Cough

Last updated: November 8, 2022

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A cough is a protective mechanism that forcefully expels air from the lungs to clear secretions, foreign bodies, and irritants from the airway, and can be triggered by various conditions. A cough can be classified as acute, subacute, or chronic, in addition to productive (with sputum expectoration) or dry. The most common causes of acute cough are upper respiratory tract infections (URTIs), exacerbations of chronic conditions, and pneumonia. Subacute cough is often a sequela of a URTI (postinfectious cough) but can also be caused by upper airway cough syndrome (UACS) or pertussis. Common causes of chronic cough in adults include UACS, asthma, gastroesophageal reflux disease (GERD), nonasthmatic eosinophilic bronchitis (NAEB), and certain medications (e.g., ACE inhibitors, sitagliptin). The cause of an acute cough can often be determined clinically with a thorough medical history and physical examination. Chronic cough or the presence of red flag symptoms (including dyspnea, fever, hemoptysis, and weight loss) indicate that further investigation is required. Treatment depends on the underlying etiology and often includes symptomatic therapy.

See also “Dyspnea” and “Chest pain.”

Cough is a protective mechanism that forcefully expels air from the lungs to clear secretions, foreign bodies, and irritants from the airway.

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

Cough is usually classified by duration.

Causes of cough
Adults [7][13][14] Children [8][12][13]
Acute cough
Subacute cough
Chronic cough

In endemic areas, consider pulmonary tuberculosis in all patients with a cough of any duration. [7]

Consider pertussis in patients with risk factors, e.g., underimmunization and/or contact with an infected individual. [12]

Initial management

Life-threatening causes of cough

The following conditions should be considered in all adults who present with a cough accompanied by signs of respiratory distress, hemodynamic instability, and/or red flags for cough (see also “Dyspnea”):

If the patient is unstable, follow the ABCDE approach and consider immediate oxygen therapy, airway management, and/or mechanical ventilation.

A large proportion of malignancies are first diagnosed following an emergency presentation of illness, more often in vulnerable and marginalized patients. Maintain a high index of suspicion for lung cancer in patients with red flags for cough and consider expedited referral for definitive diagnosis, staging, and treatment to prevent poor outcomes. [15]

Red flags for cough

These red flag features may indicate a life-threatening cause of cough and typically warrant rapid evaluation and treatment. [7][13]

  • Smoking history, in particular:
    • Current smokers > 45 years of age with a new or worsening cough and/or voice changes
    • Patients 55–80 years old with ≥ 30 pack-years who either currently smoke or quit smoking ≤ 15 years ago
  • Symptoms
  • Abnormal physical examination and/or abnormal imaging findings

An abnormal screening chest x-ray in a patient with cough is also a red flag.

A detailed history and physical examination are essential to help narrow down the possible causes of cough and guide initial investigations and management. [7][16]

Focused history

  • Duration of cough (weeks): Ascertaining the symptom duration is a recommended first step in evaluating adults presenting with cough (see “Classification”). [7][16]
  • Other cough characteristics
    • Presence of sputum
      • Productive cough
      • Nonproductive cough
    • Onset
      • Sudden
      • Gradual
    • Quality: classic cough presentations in children [8][12]
  • Aggravating factors
    • Symptom variation depending on the weather and/or season
    • Supine position
    • Exercise
    • Daytime or nighttime worsening of symptoms
  • Associated symptoms

Cough exacerbated by exercise and at nighttime is characteristic of cough-variant asthma.

Coughing paroxysms, inspiratory whoop, and posttussive emesis are characteristic of pertussis. [17]

Other key historical features

Focused physical examination

Diagnostic approach

Diagnostic studies for acute or subacute cough are not routinely indicated in patients without red flags for cough. [7][13][16]

Imaging [7]

Chest x-ray

Additional imaging

Laboratory studies

Consider in patients with red flags for cough, signs of respiratory distress, suspected sepsis/bacteremia, or risk factors for specific infections.

In endemic areas, screen all patients with cough for tuberculosis regardless of cough duration. [12]

Pulmonary function tests

Consider based on clinical suspicion of chronic lung disease. [12]

Additional studies [7][20][21][22][23]

Consider the following on a case-by-case basis depending on clinical evaluation for cough, duration, and results of initial investigations.

