This document discusses cough and its evaluation and management. It defines cough as a protective reflex that clears secretions from the airways. It notes that cough can be acute, subacute, or chronic depending on duration. Common causes include infection, asthma, chronic bronchitis, and gastroesophageal reflux disease. A thorough history, physical exam, and initial tests like chest x-ray are important for evaluating cough. Further tests may be needed to identify specific causes and guide treatment. Upper airway cough syndrome is a common cause of chronic cough.

2. PRESENTED BY
DR.MD.SHARIF AHSAN
MD RESIDENT(PULMONOLOGY)
PHASE-B
DHAKA MEDICAL COLLEGE HOSPITAL

4.  One of the most common symptoms for which patients
seek medical attention
 Defensive reflex that enhance the clearance of
secretions and particles from the airway
 Protects the lower airways from the aspiration of foreign
materials

5.  Coughing may be initiated either voluntarily or
reflexively.
 It has both afferent and efferent pathways .
 The cough starts with a deep inspiration followed by
glottic closure, relaxation of the diaphragm, and muscle
contraction against a closed glottis.

6. ◼ Increasing intensity that lasts for a week or more
◼ Hyperthermia >38°C for 3 days or more
◼ Dyspnea and chest pain on breathing
◼ Hemoptysis
◼ Weakness, and weight loss
◼ Excessive sweating, shivering
◼ Sudden attack of severe cough
◼ Severe cough during an hour without any interval
◼ Excessive expectoration of sputum

7.  Massive sputum production: bronchiectasis
 Systemic symptoms – fever, sweats, weight
loss: TB, lymphoma, bronchial carcinoma
 Hemoptysis: TB, bronchial carcinoma, PE
 Significant dyspnea: CHF, COPD, restrictive
lung diseases

8. Acute
cough
~ maximum
of 3 weeks
Subacute
cough
~ 3 to 8
weeks
Chronic
Cough
~ more than
8 weeks
De Blasio et al. Cough 2011, 7:7

9. Acute cough
• Upper
Respiratory
Infection
(common
cold, acute
bacterial
sinusitis, and
pertussis)
• Pneumonia
• Pulmonary
embolus
• Congestive
cardiac
failure
Subacute cough
~ 3 to 8 weeks
• Post-
infectious
• Postnasal
drip following
viral infection,
• Pertussis
• Tuberculosis
• Mycoplasma
or Chlamydia
infection
Chronic Cough
~ more than 8
weeks
• Asthma
• COPD
• Tuberculosis
• Bronchogenic
carcinoma
• Eosinophilic
Bronchitis
• Esophageal
Disease,
• Post Nasal Drip
• ACEI
• Smoking.

10.  Infection: viral upper and lower respiratory tract infection,
bacterial pneumonia, tuberculosis (TB), pertussis
 Chronic bronchitis
 Obstructive airways disease: COPD, asthma
 Cough variant asthma
 Eosinophilic bronchitis
 Obstructive sleep apnoea (OSA) (nocturnal only)
 Lung cancer
 Bronchiectasis, cystic fibrosis (CF)
 ILD
 Airway irritants: smoking, dusts and fumes, acute smoke
inhalation
 Airway foreign body.

11.  External compression of trachea by enlarged
lymph nodes (e.g. lymphoma, TB)
 Mediastinal tumours/cysts/masses

12. • LVF
• Left atrial enlargement (e.g. severe mitral stenosis).

13. • Upper airway cough syndrome, including:
• Acute or chronic sinusitis
• Post-nasal drip due to perennial, allergic, or
vasomotor rhinitis.

14.  GORD
 Oesophageal dysmotility, stricture, or pharyngeal
pouch causing repeated aspiration
 Oesophago-bronchial fistula.

15.  Neurological disease affecting swallowing,
causing repeated aspiration, such as
Stroke
Multiple sclerosis,
Motor neurone disease (MND),
Parkinson’s diseas

16.  • ACE inhibitors
 • Some inhaled preparations can cause cough—
particularly ipratropium.

