Cough acute and chronic in clinical settings 2024

1. Cough

2. Agenda
• History taking
• Definition
• Hemoptysis causes
• Acute cough
• Red Flags
• Subacute and chronic cough
• MCQ

3. History taking
Character/circumstance:
Productive or dry, hacking, hemoptysis.
Exacerbating/alleviating factors:
Look for triggers (e.g., only at work or after mowing lawn).
Over-the-counter or prescription drugs.
Associated symptoms:
Systemic: Fever, shaking chills, sweats, weight loss.
Cardiac and pulmonary: Dyspnea, chest pain.
HEENT: Sneezing, postnasal drip.
Gastrointestinal: Heartburn.
https://www.acponline.org/sites/default/files/documents/clinical_information/journals_p
ublications/books/teaching-in-your-office/cough.pdf

4. History taking
• Severity: Affecting work or sleep? Causing syncope or incontinence?
• Timing: Night ?
• Pattern: acute or chronic, constant or intermittent?
• Onset?
• Duration?
• Why is the patient coming in now?
https://www.acponline.org/sites/default/files/documents/clinical_information/journals_p
ublications/books/teaching-in-your-office/cough.pdf

5. History taking
• Relevant past medical history:
Asthma, atopy, drug allergies (always), currently taking or recently run out of any
medications, exposure to TB or other infectious diseases?
• Relevant social history:
Travel or immigration, occupation and hobbies (i.e., glue or chemical exposures),
alcohol or tobacco use, new pets or rugs, etc. What is patient’s concern?
• Relevant family history:
Atopy, asthma, eczema, TB exposure.

6. Definitions of cough
Cough: is an innate primitive reflex and acts as part of the
body’s immune system to protect against foreign materials.
• Acute cough: cough lasting up to 2 weeks
• Protracted acute cough:
• ‣ in children — cough lasting 2 to 4 weeks
• ‣ in adults — cough lasting 2 to 8 weeks
• Chronic cough:
• ‣ in children — cough lasting more than 4 weeks
• ‣ in adults — cough lasting more than 8 weeks

7. Causes of Hemoptysis
Infection (60-70% of Hemoptysis in children; 18% in outpatient adults, 23% of inpatient adults)
Acute Bronchitis (26% of Hemoptysis)
Viral Bronchitis
Streptococcus Pneumoniae
HaemophilusInfluenzae
Moraxella catarrhalis
Pneumonia (10% of Hemoptysis)
Staphylococcus aureus
Pseudomonas aeruginosa
Tuberculosis (0.2% of Hemoptysis in outpatient adults, 2.5% of inpatients, 65% in low resource countries)
Nontuberculous Mycobacteria may also cause Hemoptysis
Tuberculosis may cause spontaneous, massive Pulmonary Hemorrhage
Influenza
Leptospirosis
Lung Abscess

8. Causes of Hemoptysis
Fungal organisms (e.g. fungal ball or Mycetoma)
Aspergillosis (most common of the fungal-related Pulmonary Hemorrhage Causes)
Actinomycosis
Blastomycosis
Parasite Infections
Paragonimiasis (trematode or fluke infection)
Lung Cancer (7% of Hemoptysis in children, 4% in outpatient adults, 18% in inpatient adults)
Hemoptysis is rarely due to metastases
Bronchial Tumors
Obstructive Lung Disease (6% of Hemoptysis in outpatient adults)
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Bronchiectasis (e.g. Cystic Fibrosis)

9. Causes of Hemoptysis
Fungal organisms (e.g. fungal ball or Mycetoma)
Aspergillosis (most common of the fungal-related Pulmonary Hemorrhage Causes)
Actinomycosis
Blastomycosis
Parasite Infections
Paragonimiasis (trematode or fluke infection)
Lung Cancer (7% of Hemoptysis in children, 4% in outpatient adults, 18% in inpatient adults)
Hemoptysis is rarely due to metastases
Bronchial Tumors
Obstructive Lung Disease (6% of Hemoptysis in outpatient adults)
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Bronchiectasis (e.g. Cystic Fibrosis)

