Management of Cough

Initial Assessment and Red Flags

The American College of Chest Physicians recommends beginning with a focused history to determine cough duration, ACE inhibitor use, smoking status, and presence of life-threatening conditions, as this classification drives the entire management algorithm 1, 2
The American College of Chest Physicians suggests ruling out serious illness such as pneumonia or pulmonary embolism before proceeding with algorithmic management of benign causes 2
ACE inhibitor use should be stopped immediately if present, as this is a common reversible cause 1, 2
Smoking status should be assessed and patients should be counseled and assisted with cessation, as smoking exacerbates cough 1, 2

For acute cough, the American College of Chest Physicians recommends determining if this represents a serious illness versus a benign respiratory tract infection or exacerbation of underlying disease 2
For viral upper respiratory infections, treatment is supportive 2
Chest radiography should be obtained if pneumonia is suspected based on symptoms or abnormal lung findings 3
Antibiotics should be avoided for viral causes 3

The American College of Chest Physicians recommends using sequential and additive empiric therapy because multiple causes frequently coexist 1, 2
Upper airway cough syndrome (UACS) should be treated first with a first-generation oral antihistamine/decongestant combination as initial empiric treatment 1, 2, 3
If cough persists after UACS treatment, asthma should be evaluated and treated next 1, 2
Medical history is not reliable for ruling asthma in or out, and spirometry or bronchoprovocation challenge should be performed 1, 2

Idiopathic cough is a diagnosis of exclusion that should not be made until thorough diagnostic evaluation is performed, specific treatment has failed, and uncommon causes have been ruled out 1, 2
Treatment options for idiopathic cough are limited and include dextromethorphan, baclofen, nebulized local anesthetics, and low-dose morphine 4, 5

In pneumonia and bronchiectasis, cough clearance is important and suppression is relatively contraindicated 4, 5
High-resolution CT scan and bronchoscopy should be considered if cough persists despite appropriate sequential treatment or if red flag symptoms are present 3

Cough characteristics (timing, quality) should not be relied on for diagnosis—they have minimal diagnostic value 1, 2, 3
Antibiotics should not be used for viral causes of acute or subacute cough 3
Only one cause of cough should not be treated—therapy should be given in sequential and additive steps as multiple etiologies frequently coexist 1, 2
Idiopathic cough should not be diagnosed prematurely—ensure thorough evaluation and treatment trials first 1, 2
Cough should not be suppressed when clearance is important (pneumonia, bronchiectasis) 4, 5