/inhaled corticosteroids
  • Suspected pertussis: early administration of macrolide antibiotics and quarantine (for 5 days after initiating antibiotics)
  • See "treatment" of pneumonia and COPD.

Chronic cough

Symptomatic treatment of a cough

Antibiotics

Bronchodilators

References:[21][22][9][12][17][23][24][25][26][27][28][29][30][31]