Initial Approach to Chronic Cough

Mandatory Initial Workup

The American Thoracic Society recommends obtaining a chest radiograph to exclude structural lung disease, malignancy, pneumonia, or other serious thoracic conditions 1
The European Respiratory Society suggests performing spirometry to assess for airflow obstruction and bronchodilator response 2, 3
The American College of Chest Physicians advises reviewing all medications immediately and discontinuing ACE inhibitors or sitagliptin if present, as these are common iatrogenic causes that must be eliminated before pursuing extensive workup 4
The British Thoracic Society recommends assessing cough severity using validated cough visual analogue scores or quality-of-life questionnaires to objectively measure treatment response 2, 3

The American Academy of Allergy, Asthma, and Immunology recommends starting first-generation antihistamine-decongestant combination as UACS accounts for 33-44% of chronic cough cases 1
The American Gastroenterological Association suggests implementing comprehensive GERD management including lifestyle modifications and potentially prokinetic agents 1
The National Asthma Education and Prevention Program recommends initiating inhaled corticosteroids even with normal spirometry, as cough-variant asthma may not show airflow obstruction 1

The American College of Physicians notes that up to 40% of patients have two or more contributing factors requiring combination therapy 4, 1
The European Respiratory Society advises continuing effective treatments while adding new ones for partial responders 1

The American Thoracic Society recommends stopping the algorithmic approach and referring urgently if hemoptysis is present, mandating evaluation for life-threatening conditions 4
The American College of Chest Physicians suggests referring urgently if smoker >45 years with new cough, change in cough, or coexisting voice disturbance 4

The American College of Radiology recommends proceeding to advanced investigations only after 4-6 weeks of failed empiric treatment for each of the top three diagnoses 1
The American Thoracic Society suggests considering high-resolution CT in patients with normal chest radiograph and failed empiric trials 2, 3

The American Academy of Allergy, Asthma, and Immunology recommends verifying all three top diagnoses (UACS, asthma, GERD) were properly treated with adequate duration 5
The American College of Chest Physicians suggests considering nonasthmatic eosinophilic bronchitis as an important but less common cause requiring specific identification 4, 5