10. Causes of Hemoptysis
Trauma
Lung Contusion
Airway Trauma (Hematoma, fistula)
Airway Foreign Body (esp. children)
Post-procedure (e.g. lung biopsy, heart catheterization, bronchoscopy)
Cardiovascular causes
Pulmonary venous Hypertension (Acute Pulmonary Edema)
Congestive Heart Failure
Severe Mitral valve stenosis
Pulmonary Hypertension
Bronchovascular Fistula
Dieulafoy Lesion
Pulmonary Embolism or infarction
Aneurysm (e.g. thoracic artery, aorta)
Arteriovenous Malformation
Pulmonary artery rupture
Systemic Coagulopathy
Catamenial Hemoptysis (pulmonary Endometriosis)
Endocarditis (right-sided)
Rheumatologic causes
Goodpasture's Syndrome
Eosinophilic Granulomatosis with Polyangiitis (previously known as Wegener's
Granulomatosis)
Other Lung and Tracheobronchal causes
Bronchiectasis (e.g. Cystic Fibrosis)
Broncholithiasis
Acute Lung Allograft rejection , Idiopathic pulmonary Hemosiderosis
Pulmonary Capillary Hemangiomatosis Lymphangiomyomatosis
Medications and Toxins
Anticoagulation (e.g. Warfarin, DOACs)
Antiplatelet agents (Clopidogrel, Aspirin)
Thrombolytics
Bevacizumab (Avastin)
Cocaine Inhalation
Hematologic
Coagulopathy (e.g. Hemophilia, Von Willebrand Disease)
Thrombocytopenia

11. Causes of Hemoptysis
Causes: Blood streaked Sputum
1.Upper respiratory inflammation
1. Nose or nasopharynx
2. Gums
3. Larynx
2.Severe coughing paroxysms
3.Trauma
Causes: Pink Sputum
1.Blood and secretions mix in alveoli, small Bronchioles
2.Conditions associated with pink Sputum
1. Pneumonia
2. Pulmonary Edema

13. Common causes of acute cough
Diagnosis Associated clinical features
Upper respiratory tract infection
(URI) or common cold
Rhinorrhea, nasal obstruction, sneezing, scratchy or sore throat, malaise, headache
Acute bronchitis
Antecedent (URI), absence of high fever or other systemic signs or symptoms, absence
of signs of consolidation on chest exam
Pneumonia
Fever, tachycardia, tachypnea, signs of consolidation on chest exam, mental status
change in those >75 years old
Post-nasal drip Post-nasal drainage, need to clear throat, rhinorrhea
Gastroesophageal reflux disorder Heartburn, regurgitation, dysphagia
Asthma History of episodic wheezing, shortness of breath, allergen exposure or exercise
ACE inhibitor use Nonproductive cough, tickling or scratchy sensation in the throat
Heart failure
Shortness of breath, orthopnea, gallop rhythm, elevated jugular venous pulse,
peripheral edema
Pulmonary embolism Tachycardia, shortness of breath, pleuric chest pain, hemoptysis
Lung cancer
Past or present smoking history, change in a chronic "smoker's cough," hemoptysis,
signs of focal airway obstruction on chest exam

14. Cough (subacute and chronic)
Prevalence
• Prevalence of chronic cough is 14% to 23% in nonsmoking adults.
• Chronic cough is reported in up to 9% of preschool-aged children.

15. Cough (subacute and chronic)
• Ninety percent of patients with chronic cough have gastroesophageal reflux disease
(GERD), postnasal drip (PND) syndrome, and/or asthma; nearly two-thirds of patients
will have more than one of these contributing to their cough. B
• Evaluation should begin with a CXR in all patients, as well as pulmonary function
testing (PFT) in patients with suspected asthma. C
• In nonsmoking adults not taking an ACE-I, diagnosis is interrelated with empiric
treatment of PND, asthma, and GERD in stepwise fashion. Re-evaluate every 1 to 2
weeks until the cough resolves . C

16. Chung, K.F., McGarvey, L., Song, WJ. et al. Cough hypersensitivity and chronic cough. Nat
Rev Dis Primers 8, 45 (2022). https://doi.org/10.1038/s41572-022-00370-w

17. Differential Diagnosis
• Henderson, Mark C., etc"The patient history: An evidence-based approach to differential diagnosis." (2020).

