Chronic coughBMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7383.261 (Published 01 February 2003) Cite this as: BMJ 2003;326:261
- Graeme P Currie (), specialist registrar in respiratory medicinea,
- Robert D Gray, clinical lecturerb,
- John McKay, honorary clinical senior lecturerc
- a Chest Clinic C, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB252ZN
- b Asthma and Allergy Research Group, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY
- c Department of Postgraduate Medicine (General Practice), University of Glasgow, Glasgow G12 9LX
- Correspondence to: G P Currie
A 42 year old woman presents with an eight month history of non-productive chronic cough. Her general health is good other than hypertension. She finds social situations embarrassing and is fed up as the cough causes urinary incontinence and disrupts her sleep.
What issues you should cover
Chronic cough has been defined as lasting more than two months.
Take a history to elucidate the cause of the cough. In particular, ask about symptoms of asthma (including any occupational association) and symptoms of postnasal drip, such as repeated throat clearing, nasal discharge, or excessive production of phlegm. Ask specifically about heartburn and regurgitation.
Does the patient smoke?
Has the patient been prescribed an angiotensin converting enzyme inhibitor?
Look out for worrying features associated with the cough that merit specialist referral (box).
Chronic cough can cause exhaustion and irritability, headaches, difficulty sleeping, urinary incontinence, syncopal episodes, sore throat, self consciousness, and fear of underlying serious illness.
Psychogenic cough and habit cough are diagnoses of exclusion, and in most cases a cause can be found.
Explain that to make a diagnosis several consultations may be needed.
Patients with chronic cough
Reasons for specialist referral
Risk factors of immunosuppression
Difficult symptom control
Asthma and chronic obstructive pulmonary disease
Follow British Thoracic Society guidelines
Postnasal drip syndrome
Perennial or seasonal allergic rhinitis: advise allergen avoidance and prescribe nasal corticosteroid spray or oral antihistamine
Non-allergic rhinitis: consider ipratropium nasal spray
Sinusitis: consider antibiotics
Nasal decongestants—for short term use only—can also be useful in postnasal drip when combined with other treatments
Gastro-oesophageal reflux disease
Advise lifestyle changes, take conservative measures, and prescribe acid suppression drugs
What you should do
Examine the patient, with particular attention to the upper and lower respiratory tracts. Look for signs of asthma and postnasal drip with its possible causes (allergic rhinitis, non-allergic rhinitis, and sinusitis). Remember that examination often shows nothing abnormal.
Diurnal peak flow monitoring for two to three weeks may help to clarify a diagnosis of asthma, and spirometry can determine if there is airflow obstruction. Normal spirometry is useful in excluding chronic obstructive pulmonary disease.
Arrange chest radiography in smokers and in those at risk of tuberculosis or immunosuppression—also in non-smokers if the diagnosis is not clear.
A skin prick or radioallergosorbent test to common aeroallergens may be helpful to determine if postnasal drip has an allergic aetiology.
If the patient smokes, the cough may be due to physical irritation or chronic obstructive pulmonary disease.
In non-smokers who do not take an angiotensin converting enzyme inhibitor, and whose chest radiograph is essentially normal, the most likely causes of chronic cough are asthma, postnasal drip from the nose or sinuses, or gastro-oesophageal reflux disease.
Less common causes include bronchiectasis, sarcoidosis, bronchial carcinoma, left ventricular failure, tuberculosis, eosinophilic bronchitis, interstitial lung disease, and chronic aspiration.
The value of anti-tussive drugs for short term relief of symptoms is debatable. Opioids should generally be avoided in view of their addictive nature.
Where necessary, encourage smoking cessation.
Angiotensin converting enzyme inhibitors cause a non-productive cough in 5-10% of cases, which is not dose dependent. If this is the cause, the cough should settle within a month of discontinuing the drug. An alternative agent, such as an angiotensin II receptor antagonist, should be considered.
Ask the patient to make another appointment to assess response. This will also provide an opportunity to discuss the diagnosis and management if initial treatment fails.
The series is edited by general practitioners Ann McPherson and Deborah Waller ()
The BMJ welcomes contributions from general practitioners to the series
This is part of a series of occasional articles on common problems in primary care