17.  Idiopathic
 Ear wax (vagal nerve stimulation)
 Psychogenic/habitual.

18. CLINICAL ASSESMENT

19. History Reasons
Onset To determine acute/subacute or chronic
causes of cough
Aggravating factor, relieving factor • Cough due to GERD affected by
postural changes, post meal
• Cold induced or MDI relieved cough in
asthma or COPD
Sputum colour Normal sputum: clear to white colour, thin,
odourless n tasteless
Yellow-green: bacterial infection
Rust-colored: pneumonia
Sputum character Mucoid or mucopurulent: cigarette
smokers as a result of chronic bronchitis
Commonly purulent in bronchiestasis
Sputum amount Significant volumes: more than 1 cup per
day

20. History Reasons
Fever Ongoing infection
SOB Respiratory distress
Noisy breathing Wheezing suggest asthma/COPD
Loss of appetite, loss of weight,
hemoptysis
Suggesting Tuberculosis, malignancy
Allergy, nasal obstruction or congestion,
rhinorrhoea, sneezing, facial pain, post-
nasal drip or repetitive throat clearance
Suggesting Rhinosinusitis
Dyspepsia, heartburn, waterbrash GERD
Medication used ACE-inhibitor
Occupation Exposure to asbestos, chemical or
cigarette smoke
Family history Asthma, tuberculosis, lung cancer, cystic
fibrosis
Social history Contact with PTB suggesting PTB

21. PHYSICAL EXAMINATION

22. Physical examination Reasons
General condition such as altered
conscious level, accessory muscles
usage, cyanosis, grunting, nasal
flaring, clubbing, nicotine stain
To assess severity and to look for
respiratory distress
Vital signs Fever – infection
Tachycardia, tachypnoea – respiratory
distress
Pulsus paradoxus – asthma
Nasal polyps Allergy rhinitis
Pharynx: erythema, a cobblestone
appearance of posterior pharyngeal
mucosa or mucoid secretions dripping
from the nasopharynx
Post nasal drip
Chest:
Hyperinflated
Recession
Silent chest
Crepitations, wheezing
Suggest air trapping due to chronic
disease
Respiratory distress
Severe asthma
Pneumonia, asthma, heart failure

23. Physical examination Reasons
CVS: Displaced apex beat,
raised JVP, loud P2, RV heave
Cor pumonale
Eczema, transverse nasal
crease, injected conjunctiva
Signs of atopic disease
Lymphadenopathy To suggest infection
• Abnormal physical signs are rare in a chronic dry
cough
• Wheeze may be audible on examination but is
usually absent in cough variant asthma (CVA)

24.  • Ensure CXR is normal
 • Spirometry may indicate restrictive or obstructive defect.
Performance of spirometry may provoke cough and
bronchospasm
 • Methacholine challenge test provides the best positive
predictive value for cough due to asthma. Lack of response
means cough variant asthma is extremely unlikely. PC20 is
normal in eosinophilic bronchitis
 • Serial peak flow recordings twice daily for 2 weeks.
>20% diurnal variation suggests asthma. Can be normal in
cough variant asthma
 • Induced sputum examination, if available, for eosinophil
count, to suggest either asthma or eosinophilic bronchitis.
 .

25.  • Consider chest HRCT if any features suggestive of lung
cancer or interstitial lung disease (ILD), as a small proportion
may present with a normal CXR (central tumour)
 • Consider ENT examination if predominantly upper
respiratory tract disease, resistant to treatment. Consider
sinus CT
 • Consider bronchoscopy if foreign body possible, or history
suggestive of malignancy, small carcinoid, endobronchial
disease. Perform after CT to help guide bronchoscopist
 • Consider 24h ambulatory oesophageal pH monitoring
 • Consider oesophageal manometry for oesophageal
dysmotility

26. In non-smoking adults with a normal CXR who are not
taking ACE inhibitors, chronic cough is almost always
due to which of the following 4 conditions?
a) Upper Airway Cough Syndrome (UACS)
b) Asthma
c) Gastroesophageal reflux disease (GERD)
d) Chronic Bronchitis

28. Smyrnios et al Arch Intern Med 1998
158:1222 3

31. • A systematic, diagnostic approach has been validated in
immunocompetent patients-
5 steps plan:
Step 1: Review history and exam focusing on the most
common causes of chronic cough

32.  Step 2: Order a CXR in all patients
 Step 3: Do not order additional tests in present smokers
or patients taking ACE inhibitors until the response to
smoking cessation or drug discontinuation for at least 4
weeks can be assessed.
- Cough due to smoking or ACE inhibitors should
improve substantially or disappear during this
time- frame of abstinence.
Step 4: Order additional diagnostic tests or embark on
empiric treatment

33.  Spirometry:
-demonstrate significant airway reversibility
(asthma)
-unavailable or normal and history suggestive:
serial
measurement of PEF (diurnal variability)
 Bronchoprovocation test :
- negative: rules out asthma but does not rules out
steroid- responsive cough
 Plain sinus radiography: low specificity but
improves with history and findings
 Sputum eosinophilia

34. NORMAL OBSTRUCTIVE RESTRICTIVE

37. Step 5: Determine the cause(s) of cough by observing
which specific therapy eliminates cough
• If the evaluation suggests more than one possible cause,
initiate treatment in the same sequence that the
abnormalities were discovered
• Since cough can be simultaneously caused by more than
one condition, do NOT stop therapy that appears to be
partially successful; rather, sequentially add to it.