18. Benich, Joseph John 3rd, and Peter J Carek. “Evaluation of the patient with chronic cough.”
American family physician vol. 84,8 (2011): 887-92.

19. Conditions associated with chronic cough
in adults

20. Red flags in Children
•Dyspnoea (at rest or exertional)
•Recurrent episodes of chronic or wet or productive cough
•Recurrent pneumonia
•Chest pain
•Haemoptysis
•Systemic symptoms: fever, weight loss, growth failure
•Neurodevelopmental abnormality
•Feeding difficulties (including choking/vomiting)
•Stridor and other respiratory noises
•Abnormal clinical respiratory examination (eg, crackles, digital clubbing)
•Abnormal systemic examination (eg, growth failure)
•Abnormal chest x‐ray
•Abnormal lung function
•Co‐existing chronic diseases (eg, immunodeficiency, syndromes )

21. Red flags in Adults
• Haemoptysis
• Smoking/vaping (especially new/altered cough, cough with voice disturbance)
• Prominent dyspnoea (especially at rest or at night)
• Chronic productive cough with substantial sputum production
• Hoarseness
• Recurrent pneumonia
• Systemic symptoms: fever, weight loss
• Swallowing difficulties (including choking/vomiting)
• Abnormal clinical respiratory examination (eg, crackles, wheeze, digital clubbing)
• Abnormal chest radiograph

24. DRUGS FOR COUGH
1.Pharyngeal demulcents – Lozenges, Syrups, Glycerine, Liquorice
2.Expectorants (Mucokinetics)
1. Secretion enhancers – Pot. citrate, Pot. iodide, Guaiphenesin, Tolu balsam, Vasaka, Ammon. chloride
2. Mucolytics – Bromhexine, Ambroxol, Acetyl cysteine, Carbocisteine
3.Antitussives (Cough centre suppressants)
1. Opioids – Codeine, Ethylmorphine, Pholcodine
2. Nonopioids – Noscapine, Dextromethorphan, Chlophedianol
3. Antihistaminics – Chlorpheniramine, Diphenhydramine, Promethazine
4. Pulmonary receptor desensitizer – Prenoxdiazine
4.Adjuvant antitussives (Bronchodilators)– Salbutamol, Terbutaline

25. Preventive strategies for chronic cough
• Immunisations: pneumococcus, Haemophilus influenzae, Bordetella pertussis, influenza
• Avoidance of airway pollutants, irritants and triggers:
• ‣ cigarette smoke, wood‐fire smoke, e‐cigarettes
• ‣ fumes, strong odours, subfreezing air
• ‣ for those susceptible, animals, pollens, and other allergens
• Health education:
• ‣ early clinical review and adequate treatment of a chronic wet cough including post‐acute
respiratory infection (> 4 weeks in children, > 8 weeks in adults)
• ‣ workplace education about hazard minimisation for workers in high risk occupations

