Management of Chronic Cough

Initial Assessment and Diagnosis

The American College of Chest Physicians recommends systematically evaluating and empirically treating for the four most common causes of chronic cough in adults: upper airway cough syndrome (UACS), asthma, gastroesophageal reflux disease (GERD), and nonasthmatic eosinophilic bronchitis (NAEB), as these account for over 90% of chronic cough cases 1, 2, 3
The American College of Chest Physicians suggests immediately assessing for red flag symptoms, such as hemoptysis, unintentional weight loss or fever, prominent dyspnea at rest or night, and hoarseness or trouble swallowing, which may indicate serious underlying conditions 1, 3
Obtaining a chest radiograph is recommended to exclude structural lung disease, malignancy, pneumonia, or other serious thoracic conditions before proceeding with empiric treatment 1, 3

The American College of Chest Physicians recommends treating for upper airway cough syndrome (UACS) first, using a first-generation antihistamine-decongestant combination, as UACS is the single most common cause of chronic cough (33-44% of cases) 4, 5
If UACS treatment fails or provides only partial relief, the American College of Chest Physicians suggests evaluating and treating for asthma, using spirometry with bronchodilator response testing and inhaled corticosteroid therapy 4, 1
The American College of Chest Physicians recommends addressing gastroesophageal reflux disease (GERD) if cough persists after adequate trials of UACS and asthma treatment, using comprehensive lifestyle modifications and potentially prokinetic agents, not just proton pump inhibitors 1, 2, 3

The American College of Chest Physicians emphasizes that multiple causes frequently coexist, and sequential and additive therapy is essential, with up to 25% of patients having two or more contributing factors 4, 5
The American College of Chest Physicians recommends using validated cough severity or quality-of-life tools to objectively assess treatment response at each step 1, 2, 3
The American College of Chest Physicians suggests scheduling follow-up within 4-6 weeks after initial evaluation to reassess response and adjust treatment 1, 2, 3