Cough Assessment and Management

Patient History and Symptoms

The American Thoracic Society recommends assessing the onset and duration of cough, as well as any associated symptoms such as pain or discomfort in the chest, to determine the underlying cause of the cough 1
Patients with cough often experience postnasal drip or throat clearing, and may have a dry or productive cough with varying characteristics such as color, consistency, and amount of sputum 1
Chronic cough is defined as a cough lasting more than 8 weeks, as defined by the European Respiratory Society and the American Thoracic Society 2, 1
Smoking history and exposure to irritants can contribute to the development and severity of cough, and assessing smoking status is crucial, with the majority of patients experiencing cough resolution within 4 weeks after smoking cessation, as recommended by the American College of Chest Physicians 3, 1

Spirometry is a mandatory examination for all patients with chronic cough, allowing the identification of bronchial obstruction, and a normal result does not exclude asthma or eosinophilic bronchitis, as recommended by the American Thoracic Society 1
The evaluation of sputum can help diagnose non-asthmatic eosinophilic bronchitis, as recommended by the European Respiratory Society 4

The following diagnostic studies may be considered:

Diagnostic Study	Indication
Chest radiograph	Concerning symptoms or persistent cough [1]
Spirometry	Symptoms persisting > 3 weeks [1]
Peak flow measurements	Asthma suspected [1]
Complete blood count	Infection suspected [1]
Exhaled nitric oxide (FeNO) testing	Asthma suspected [5, 6]
Blood gas analysis	Moderate to severe respiratory distress [1]
Sputum evaluation	Suspected infection or inflammatory response [1, 7]
Chest CT scan and bronchoscopy	Persistent cough after standard evaluation [7]

C-reactive protein (CRP) is recommended for suspected pneumonia, with a level of 30 mg/L or higher increasing the likelihood of pneumonia, and a level less than 10 mg/L making pneumonia less likely, according to the American College of Chest Physicians 8

The following treatments are recommended for specific causes of cough:

Cause	Treatment
Upper airway cough syndrome	First-generation antihistamine/decongestant combination for 2-4 weeks, such as brompheniramine with sustained-release pseudoephedrine [7, 3]
Asthma/bronchial hyperresponsiveness	Inhaled corticosteroids and bronchodilators for 4 weeks [7]
GERD	Proton pump inhibitor with lifestyle modifications for 4-8 weeks [3]
Postinfectious cough	Short course of inhaled corticosteroids if cough affects quality of life, and inhaled ipratropium bromide may be considered as first-line therapy, as recommended by the American College of Chest Physicians [1, 7, 9]
Refractory cough	Neuromodulators like gabapentin, speech pathology therapy for cough suppression techniques [2, 10]

Symptomatic treatment for cough may include:

Treatment	Indication
Dextromethorphan	Non-productive cough [1, 11]
First-generation antihistamines	Nocturnal cough [7, 11]
Inhaled corticosteroids and bronchodilators	Episodic wheezing, nocturnal cough, or exercise-induced symptoms [5]
Short course of oral corticosteroids	Severe symptoms, with FeNO testing to identify steroid-responsive cough [5]

Re-evaluate patients if cough persists beyond 4-6 weeks, and consider specialist referral if cough persists despite appropriate treatment, suspected serious underlying pathology, or significant impact on quality of life, with a strength of evidence based on clinical expertise 12, 1, 13
Assess cough severity or quality of life before and after treatment using validated tools such as a visual analog scale, and schedule routine follow-up 4-6 weeks after the initial visit to ensure resolution of symptoms, as recommended by the American Academy of Pediatrics 12, 14
Monitor for signs of aspiration pneumonia, including fever, increased respiratory rate, and decreased oxygen saturation 15
The American Academy of Allergy, Asthma, and Immunology advises monitoring for local side effects, such as mucosal erosions, and directing sprays away from the nasal septum to minimize irritation and bleeding 16
In elderly patients, the American Geriatrics Society recommends monitoring for potential systemic effects of intranasal corticosteroids, though these are minimal at recommended doses 16