1. Cough 101

2. Recommended Reading
•The Diagnosis and Treatment of Cough
Richard S. Irwin and J. Mark Madison
NEJM Volume 343, Number 23
Pages 1715-1721. December 2000
•Diagnosis and Management of Cough
Executive Summary. ACCP Evidence-
Based Clinical Practice Guidelines
Chest Volume 129 Supplement 2006

3. Recommended Reading
•Prevalence, pathogenesis, and causes of
chronic cough
Kian F. Chung and Ian D. Pavord
Lancet 371(9621):
Pages 1364-74 April 2008
•Management of chronic cough
Ian D. Pavord and Kian F. Chung
Lancet 371(9621):
Pages 1375-84 April 2008

4. Recommended Reading
•Concise Clinical Review: Controversies in the
Evaluation and Management of Chronic Cough
Surinder S. Birring
Am J Resir Crit Care Med 183(6)
Pages 708-715 March 2011

5. Cough 101
• Acute cough
– Lasting less than 3 weeks
• Sub-acute
– Lasting 3-8 weeks
• Chronic cough
– Lasting 8 weeks or more
Cough is the most common reason
patients seek medical attention in
the United States

6. Acute Cough
• Duration less than 3 weeks
• Most commonly due to:
1. Upper respiratory tract infection
2. Lower respiratory tract infection
3. Pulmonary embolism

7. Acute Cough
• Duration less than 3 weeks
• Most commonly due to:
1. Upper respiratory tract infection
2. Lower respiratory tract infection
3. Pulmonary embolism

8. Acute cough algorithm for the management of patients ≥ 15 years of age with cough lasting
< 3 weeks
Irwin R S et al. Chest 2006;129:1S-23S
©2006 by American College of Chest Physicians

9. Cough and Pulmonary Embolism
• Which of the following statements are
true about cough and acute PE
a) Cough associated with PE is usually
productive
b) Cough is present in 50% of patients with PE
c) Cough is the predominant symptom in some
patients with PE
d) The severity of cough predicts the extent of
thromoboembolism in patients with PE

10. Cough and Pulmonary Embolism
• Which of the following statements are
true about cough and acute PE
a) Cough associated with PE is usually
productive
b) Cough is present in 50% of patients with PE
c) Cough is the predominant symptom in some
patients with PE
d) The severity of cough predicts the extent of
thromoboembolism in patients with PE

11. Life-threatening causes of
acute cough
High index of suspicion in the elderly because
classic signs/symptoms may be absent
Pulmonary embolism Heart Failure Pneumonia

12. Subacute cough algorithm for the management of patients ≥ 15 years of age with cough
lasting 3 to 8 weeks
Irwin R S et al. Chest 2006;129:1S-23S
©2006 by American College of Chest Physicians

13. Subacute cough algorithm for the management of patients ≥ 15 years of age with cough
lasting 3 to 8 weeks
Irwin R S et al. Chest 2006;129:1S-23S
©2006 by American College of Chest Physicians

14. Post-infectious cough
• Cough more than 3 weeks following an
upper or lower respiratory tract infection
• Usually resolves in 4 weeks
• Anti-tussive medications and steroids
can help with symptoms

15. Chronic Cough
• Chronic cough of undetermined etiology
accounts for 10-40% of a
pulmonologist’s outpatient practice

16. How good can we be
at making a diagnosis?
• Studies show that the etiology of chronic
cough can be determined by a well-
trained pulmonologist…..
a) Less than 50% of the time
b) 60-70% of the time
c) 70-80% of the time
d) 80-90% of the time
e) 90-100% of the time

17. How good can we be
at making a diagnosis?
• Studies show that the etiology of chronic
cough can be determined by a well-
trained pulmonologist…..
a) Less than 50% of the time
b) 60-70% of the time
c) 70-80% of the time
d) 80-90% of the time
e) 90-100% of the time

18. How good can we be
at making a diagnosis?
• Studies show that the etiology of chronic
cough can be determined by a well-
trained pulmonologist…..
a) Less than 50% of the time
b) 60-70% of the time
c) 70-80% of the time
d) 80-90% of the time
e) 90-100% of the time

19. Can you cure your patient?
• Studies show that treatment success rates
for chronic cough can be as high as…..
a) Less than 50%
b) 50-60%
c) 60-70%
d) 70-85%
e) 85-100%

20. Can you cure your patient?
• Studies show that treatment success rates
for chronic cough can be as high as…..
a) Less than 50%
b) 50-60%
c) 60-70%
d) 70-85%
e) 85-100%

21. Chronic Cough- Etiology
• 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 3 conditions?
a) Congestive Heart Failure
b) Upper Airway Cough Syndrome (UACS)
c) Asthma
d) Gastroesophageal reflux disease (GERD)
e) Chronic Bronchitis

22. Chronic Cough- Etiology
• 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 3 conditions?
a) Congestive Heart Failure
b) Upper Airway Cough Syndrome (UACS)
c) Asthma
d) Gastroesophageal reflux disease (GERD)
e) Chronic Bronchitis

23. Etiology of Chronic Cough
= UACS + NAEB ?

24. Chronic Cough sometimes has
more than one cause
1 = single cause of cough
2 = 2 causes of cough
3 = 3 causes of cough

25. Causes of Cough in
Children and Adults
= UACS

26. Guideline for Evaluating
Chronic Cough
• A systematic, diagnostic approach has
been validated in immunocompetent
patients- 5 step plan:
– Step 1: Review history and exam focusing
on the most common causes of chronic
cough
– Step 2: Order a CXR in nearly all patients
(except perhaps young non-smokers with
presumed UACS)

27. Guideline for Evaluating
Chronic Cough
– 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

28. Tests for evaluating
Chronic Cough

29. Guideline for Evaluating
Chronic Cough
– Step 5: Determine the cause(s) of cough by
observing which specific therapy eliminates
cough as a complaint.
• 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.