Management [7][13][16]

Diagnostic studies for acute or subacute cough are not routinely indicated in patients without red flags for cough. [7][13][16]

Postinfectious cough is the most common cause of subacute cough and often resolves without treatment. If it is interfering with the patient's sleep and/or daily activities, consider the use of antitussives.

Most common causes

Most common causes of acute and subacute cough
Characteristic clinical features Diagnostic findings Management
Pertussis
COPD
  • See “Treatment of COPD.”
Postinfectious cough [21]
  • Recent URI symptoms
  • Cough lasts < 8 weeks
  • Supportive care
Tuberculosis
Exacerbation of pre-existing condition
Upper airway cough syndrome (UACS)
  • Frequent throat clearing
  • History of (allergic) rhinitis
Asthma
  • History of asthma and/or atopy
  • Decreased breath sounds, wheezing, or (in severe cases) silent chest
GERD [26][27]
  • Postprandial substernal chest pain, pressure, burning, reflux symptoms
  • Symptoms aggravated by lying in the supine position and certain foods (e.g., coffee, spices)
  • Epigastric tenderness
Bronchitis
Bronchiectasis

Additional causes to consider

Management

  • Obtain CXR (if not already performed). [7][12]
  • Perform sequential diagnostics and/or empiric treatment for the most common causes of chronic cough.
    • Consider the four most common etiologies and start empiric therapy for what is clinically most likely (see “Most common causes of chronic cough”). [16]
    • If suboptimal response after 4–6 weeks, proceed to the next condition. [7]
  • If symptoms persist despite evaluation and treatment for the most common causes:
    • Consult or refer to a specialist, e.g., pulmonology, otolaryngology.
    • Consider further diagnostic testing for less common causes (see “Diagnostics”).

Common causes

Most common causes of chronic cough in adults
Characteristic clinical features Diagnostic findings Management
UACS
  • Frequent throat clearing
  • History of (allergic) rhinitis
Asthma (e.g., cough-variant asthma)
  • History of asthma and/or atopy
  • Decreased breath sounds, wheezing, or (in severe cases) silent chest
Nonasthmatic eosinophilic bronchitis (NAEB)
GERD
  • Postprandial substernal chest pain, pressure, burning, reflux symptoms
  • Symptoms aggravated by lying in the supine position and certain foods (e.g., coffee, spices)
  • Epigastric tenderness

Additional causes to consider

Also consider new-onset COPD, interstitial lung disease, and lung cancer, especially in patients with red flags for cough.

General principles

Antibiotics are not recommended for the routine treatment of cough unless there is a proven indication, e.g., in pneumonia or acute bacterial sinusitis.

Symptomatic treatment for cough [24][25][28][29]

Expectorants

Cough suppressants (antitussives)

Antitussive medications decrease coughing and, therefore, should only be used in nonproductive cough, as coughing promotes the expectoration of mucus. Antitussives are not indicated in productive coughs or coughs caused by an infection.

Avoid prescribing opioids as antitussive medication in patients with risk factors for or a history of substance use disorders.

Mucolytics (e.g., N-acetylcysteine)

Chest physiotherapy

Supportive care

  • Rest and adequate hydration
  • Avoid lung irritants, e.g., smoke, incense. [31][32]
  • Nonpharmacological measures may be beneficial, e.g.: [14]
    • Nasal saline for nasal congestion
    • Honey [33][34][35]
    • A humidifier

Monitoring and disposition [7]

  • Adults
    • Routine follow-up 4–6 weeks after treatment initiated
    • Use validated cough severity and quality of life measurement tools if available.
  • Children: Reassess if acute cough becomes chronic, i.e., lasts ≥ 4 weeks. [12]

Specialist referral [7]

  • Persistent symptoms despite treatment for most common causes
  • Consider expedited specialist referral (e.g., pulmonology, ENT, GI) for:
    • Suspected serious underlying conditions
    • Chronic cough of unclear etiology

Refractory symptoms [7]

  • If symptoms persist despite evaluation and treatment for the most common causes:
    • Reconsider the working diagnosis if treatment is unsuccessful.
    • Consider specialist referral, e.g., pulmonology, otolaryngology.
    • Consider further diagnostic testing for less common causes (see “Diagnostics”).
  1. Irwin RS, French CL, Chang AB, et al. Classification of Cough as a Symptom in Adults and Management Algorithms. Chest. 2018; 153 (1): p.196-209. doi: 10.1016/j.chest.2017.10.016 . | Open in Read by QxMD
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