26. Strength of recommendations for the efficacy of treatment of
cough in association with the conditions (Children)
Recommendations
Level of
evidence
Strength of
recommendation
Cessation of parental smoking to reduce cough Good Strong
Cough with allergic rhinitis
Treatment according to current rhinitis management guidelines involving topical nasal
corticosteroid, antihistamines, and allergen management
Poor Weak
Cough with obstructive sleep apnoea
Tonsillectomy and adenoidectomy Poor Weak
Cough with asthma
Treatment according to current asthma management guidelines involving education and
self‐management, inhaled bronchodilators, and inhaled corticosteroids; if empirical treatment
is used, review in 2–4 weeks
Good Strong
Cough with protracted bacterial bronchitis
Medium term (2–4 weeks) antibiotics for protracted bacterial bronchitis Excellent Strong
Cough with GORD
Treatment(s) for GORD should not be used when there are no gastro‐intestinal clinical
features of GORD; paediatric GORD guidelines should be used to guide treatment and
investigations
Good Weak
Treatment with laparoscopic fundoplication Poor Strong recommendation against
Non‐specific or refractory cough
Address patient/parental stress and concerns Poor Strong
Address exacerbating factors, such as tobacco smoke exposure Good Strong
Minimise use of medications other than demulcents (eg, honey) if no contraindications
(young age) exist
Good Strong
Adopt counsel, watch, wait and review approach Excellent Strong
Empirical trial of inhaled corticosteroid therapy Poor No recommendation
Empirical trial of proton pump inhibitors Good Strong recommendation against
Marchant, Julie M et al. “Cough in Children and Adults: Diagnosis, Assessment and Management (CICADA). Summary of an updated position
statement on chronic cough in Australia.” The Medical journal of Australia vol. 220,1 (2024): 35-45. doi:10.5694/mja2.52157

27. Cough with allergic rhinitis
nasal corticosteroid spray, nasal antihistamine spray, combination
corticosteroid/antihistamine nasal spray Good
Weak
Cough with chronic rhinosinusitis
involving nasal corticosteroid spray, large volume saline irrigation, long term
antibiotic therapy (macrolide, 3 months) Poor
Weak
Cough with laryngeal hypersensitivity
Treatment with speech pathology management Good Strong
Cough with vocal cord dysfunction/intermittent laryngeal
obstruction
Treatment with speech pathology management Good Strong
Cough with GORD/dysmotility
Treatment(s) for GORD in adults with cough alone and no other symptoms of
GORD with PPI therapy; when other symptoms of GORD occur, use appropriate
clinical guidelines40
Good
Strong
recommendation
against use of PPI for
cough alone
Cough with asthma
education inhaled bronchodilators, inhaled corticosteroids
Excellent Strong
Leukotriene receptor antagonists, alone or with inhaled corticosteroids Good Weak
Cough with eosinophilic bronchitis
Treatment with inhaled corticosteroids Satisfactory Strong
Leukotriene receptor antagonists, alone or with inhaled corticosteroids Satisfactory Weak
Strength of recommendations (Adults)

28. Cough with COPD
Treatment according to current COPD management guidelines involving
education and self‐management, smoking cessation, pulmonary
rehabilitation and treatment of exacerbations
Excellent Strong
Addition of combination inhaled long‐acting bronchodilators and
corticosteroids may reduce cough severity
Good Weak
Cough with bronchiectasis
Treatment according to current bronchiectasis management guidelines
involving treatment of exacerbations with 14 days antibiotics, regular
airway clearance and pulmonary rehabilitation
Good Weak
Unexplained chronic cough
An empirical treatment trial supervised by a specialist cough clinic
using validated, objective measures of cough severity (cough severity
scales, the cough severity diary, quality‐of‐life measures [Leicester
cough questionnaire, cough specific quality of life questionnaire],
objective cough recording devices and cough reflex sensitivity
challenges)
Satisfactory Weak
Cessation of smoking, nicotine containing cigarettes or e‐cigarettes Excellent Strong
Identify and minimise environmental/occupational exposures Satisfactory Weak
Cessation of angiotensin‐converting enzyme inhibitors Satisfactory Strong
Speech and language therapy Excellent Strong
Inhaled corticosteroids or leukotriene antagonist empirical treatment
trial
Poor Weak
Macrolide antibiotics Satisfactory
Weak
recommendation
against
Acid suppressive therapy, proton pump inhibitors, or H2 antagonist
Strong

29. Complications of cough
• Persistent cough or severe bouts of cough can cause complications, and these
include:
• Sleep disruption
• Headache
• Vomiting
• Syncope
• Excessive sweating
• Rib fracture
• Urinary incontinence

