Treatment of Chronic Cough

Initial Assessment and Management

The American College of Chest Physicians recommends discontinuing ACE inhibitors immediately if the patient is taking one, regardless of temporal relationship to cough onset, as resolution typically occurs within days to 2 weeks, though median time is 26 days 1
The American College of Chest Physicians suggests that if the patient is a current smoker, smoking cessation is the priority intervention, as most patients achieve cough resolution within 4 weeks of cessation, though some may take longer 1
The evidence strongly supports treating empirically rather than extensive upfront testing, as this approach is more cost-effective when upper airway cough syndrome (UACS) prevalence is approximately 44% 1

The American Thoracic Society notes that UACS accounts for the majority of chronic cough cases in immunocompetent nonsmokers 1
The British Thoracic Society recommends initiating inhaled corticosteroids with or without bronchodilators, even without spirometric evidence of obstruction, for patients with suspected asthma, as many patients with cough-variant asthma lack sufficient reversibility to meet traditional asthma criteria 3
The American Gastroenterological Association suggests that gastroesophageal reflux disease (GERD) is frequently overlooked as an extrapulmonary cause in general respiratory clinics, and recommends initiating intensive acid suppression therapy for at least 3 months 3

The American College of Radiology recommends proceeding to high-resolution CT (HRCT) only after sequential empiric treatment for all three common causes has failed, and adequate treatment duration has been allowed (several weeks for UACS/asthma, ≥3 months for GERD) 4
HRCT is the reference standard for detecting bronchiectasis, which accounts for up to 8% of chronic cough cases and may be missed on chest radiography 4
The British Thoracic Society notes that HRCT identifies abnormalities in up to 42% of patients with presumed normal chest radiographs, and is diagnostic in 24% of patients with chronic cough who had normal radiographs and failed initial protocols 3

The American College of Chest Physicians recommends pursuing direct investigation if any red flags are present, including hemoptysis, significant dyspnea, fever or systemic symptoms, weight loss, history of cancer, tuberculosis, or AIDS, or chest radiograph findings suggestive of mass or malignancy 1
The American Thoracic Society advises against ordering extensive testing upfront, as sequential empiric treatment is more cost-effective than comprehensive initial investigation 1
The British Thoracic Society warns against relying on chest radiography alone to exclude bronchiectasis, as up to 34% of CT-proven bronchiectasis cases have normal chest radiographs 3