30. Guideline for Evaluating
Chronic Cough
Step 1 Step 2 Step 3
Step 4 Step 5

31. Upper Airway Cough Syndrome

32. Upper Airway Cough Syndrome
• 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

33. Upper Airway Cough Syndrome
• 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

34. Causes of Upper Airway
Cough Syndrome

35. UACS
• 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
pharyxnx
c) cough responds favorably to specific
therapy aimed at eliminating the drip

36. UACS
• 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
pharyxnx
c) cough responds favorably to specific
therapy aimed at eliminating the drip

37. UACS-Sinusitis

38. Treatment-Sinusitis
• Antibiotics directed against H. Flu, S.
Pneumonia, oral anaerobes
• Oral antihistamine/decongestant x 3 weeks
• Intranasal decongestant for maximum of 5
days
– e.g. oxymetazoline 2 sprays each nostril bid
x 3 days only

39. Treatment- Allergic Rhinitis
• Allergen avoidance
• Intranasal steroid
• Antihistamine
• Antihistamine/decongestant
• Allergen immunotherapy

40. Nasal Steroids

41. Antihistamines

42. Treatment- other UACS
• Perennial non-allergic, post-infectious,
environmental irritant, vasomotor rhinitis
– Antihistamine/decongestant
– Intranasal steroids
– Intranasal ipratropium bromide for vasomotor rhinitis
– Non-histamine mediated rhinitidies do not respond
as well to newer generation H1-antagonists; try
older ones with anti-cholinergic activity

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

44. Cough Variant Asthma
• 30-60% of patients presenting with
chronic cough that was due to asthma
had cough as their ONLY symptom

45. Non-asthmatic
Eosinophilic Bronchitis (NAEB)
•Normal CXR
•Normal spirometry
•Normal methacholine challenge
•Sputum eosinophilia
•Treatment- inhaled corticosteroids

46. Treatment- Asthma
• Inhaled corticosteroid
• ICS/LABA combination
• Oral steroids for empiric trial of
efficacy is not recommended
since oral steroids may improve
cough resulting from any
inflammatory disease

47. GERD
• 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

48. GERD
• Cough due to GERD occurs most
commonly while patients are awake and
upright, and usually does not occur or is
not noted during the night
• Diagnosis of GERD as cause of
chronic cough requires resolution of
cough with GERD treatment

49. Treatment- GERD
• Intensive anti-reflux medical regimen:
– Diet is most important factor
• High protein, low fat anti-reflux diet
• 3 meals per day
• Avoid food, drinks, and meds that lower esophageal
sphincter pressure
• NPO between meals and 2 hours prior to reclining
• Improve compliance by referring to dietician and monitoring
weight at follow-up visit
– Elevate head of bed 4 inches
– Proton pump inhibitors

50. Treatment- GERD
– Successful treatment for GERD takes on
average 161-179 days, vs. 67-70 days for
cough due to UACS or asthma
– Continue treatment for at least 3 months
after cough has disappeared as a complaint,
then gradually discontinue it
– If medical therapy fails
• Consider OSA
• Consider offending med
(CCB, nitrate, progesterone, theo)
• Consider surgery

51. Algorithm for the management of patients ≥ 15 years of age with cough lasting > 8 weeks
Irwin R S et al. Chest 2006;129:1S-23S©2006 by American College of Chest Physicians

52. ACE inhibitor cough
• Accounts for 2% of cases of chronic cough
• Non-productive, irritating, tickling, scratching
sensation in the throat
• Can occur after 1st
dose, or weeks to months
later
• Usually will recur with switch to any other ACE
inhibitor
• Diagnosis is confirmed when cough
disappears after drug in discontinued

53. Bronchogenic Carcinoma

54. Bronchogenic Carcinoma
• Cough is a common symptom of lung
cancer, but lung cancer is NOT a
common cause of chronic cough
• Suspicion for cancer as a cause of
cough should be heightened
– If CXR shows a central lesion
– In cigarette smokers who develop a new
cough that persists or have a change in
character of their chronic cough

55. Cough 102

56. Unexplained Chronic Cough
• Middle aged females around the onset of
menopause
• Onset triggered by a viral illness,
Bordetella pertussis, basidiomycetous
fungi
• Concomitant anxiety and depression (due
to the chronic, persistent cough)
• *psychogenic cough is extremely rare

57. Pathogenesis of Unexplained
Chronic Cough
• Cough reflex hypersensitivity
– Increased sensitivity to cough challenge with
capsaicin
– Increased density of sensory nerve fibers in
the airways
– Increased TRPV-1 receptor expression on
sensory c-fibers

58. Cough reflex hypersensitivity
Increased density of sensory
nerve fibers in the airways
Increased TRPV-1 receptor
expression on sensory c-fibers

59. Cough hypersensitivity syndrome
• Chronic cough > 2 months duration
• Minimal or no sputum production
• One or more cough reflex triggers (cold air,
speech, eating, odors such as perfumes)
• Urge to cough (tickle or itch) located in throat
• Adverse impact of cough on QOL
• Positive cough reflex challenge test (e.g.
capsaicin)

60. Non-specific Anti-tussives
– Codeine 30-60 mg
– Dextromethorphan 60 mg
– Diphenhydramine 25-50 mg
– Benzonatate (Tessalon pearls)
• 100-200 mg tid prn, maximum 600 mg/d

61. – Down-regulate neural activity
– amitriptyline
– gabapentin
Cough hypersensitivity syndrome

62. New concepts in the management of
chronic cough
• Obstructive sleep apnea
• Tonsillar enlargement
• Autoimmune disease (hypothyroidism)
• Basidomycetous fungi