38.  Also called “Post-nasal drip syndrome” (PNDS)
 Common cause of chronic cough in all age groups
– Second most common cause in children
– Most common cause in adults and the elderly
 In addition to cough, UACS can also cause
- Wheeze
- Dyspnea

40. .
Rhinitis
 Defined as sneezing, nasal discharge, or blockage for
>1h on most days for either a limited part of the year
(seasonal) or all year (perennial).
 Rhinitis may be allergic (e.g. hay fever), non-allergic,
vasomotor or infective.
 The associated nasal inflammation may irritate cough
receptors directly or produce a post-nasal drip

41.  Infection of the paranasal sinuses, which may
complicate an URTI and is frequently caused
by Haemophilus (H.) influenzae or Streptococcus (S.)
pneumoniae.
 It causes frontal headache and facial pain.
 Chronic sinusitis may require further investigation with
CXR or CT, which shows mucosal thickening and air-
fluid levels.
 Surgery may be indicated
Sinusitis

42.  Rhinosinusitis describes inflammation and infection within
the nasal passages and paranasal sinuses, with
 chronic rhinosinusitis defined as symptoms persisting for
more than 12 weeks

43.  Clues to UACS
– History of
• Need to frequently clear their throat
• Friend/relative notices that the patient
frequently clears their throat
• Sensation of dripping into throat
• Nasal symptoms
– Physical Exam demonstrating
• Secretions in nose or oropharynx
• Cobblestone appearance of mucosa

44.  Diagnosis of UACS as a cause of cough is established
when:
a) frequent throat clearing is elicited from the history
b) cobblestoning and phlegm are present on
physical examination of the posterior pharynx
c) cough responds favourably to specific therapy
aimed at eliminating the drip

45. Nasal preparations should be taken by kneeling
with the top of the head on the floor (‘Mecca’
position) or
lying supine with the head tipped over the end of
the bed.
Improvements in cough should be found within 2
weeks.
TREATMENT:UACS

47. •
Non-allergic rhinitis :
 Initial 3 weeks of nasal decongestants with first-
generation antihistamines (which have helpful
anticholinergic properties) and pseudoephedrine.
Alternatives are nasal ipratropium bromide or
xylometazoline.
 Followed by 3 months of high-dose nasal steroids,
which are ineffective when used as first-line treatment.
 Second-generation antihistamines (i.e. non-sedating)
are of no use in non-allergic rhinitis
TREATMENT:UACS

48. • Allergic rhinitis: Second-generation oral
antihistamine (e.g. cetirizine, loratadine, fexofenadine)
and high-dose nasal steroids for 3 months at least
• Vasomotor rhinitis:Nasal ipratropium bromide for 3
months; nasal steroids may also have a role
TREATMENT:UACS

49. • Chronic rhinosinusitis:
Nasal steroids and saline lavage, which should have an
effect by 4 weeks, and, if so, treatment should continue,
although optimal duration unclear.
.
TREATMENT:UACS
• Chronic sinusitis:
Treat as for non-allergic rhinitis, but include 2 weeks of
antibiotics active against H. influenzae such as
doxycycline or co-amoxiclav

50.  Second most common cause of cough in adults
• Clues that chronic cough is due to asthma:
– Episodic wheezing, dyspnea , cold or exercise
induced
– Reversible airflow obstruction
– Bronchial hyperresponsiveness
• Confirmed by resolution of cough with asthma treatment

51. • 30-60% of patients presenting with chronic cough
that was due to asthma had cough as their ONLY
symptom
 Clues:
- nocturnal cough, exercise induced, after allergen
exposure
 Bronchoprovocation test: positive
 Negative test exclude asthma but does not rule out
steroid responsive cough

52. Treatment
• Inhaled corticosteroid
• ICS/LABA combination > 8 weeks
 Leukotrine receptor antagonist
-Confirmed by resolution of cough with asthma
treatment

53.  Eosinophilic airway inflammation WITHOUT variable airflow
obstruction or airway hyperresponsiveness
• Diagnostic tests:
- Spirometry: normal
- Methacholine challenge: normal
- Sputum or BAL eosinophilia: >3% eosinophils
• Diagnostic/Therapeutic trial: inhaled corticosteroid for ≥ 4
weeks
• Characteristically resistant to bronchodilator but reponds ICS
• Confirmed diagnosis if responded to ICS

