Evaluation and Management of Chronic Cough

Initial Assessment

A 2-month persistent cough should be systematically evaluated and treated by sequentially addressing the three most common causes: upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD), which together account for approximately 90% of chronic cough cases 1, 2
Rule out serious conditions first by checking vital signs and performing chest examination to exclude pneumonia, and obtain chest radiograph to identify structural abnormalities, masses, interstitial disease, or congestive heart failure 1, 2, 3
Assess smoking status, as chronic bronchitis is a leading cause in this population, and counsel on cessation 1, 4

Duration of cough (2 months qualifies as chronic cough, defined as >8 weeks in adults) is an important factor in diagnosis 3
Presence of upper respiratory symptoms (nasal discharge, throat clearing, postnasal drip sensation) suggests UACS 1, 2
Triggers such as cold air, exercise, or nighttime worsening suggest asthma 2, 3
Heartburn, regurgitation, or sour taste suggests GERD 1, 4

Initiate empiric therapy with a first-generation antihistamine-decongestant combination for UACS 1, 2
Perform bronchoprovocation challenge or spirometry with bronchodilator response to evaluate for asthma, and initiate empiric trial of inhaled bronchodilators and/or inhaled corticosteroids if testing is unavailable 1, 2
Initiate high-dose proton pump inhibitor (PPI) therapy along with dietary modifications and lifestyle changes for GERD 1, 4

High-resolution CT (HRCT) scan of chest to evaluate for bronchiectasis, interstitial lung disease, or occult masses 1, 4
24-hour esophageal pH monitoring if GERD is suspected but empiric therapy failed 1, 4
Bronchoscopy to evaluate for endobronchial lesions, sarcoidosis, eosinophilic bronchitis, or occult infection 1, 4

Consider gabapentin trial starting at 300 mg once daily, escalating as tolerated to maximum 1,800 mg daily in divided doses 5, 6
Discuss potential side effects and reassess risk-benefit at 6 months before continuing 5, 6
Multimodality speech pathology therapy is a reasonable alternative approach 6
Avoid inhaled corticosteroids if bronchial hyperresponsiveness and eosinophilia testing are negative 5, 6
Do not prescribe PPIs if objective testing for acid reflux is negative 5, 6

Assuming purulent sputum indicates bacterial infection requiring antibiotics 3, 7
Inadequate treatment duration (stopping therapy before expected response time) 1, 2
Failing to recognize multiple simultaneous causes requiring combined therapy 2
Diagnosing unexplained cough before completing systematic evaluation and adequate therapeutic trials 5, 6, 8