Approach to Chronic Cough Assessment

Definition and Initial Screening

Chronic cough is defined as cough lasting ≥8 weeks in adults, and the assessment should follow a systematic algorithmic approach starting with mandatory baseline investigations, according to the American College of Radiology 1, 2, 3
The American Thoracic Society defines chronic cough as lasting >8 weeks in adults (>4 weeks in children) 1
In high TB prevalence areas, the American Thoracic Society defines chronic cough as ≥2-3 weeks duration 4

The American College of Chest Physicians recommends considering upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD) as the most common causes of chronic cough 1, 2, 3
The American College of Chest Physicians suggests that nonasthmatic eosinophilic bronchitis (NAEB) is another common cause of chronic cough 1, 2, 3
The American Thoracic Society recommends considering chronic bronchitis/COPD, defined as cough and sputum on most days for ≥3 months over ≥2 consecutive years, as a cause of chronic cough in smokers 5

The American College of Chest Physicians recommends assessing cough characteristics, including duration and progression, quality, timing, and paroxysmal nature 1, 6
The American Thoracic Society suggests that associated symptoms, such as UACS indicators (postnasal drip sensation, throat clearing, nasal discharge), asthma indicators (wheezing, chest tightness, dyspnea, nocturnal symptoms), and GERD indicators (heartburn, regurgitation, dysphagia), should be evaluated 2, 3, 6
The American College of Chest Physicians recommends performing a physical examination, including nasal examination, oropharyngeal examination, lung auscultation, and digital clubbing assessment 2, 3, 6

The American College of Radiology recommends that all patients with chronic cough undergo mandatory initial investigations, including chest radiograph and spirometry with bronchodilator response 1, 7
The American College of Chest Physicians suggests that additional first-line tests, such as exhaled nitric oxide (FeNO) and blood eosinophil count, may be helpful in some cases, but are not always necessary 7
The American Thoracic Society recommends that if the chest X-ray is abnormal, specific findings should be pursued, including mass/nodule, interstitial pattern, infiltrate, cardiomegaly/pulmonary edema, and mediastinal mass 2, 3, 4

The American College of Chest Physicians recommends a sequential empiric treatment approach, starting with UACS, then asthma, then GERD, as this is more cost-effective than extensive upfront testing 2, 3, 7
The American Thoracic Society suggests that treatment trials should be adequate in duration, with GERD requiring ≥3 months of intensive acid suppression, and UACS requiring several weeks of antihistamine-decongestant treatment 3, 7
The American College of Chest Physicians recommends reassessing patients after treating all three common causes, and referring to a specialist for advanced evaluation if no response is observed 8, 7

The American Thoracic Society defines chronic cough as lasting ≥8 weeks in adults, and it is essential to ask specifically about cough duration 9, 10, 11
Smoking is responsible for 85-90% of chronic bronchitis cases and is dose-related, making current and past tobacco use crucial to assess 12
A detailed occupational history is necessary to identify exposure to dust, chemicals, fumes, or other respiratory irritants 10, 11, 12
The presence of significant sputum usually indicates primary lung pathology and requires a different diagnostic approach 10, 11
Quantify cough severity using visual analogue scales or validated cough-specific quality of life questionnaires to assess the impact on sleep, work, and social activities 10, 11
Ask about daily productive cough to identify patients who meet the criteria for chronic bronchitis, defined as cough with sputum production occurring most days for at least 3 months per year for 2 consecutive years 12
Hemoptysis, unintentional weight loss, fever, or prominent systemic illness are red flag symptoms that require urgent investigation 9, 11
The European Respiratory Society recommends assessing progression, including sudden onset versus gradual, worsening versus stable, to determine the severity of the cough 9, 11