30. MCQ
• Which of the following is a common cause of chronic cough?
• A. Pneumonia
• B. Blood clot in the lungs
• C. Postnasal drip
• D. Tuberculosis

31. MCQ
• Which one of the following treatments for cough has evidence of efficacy and safety
when used
for children from 1 to 2 years of age?
• A) Honey
• B) Dextromethorphan
• C) Diphenhydramine (Benadryl)
• D) Codeine
• E) Guaifenesin

32. MCQ
• Which one of the following treatments for cough has evidence of efficacy and safety when used
for children from 1 to 2 years of age?
• A) Honey
• B) Dextromethorphan
• C) Diphenhydramine (Benadryl)
• D) Codeine
• E) Guaifenesin
ANSWER: A
Honey has been shown to decrease the frequency and severity of cough in children. Honey is safe in
children 2 years of age or older, but should be avoided before then due to the risk of botulism. Safety
and/or efficacy data is not available for the other agents listed in children under 2 years old. Codeine
in
particular has serious safety problems in young children and should be avoided

33. MCQ
A 12-year-old male has a 1-week history of fever, headache, sore throat, and a mildly
productive cough. He also began having ear pain yesterday. On examination he does not appear
to be toxic. He has a temperature of 37.8°C (100.0°F). Examination of his ears shows a bulla on
the right tympanic membrane, as well as mild to moderate erythema of the posterior pharynx.
The neck is supple. The lungs have a few scattered crackles. The remainder of the examination is
unremarkable. A chest radiograph reveals thickened bronchial shadows, as well as interstitial
infiltrates in the lower lobes.
The most appropriate treatment at this time would be
• A) amoxicillin
• B) azithromycin (Zithromax)
• C) ceftriaxone (Rocephin)
• D) cefuroxime (Zinacef)
• E) vancomycin

34. MCQ
ANSWER: B
Community-acquired pneumonia in children is treated based on age. The most likely
etiologic agents in a school-age child are Mycoplasma pneumoniae, Chlamydia
pneumoniae, and Streptococcus pneumoniae. Group A Streptococcus and
Haemophilus influenzae are less common causes. Staphylococcus aureus that is
methicillin-resistant has become increasingly common. The preferred treatment for
community-acquired pneumonia is a macrolide antibiotic such as azithromycin.
In children ages 5–16, Mycoplasma pneumonia tends to have a gradual onset of
symptoms and seldom causes respiratory distress. Signs and symptoms may vary. The
patient may develop a rash, musculoskeletal symptoms, or gastrointestinal symptoms.
Radiographs may reveal bronchopneumonia, nodular infiltrates, hilar adenopathy,
pleural effusions, or plate-like atelectasis. Ear pain may be due tobullous myringitis,
although this may be viral as well. Laboratory findings may not be helpful, as the WBC
count may be normal or slightly elevated. There may be thrombocytosis, an elevated
erythrocyte sedimentation rate, an elevation of cold agglutinins, or an elevated

35. MCQ
A 22-year-old female who was diagnosed with bronchitis at an urgent care clinic 3
days ago sees you because her cough is still present. She is very annoyed by the cough
and is concerned because she read online that she could have pneumonia. She asks if
she should have a chest radiograph.
• Which one of the following would be an indication for a chest radiograph in this
patient?
• A) A cough lasting more than 14 days
• B) A respiratory rate >24/min
• C) A temperature >37.5°C (99.5°F)
• D) Wheezing on the lung examination
• E) Cigarette smoking

36. • ANSWER: B
Adult patients with acute bronchitis rarely require a chest radiograph to rule out
pneumonia. Indications
for a chest radiograph include dyspnea, tachypnea, tachycardia, temperature >100.0°F,
bloody sputum,
or signs of focal consolidation on lung auscultation. In patients with bronchitis the
cough lasts an average
of 18 days, so a chest radiograph would not be indicated after only 14 days. Smoking
does not influence the need for a chest radiograph, and wheezing is common in
uncomplicated acute bronchitis