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Chronic cough

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Cough is a vital protective reflex necessary to prevent aspiration and clear the airways of mucous. However excessive and protracted coughing can be very disabling and greatly affect a patient’s quality of life.

It affects an estimated 5 to 10% of adults.

As cough is a common medical symptom which can be associated with a number of different conditions, this guideline aims to aid clinicians in the diagnosis and management of chronic cough.

Quick reference guide

Reflux Guide line https://tam.nhsh.scot/for-healthcare-professionals/therapeutic-guidelines/gastro-intestinal/upper-gastro-intestinal/upper-gi-guidelines/

ENT guidelines https://tam.nhsh.scot/for-healthcare-professionals/therapeutic-guidelines/ear-nose-and-oropharynx-ent/

Asthma guidelines https://tam.nhsh.scot/for-healthcare-professionals/therapeutic-guidelines/respiratory/adults-with-asthma/

Urgent suspected lung cancer https://tam.nhsh.scot/for-healthcare-professionals/therapeutic-guidelines/respiratory/urgent-suspected-lung-cancer/

Assessment and Investigation
  • Take a comprehensive history including:
    • Duration
    • Triggers
    • Diurnal variability
    • Red flag symptoms/features- exclude malignancy
    • Associated symptoms – Chest, Throat
    • Infective symptoms- Exclude active infection
    • Recent respiratory tract infection
    • Co-morbid conditions causing cough- exclude exacerbation of known condition
    • Gastrointestinal symptoms
    • Symptoms of heart failure
    • Smoking history
    • Occupational history
    • Recent travel
    • Environmental factors
    • Cough scoring – out of 10/ Visual analogue scale
    • Drug history – exclude iatrogenic cause
  • Assess the effect of the cough on a patient’s quality of life using tools, such as the Leicester Cough Questionnaire:https://hgs.uhb.nhs.uk/wp-content/uploads/cough_questionnaire.pdf (Hyper link to be named The Leicester Cough Questionnaire)  and specifically ask about symptoms of:

            And offer appropriate support and management.

  • Exclude the presence of a respiratory condition (infection, COPD, ILD, Asthma etc)

Examination

Complete a thorough examination including

  • Chest
  • Heart
  • Ears
  • Pharynx

Investigation

  • Spirometry
  • CXR
Cough definition
Acute cough- less than 3 weeks
  • Defined as a cough which has been present for less than three weeks.
  • Most common causes to consider
    • Upper respiratory tract infection
    • COVID 19
    • Acute exacerbation of a pre-existing condition -Asthma, COPD, Bronchiectasis
    • Acute bronchitis
    • Pneumonia
  • If associated with acute onset of breathlessness and chest pain, consider
    • PE
    • Pneumothorax/tension pneumothorax
Subacute Cough 3 to 8 weeks
  • Defined as a cough which has been present for three to eight weeks.
  • Most common causes to consider:
    • Lung Cancer (especially in current/ex-smokers) -Asses for any Red flag symptoms
    • Post infectious cough (eg after Mycoplasma pneumonia or Bordetella pertussis) Persistent dry cough with a history of a recent acute respiratory infection, in a systemically well patient, with a normal examination.
Urgent suspected Cancer

Patients presenting with any of the following red flag symptoms/signs for lung cancer should follow the Urgent Suspected Cancer pathway (link to USC guideline).

  • Any unexplained haemoptysis
  • New/ not previously documented finger clubbing
  • Persistent or recurrent chest infections
  • Cervical and/or persistent supraclavicular lymphadenopathy
  • Thrombocytosis where symptoms and signs do not suggest other specific cancer

Unexplained and persistent symptoms lasting more than 3 weeks:

  • change in cough or new cough
  • dyspnoea
  • chest/shoulder pain
  • loss of appetite
  • weight loss
  • chest signs
  • hoarseness (if no other symptoms present to suggest lung cancer refer via Head & Neck pathway)
  • fatigue in a smoker aged over 40 years

Any patient who has consolidation on chest x-ray should have a repeat no more than 6 weeks later to confirm resolution regardless of hospital admission or not if:

  • Symptoms/physical signs persist
  • There is higher risk of underlying malignancy
    • smokers
    • aged over 50 years
Chronic Cough greater than 8 weeks duration
  • Defined as a cough which has been present for more than eight weeks.
  • The most common causes of chronic cough are listed below in Differential diagnosis and management
  • Other causes of chronic cough to consider are:
    • Infective causes - Pertussis
    • Pulmonary tuberculosis
  • Respiratory conditions
    • COPD
    • Asthma
    • Interstitial lung disease
    • Bronchitis
    • Obstructive sleep apnoea – awaking from sleep with cough
    • Lung Cancer
    • Bronchiectasis
  • Other conditions causing cough
    • Heart Failure
    • Somatic cough syndrome
  • Environmental/occupational exposure to a cough trigger
Differential diagnosis and management
Bronchiectasis
  • Bronchiectasis is characterized by permanent, irreversible dilation of the bronchi due to inflamation and damage to the airways.
  • Symptoms include intermittent infection and persistent daily expectoration of purulent sputum
  • Due to the widening of the airways, mucous is able to accumulate which increases the risk of respiratory infection.
  • Because of this, it is beneficial for patients with bronchiectasis to cough regularly to expectorate the sputum and reduce their risk of infection.
  • However patients can struggle with regular coughing, particularly if their cough is ineffective and may find it exhausting.