54.  Suspect GERD when…
– Symptoms of heartburn or sour taste in
mouth
– Reflux demonstrated by
• 24-hour pH-impedance monitoring
• Barium x-ray
• Cough is the only symptom of GERD in 40-75% of
patients with chronic cough due to GERD

55.  Cough due to GERD occurs most commonly
while patients are awake, stooping posture,
meal related, and usually does not occur during
the night
• Diagnosis of GERD as cause of chronic cough
requires resolution of cough with GERD
treatment

56. Life-style changes
 Stop smoking
 Avoid alcohol
 Lose weight
 Elevate HOB
 Small meals
 Avoid fatty/acidic foods /low fat diet
 Avoid caffeine
 Avoid – tight clothes, eating < 4 hrs pre-bed, recumbency
3 hrs post meal

57. Conservative measures :
• Antacid therapy ≥ 2 months :
– Proton pump inhibitor (high dose)
– H2 blockers less effective
• Motility therapy:
– Metoclopromide
Surgery is last resort

60. • Occurs in 10–15% of people on ACE inhibitors; more
frequent in women.
• Can occur within weeks of starting the drug, but up to 6
months;
• the cough may be initiated by a respiratory tract infection but
persists thereafter.
• Cough usually settles within a week of stopping the drug but
may take months.

61.  accounts for 20% of referrals to a specialist cough
clinic. It is diagnosed after a thorough assessment.
 there is lymphocytic airway inflammation,
 Typically, the patients are middle-aged women with a
long-standing dry cough, often starting around the
time of the menopause and triggered by an URTI.
 Organ-specific autoimmune disease is present in up
to 30%, particularly hypothyroidism.
 Treatment is often ineffective.

62.  A diagnosis of exclusion
 Most common in adolescents with concomitant
emotional disorders
 No sputum production
 Usually does not occur at night or during enjoyable
distractions
 classically complain of a persistent tickling/irritating
feeling in the throat or chest, often leading to
coughing paroxysms.

63. .
• often triggered by temperature change, cigarette
smoke, strong smells, eating crumbly food, deep
breaths, laughing or talking on the phone
• Not affected by commonly used cough suppressants
• Persists for weeks to months
• Normal findings on physical examination and
investigations
Psychogenic Cough

64. Symptomatic treatment for
cough

65.  Honey and lemon
 Dextromethorphan—a non-sedating non-opiate.
 Menthol—short-lived cough suppressant
 Sedative antihistamines—suppress cough but cause
drowsiness. Good for nocturnal cough
 Codeine or pholcodine—opiate antitussives
 Opiates— Low-dose morphine sulfate 5–10mg
showed significant improvement in patients with
intractable cough
 Thalidomide—used in cough due to IPF, with RCT
showing significant improvements.

66.  Chronic
 Abdominal or pelvic hernias
 Fatigue fractures of lower ribs
 Costochondritis
 Urinary incontinence

67. 55 yo school teacher
c/o cough for 3 years Non-smoker
 Cough: Often productive
 Better with abx, but comes back
 “no better” with asthma meds
 Worst in the morning
 Frequent clearing the throat, sensation of
dripping into throat

68.  Nasal voice, afebrile,
 looks well
 Pharynx: Mild “cobblestoning”
 No facial tenderness
 Normal heart and lungs
 Normal spirometry

69.  The Computer Programmer, 35 y.o woman
c/o Yearly cough lasted for > 8 weeks
– starts only after a “cold weather” at end of
the year
– severe coughing
– goes away by itself
– has happened last year
- nocturnal cough
• Tried “everything”

70.  Denies: wheezes, PND sx, allergies, heartburn,
aspiration
• No: pets, current meds
• Family hx: negative
• PMH: negative
• Physical exam and CXR normal
• Normal spirometry
Any other Ix?
Methacholine Challenge Testing

71. The Computer Programmer…
• Aggressive asthma regimen x 8 weeks
 Not feeling better
 Now what??

72.  Classify cough into acute, subacute, and chronic
 Focused history to shortlist potential ddx
 Rule out red flags before commencing treatment for acute
cough
 CXR is an essential test in chronic cough
 Ensure treatment adherence and completion of therapy to
prevent relapses or complications

73. In patients with chronic cough and a normal CXR
finding who are nonsmokers and are not receiving
therapy with an ACE inhibitor,
the diagnostic approach should focus on the
detection and treatment of UACS (formerly
called PNDS), asthma, NAEB, or GERD, alone or in
combination.
This approach is most likely to result in a high rate
of success in achieving cough resolution.
ACCP Evidence-Based Clinical Practice Guidelines