Cough Management in Interstitial Lung Disease

Initial Evaluation and Treatment

The American Thoracic Society recommends systematically evaluating and treating alternative causes of cough before attributing it to ILD itself, then proceeding with disease-specific ILD treatment when indicated, and finally considering neuromodulators or speech pathology therapy for refractory cases 1, 2
Evaluate for common alternative causes of cough, including gastroesophageal reflux disease (GERD), asthma or nonasthmatic eosinophilic bronchitis, upper airway cough syndrome, medication side effects, and pulmonary infections 1, 3, 4, 5
Assess for ILD progression as a cause of cough, including evidence of disease progression on imaging or pulmonary function tests, temporal association between cough onset and disease worsening, and favorable response to ILD-directed therapy 1, 3, 4

The American College of Chest Physicians recommends antifibrotic therapy (pirfenidone or nintedanib) for idiopathic pulmonary fibrosis (IPF) according to standard guidelines, which may reduce cough severity as a secondary benefit 1, 4, 6
Avoid systemic corticosteroids in IPF for cough management, as they are associated with increased mortality and should be limited to IPF exacerbations or co-existing asthma/eosinophilic bronchitis 1, 4, 6
For sarcoidosis, do not routinely prescribe inhaled corticosteroids for chronic cough, as three trials demonstrated no significant reduction in cough 1, 7

Gabapentin therapy is recommended as first-line treatment for refractory cough, following dosing protocols for unexplained chronic cough, to address cough hypersensitivity syndrome 1, 2, 4
Multimodality speech pathology therapy (cough suppression techniques and breathing exercises) is also recommended as first-line for refractory cough 2, 7
Low-dose controlled-release morphine is recommended as second-line therapy for refractory cough, with regular reassessment of benefits and risks 2, 7

For patients with chronic cough adversely affecting quality of life when alternative treatments have failed, opiates should be recommended for symptom control in a palliative care setting, with reassessment of benefits and risks at 1 week, then monthly before continuing 2, 3, 7, 8