Management

  • Sign posting to relevant information about effective cough and airway clearing techniques. (see social prescribing guidance for resources)  
Smoking and Nicotine
  • Smoking and smoking exposure are a cause of chronic cough
  • Always consider COPD and Lung cancer as a cause of cough in a current or ex-smoke

Management

  • Refer to the smoking cessation service
  • Note- Nicotine is a cough suppressant so patients should be warned that they may experience a transient increase in coughing after quitting smoking.
Asthma

Classic asthma

  • Patient has features of bronchoconstriction and bronchial hyperresponsiveness
  • Spirometry or peak flow show airflow variability.

Cough variant asthma

  • Patient has features of hyperresponsiveness with cough as their main symptom
  • Patient may have normal spirometry and lack peak flow variability. 

Eosinophilic bronchitis

  • A condition characterised by eosinophilia in the airways causing cough.
  • Patient presents with cough but no features of bronchoconstriction or hyperresponsiveness
  • Patients have normal peak flow and spirometry

Management

Reflux cough
  • Reflux cough is characterised by either gastroesopahgeal or oesophagealpharangeal reflux, due to either reflux or dysmotility, causing aspiration resulting in airway inflammation
  • This inflammation may be neutrophilic or esinophilic and results in an asthma type cough and excessive mucous production.   
  • Common symptoms of reflux cough include change in voice, nasal symptoms and dysgeusia.
  • Patients may also present with recurrent aspiration pneumonia, bronchitis and bronchiectasis secondary to reflux rather than being the primary cause of the cough.

Management

Review

  • 6 to 8 weeks.
  • If improvement, manage as per GI guidelines. No further action required
  • If no improvement, Stop medication and reconsider diagnosis.  
Upper airways Cough syndrome
  • Patient presents with cough associated with symptoms of persistent throat clearing and a feeling of something in the back of the throat, nasal discharge, congestion or recurrent sneezing.  
  • Cough results from irritation of afferent nerve pathways in the upper airways.
  • Often associated with seasonal or occupational triggers
  • Can be associated with Reflux or Asthma

Management

Review

  • 6 to 8 weeks.
  • If improvement, manage as per ENT guidelines. No further action required
  • If no improvement, Stop medication and reconsider diagnosis.  
Iatrogenic cough
  • Cough secondary to medication.

ACE inhibitors

  • Can increase the sensitivity of the cough reflex and can cause cough in up to 15% of patients.
  • Should not be prescribed in patients with pre-existing cough.  

Management

  • Stop ACE inhibitor and prescribe angiotensin II inhibitor if needed as an alternative.
  • If no improvement, consider alternative diagnosis

Sitagliptin and other dipeptidylpeptidase-4 inhibitors

  • A drug sensitivity reaction causing symptoms of cough with rhinorrhoea, dyspnoea, or fatigue.

Bisphosphonates and Calcium Channel Antagonists

  • Can exacerbate pre-existing reflux disease leading to reflux cough.

Prostanoid eye drops such as latanoprost

  • Can travel down the lacrimal duct and irritate the pharynx leading to cough.
Chronic refractory cough
  • Chronic cough with unexplained aetiology despite full investigation, smoking cessation, iatrogenic causes removed and refractory to all treatment.

Management  

  • Routine referral to respiratory  
Referral
  • Routine Respiratory referral via SCI Gateway for all patients with suspected chronic refractory cough for consideration of neuromodulator medication and possible clinical trial involvement.  

Contact the Respiratory Team

Social prescribing guidance

Resources

Methods to reduce coughing

  1. Breathing through your nose as much as you can, rather than your mouth can help. Try to build it up slowly so you are eventually using your nose all the time (except when talking)
  2. If you feel a cough coming on swallow hard, relax your shoulders and concentrate on breathing slowly and gently out
  3. Retraining your breathing pattern. Develop good breathing habits by using your diaphragm, rather than muscles around your shoulders and neck to breathe.
  4. Using airway clearance techniques to help keep your airways clear.
  5. Try taking regular sips of water can help to keep your throat moist and reduce irritation. Carrying a water bottle with you can help with this.
  6. Sucking on a sweet can have a similar effect. This can be useful before talking on the phone/ for a long period of time.
  7. Some people find eating frozen pineapple chunks or frozen grapes can help with cough.

Stop Cough Remedy.

  • Try not to cough at all, but if a cough feels like it is to come then cough once only, with hand over mouth and with lips closed.
  • Swallow once or sip some water
  • Keeping lips closed, breathe out gently, pinch your nose closed and take a breath pause of 5 to 10 secs
  • Continue to breathe gently with lips closed for about 15 seconds
  • Repeat the breath pause 2 to 3 times, resisting the urge to cough
Further information for healthcare professionals

Contact the Respiratory Team

For any queries or concerns contact the respiratory consultants for advice: nhsh.raigmorerespiratory@nhs.scot

Patient information
Glossary

ICS - Inhaled corticosteroids

COPD- Chronic Obstructive Pulmonary Disease

PE – Pulmonary Embolism

USC - Urgent Suspected Cancer

GI - Gastroenterology

ENT- Ear, Nose and Throat.

NHSH – NHS Highland

ACE - Angiotensin-converting enzyme

ILD – Interstitial lung disease

CXR – Chest Xray

References

 

Editorial Information

Last reviewed: 30 April 2022

Next review: 30 April 2025

Author(s): Specialty Respiratory Research Doctor

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Specialty Respiratory Research Doctor

Document Id: TAM495