Chronic Cough: Evaluation and Management

 

Although chronic cough in adults (cough lasting longer than eight weeks) can be caused by many etiologies, four conditions account for most cases: upper airway cough syndrome, gastroesophageal reflux disease/laryngopharyngeal reflux disease, asthma, and nonasthmatic eosinophilic bronchitis. Patients should be evaluated clinically (with spirometry, if indicated), and empiric treatment should be initiated. Other potential causes include angiotensin-converting enzyme inhibitor use, environmental triggers, tobacco use, chronic obstructive pulmonary disease, and obstructive sleep apnea. Chest radiography can rule out concerning infectious, inflammatory, and malignant thoracic conditions. Patients with refractory chronic cough may warrant referral to a pulmonologist or otolaryngologist in addition to a trial of gabapentin, pregabalin, and/or speech therapy. In children, cough is considered chronic if present for more than four weeks. In children six to 14 years of age, it is most commonly caused by asthma, protracted bacterial bronchitis, and upper airway cough syndrome. Evaluation should focus initially on these etiologies, with targeted treatment and monitoring for resolution.

Cough caused by the common cold typically lasts one to three weeks and is self-limited. However, persistent chronic cough can be the first sign of a more serious disease process. According to the Centers for Disease Control and Prevention, cough of undifferentiated duration is the most common presenting symptom in patients of all ages in the primary care ambulatory setting.1 In adults, chronic cough is defined as symptoms lasting longer than eight weeks, whereas acute cough lasts less than three weeks and subacute cough from three to eight weeks.2 When persistent and excessive, cough can seriously impair quality of life and lead to vomiting, muscle pain, rib fractures, urinary incontinence, tiredness, syncope, and depression. It also has psychosocial effects, such as embarrassment and negative impact on social interactions.3 This article presents a systematic approach to the evaluation of chronic cough, derived from the results of prospective studies and an evidence-based practice guideline.4,5

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In adults with chronic cough, initial evaluation should focus on the most common causes: upper airway cough syndrome, gastroesophageal or laryngopharyngeal reflux disease, asthma, and nonasthmatic eosinophilic bronchitis. Other causes to consider include angiotensin-converting enzyme inhibitor use, environmental triggers, tobacco use, and chronic obstructive pulmonary disease.

C

2, 46, 10, 14, 2022, 24, 26, 30, 35

In patients with refractory chronic cough, referral to a pulmonologist or otolaryngologist should be considered, as well as a trial of gabapentin (Neurontin), pregabalin (Lyrica), or speech therapy.

C

4, 5, 36, 3841

In children six to 14 years of age with chronic cough, initial evaluation should focus on the most common causes: asthma, protracted bacterial bronchitis, and upper airway cough syndrome.

C

4, 6, 4244


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In adults with chronic cough, initial evaluation should focus on the most common causes: upper airway cough syndrome, gastroesophageal or laryngopharyngeal reflux disease, asthma, and nonasthmatic eosinophilic bronchitis. Other causes to consider include angiotensin-converting enzyme inhibitor use, environmental triggers, tobacco use, and chronic obstructive pulmonary disease.

C

2, 46, 10, 14, 2022, 24, 26, 30, 35

In patients with refractory chronic cough, referral to a pulmonologist or otolaryngologist should be considered, as well as a trial of gabapentin (Neurontin), pregabalin (Lyrica), or speech therapy.

C

4, 5, 36, 3841

In children six to 14 years of age with chronic cough, initial evaluation should focus on the most common causes: asthma, protracted bacterial bronchitis, and upper airway cough syndrome.

C

4, 6, 4244


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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BEST PRACTICES IN PULMONARY MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not diagnose

The Authors

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CHARLIE MICHAUDET, MD, is an assistant professor in the Community Health and Family Medicine Department at the University of Florida College of Medicine, Gainesville....

JOHN MALATY, MD, is an associate professor in the Community Health and Family Medicine Department at the University of Florida College of Medicine.

Address correspondence to John Malaty, MD, University of Florida College of Medicine, 1707 N. Main St., Gainesville, FL 32609 (e-mail: malaty@ufl.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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