Management of chronic cough

A chest X-ray is indicated if a patient has a chronic cough.

The following could be done in patients with chronic cough

• offer help and advice on smoking cessation for patients who smoke
• if the patient is on ACE inhibitors, stop the drug and prescribe an appropriate alternative e.g. - most patients tolerate angiotensin II receptor blockers
  • although it might take some months to settle down the cough following withdrawal of the ACE inhibitors

If there is no history of ACE inhibitors or irritant exposure, consider other causes of chronic cough e.g. - malignancy, bronchiectasis, persistent pneumonia, sarcoidosis, and tuberculosis and manage accordingly (2).

In patients with normal chest radiographs consider the following specific cough syndromes (3):

• asthma
  • manage according to guidelines
• gastro-oesophageal reflux disease (GORD) (1)
  • diet and lifestyle modifications (3)
  • proton pump inhibitors (PPIs) e.g. -omeprazole 20-40 mg bd or equivalent taken before meals for at least 8 weeks
  • prokinetic agents e.g - metoclopramide 10 mg three times daily may benefit some patients
  • consider stopping drugs which may worsen GORD
  • patients who do not respond to medical therapy may require surgery
• upper airway disease and cough
  • usually accompanied by nasal stuffiness, sinusitis or upper airway cough syndrome (UACS) previously called post-nasal drip syndrome (PNDS)
  • for prominent upper airway symptoms - a trial of a topical corticosteroid for one month is recommended
  • a combination of sedating antihistamine and a decongestion are recommended as first-line approach
• cough variant asthma and eosinophilic bronchitis
  • cough variant asthma can be managed according to national guidelines
  • eosinophilic bronchitis and atopic cough will respond to inhaled corticosteroids (1)

It is important to keep in mind that chronic cough in many patients is multifactorial and may be caused by a combination of the above and resolution of cough occurs when all these diseases have been effectively treated (3).

Psychogenic cough is seen less commonly in adults than in children (2).

It can be diagnosed only after all other possible causes have been eliminated. Removal of psychologic stressors, behaviour modification therapy, and short-term use of antitussives could be considered (2).

Note: A clinical statement on chronic cough in adults (published by the British Thoracic Society) can be found online.

Reference:

1. Morice AH et al. Recommendations for the management of cough in adults. Thorax. 2006;61 Suppl 1:i1-24
2. Holmes RL, Fadden CT. Evaluation of the patient with chronic cough. Am Fam Physician. 2004;69(9):2159-66
3. Pratter MR, et al. An empiric integrative approach to the management of cough: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 Suppl):222S-231S