10/2/2021 Cough - AMBOSS

Cough Last updated: Sep 23, 2021

QBANK SESSION CLINICAL SCIENCES CLINICIAN LEARNED

Summary
A cough is a protective mechanism that forcefully expels air from the lungs to clear
secretions, foreign bodies, and irritants from the airway, and can be triggered by various
conditions. A cough can be classified as acute, subacute, or chronic, in addition to
productive (with sputumexpectoration) or dry. The most common causes of acute cough
are upper respiratory tract infections (URTIs), exacerbations of chronic conditions,
and pneumonia. Subacute cough is often a sequela of a URTI (postinfectious cough) but can
also be caused by upper airway cough syndrome (UACS) or pertussis. Common causes of
chronic cough in adults include UACS, asthma, gastroesophageal reflux
disease (GERD), nonasthmatic eosinophilic bronchitis (NAEB), and certain medications
(e.g., ACE inhibitors, sitagliptin). The cause of an acute cough can often be determined
clinically with a thorough medical history and physical examination. Chronic cough or the
presence of red flag symptoms (including dyspnea, fever, hemoptysis, and weight loss)
indicate that further investigation is required. Treatment depends on the underlying etiology
and often includes symptomatic therapy.
See also “Dyspnea” and “Chest pain.”
NOTES FEEDBACK

Definition
Cough: a protective mechanism that forcefully expels air from the lungs to clear secretions,
foreign bodies, and irritants from the airway
Upper airway cough syndrome (UACS): also known as postnasal drip [1][2]
The drainage of mucus down the back of the throat due to increased nasal mucus
production; various causes, such as allergic rhinitis and chronic sinusitis
Symptoms include coughing, a feeling of obstruction in the throat, and throat clearing.
Protracted bacterial bronchitis [1]
Chronic bacterial infection that causes a productive cough
Clinical diagnosis requires all of the following:
Daily cough for > 4 weeks
Resolution within 2–4 weeks of antibiotic treatment
Absence of alternate diagnosis
NOTES FEEDBACK

https://next.amboss.com/us/article/3L0Sxg#Z9867437122918bd982da8fd411588908 1/12
10/2/2021 Cough - AMBOSS

Pathophysiology
Triggers: cough may be voluntary or a reflex to airway irritants/triggers
Mechanical
Inhaled/aspirated solid or particulate matter (e.g., smoke, dust)
Mucus
Chemical
Gastric acid (GERD)
Inflammatory mediators: bradykinin, prostaglandin E2
Thermal: cold air
Cough reflex arc
Irritation of cough receptors in the nose, sinuses, upper and lower respiratory tract (see the
triggers above)
Transmission along the afferent pathway via the internal laryngeal nerve of the vagus
nerve(CN X) to the cough center in the medulla
Generation of efferent signal in the medulla and initiation of cough via the vagus, phrenic,
and spinal motor nerves
Mechanism of cough reflex: initiation of the cough reflex arc leads to
Rapid inspiration, closure of the epiglottis and vocal cords (which traps inhaled air in
the lungs), and contraction of the diaphragm, expiratory, and abdominal muscles → rapid
increase of intrathoracic pressure
A sudden opening of the vocal cords and forceful expulsion of air from the lungs
References:[3][4][5][6][7][8]
NOTES FEEDBACK

Classification
Cough is usually classified by duration.
Adults and adolescents > 14 years of age [2]
Acute cough: < 3 weeks
Subacute cough: 3–8 weeks
Chronic cough: > 8 weeks
Children and adolescents ≤ 14 years of age [1][9][10][11]
Acute cough: < 2 weeks
Subacute cough: 2–4 weeks
Chronic cough: at least daily cough for > 4 weeks [11][12][13]
NOTES FEEDBACK

Etiology
MAXIMIZE TABLE TABLE QUIZ
https://next.amboss.com/us/article/3L0Sxg#Z9867437122918bd982da8fd411588908 2/12
10/2/2021 Cough - AMBOSS

Causes of cough
Adults [2][2][13]
[13][14]
[14] Children [1][1][12]
[12][13]
[13]

Respiratory tract infections (most

common)
URTIs, e.g., common
cold, influenza Respiratory tract infections (most common)
LRTIs, e.g., acute URTIs, e.g., common cold, influenza
bronchitis, pneumonia, pertussis LRTIs, e.g., acute
Exacerbation of chronic conditions, bronchitis, pneumonia, pertussis, bronchiolitis
Acute e.g.: Croup
cough UACS Initial presentation or exacerbation of a chronic
Acute exacerbation of condition, e.g.:
bronchiectasis Asthma
Asthma exacerbation Cystic fibrosis
AECOPD Foreign body aspiration
Acute heart failure
Pulmonary embolism
Acute inhalation injury
Postinfectious cough (most common)
Pneumonia
Pertussis
New onset or exacerbation of a chronic condition, e.g.:
UACS
Subacute Asthma
cough GERD
COPD
NAEB
Bronchiectasis
Tuberculosis
Chronic foreign body airway obstruction (especially in young children)

https://next.amboss.com/us/article/3L0Sxg#Z9867437122918bd982da8fd411588908 3/12
10/2/2021 Cough - AMBOSS

Causes of cough
Adults [2][13][14] Children [1][12][13]
Common
UACS Older children
Asthma Asthma
GERD Protracted bacterial bronchitis
NAEB UACS
Drug-induced cough, e.g., caused Gastrointestinal conditions, e.g., GERD
by ACE inhibitors, sitagliptin [13] Immunodeficiency
Irritation, e.g., due to Atypical respiratory infection, e.g., mycoplasma
environmental triggers, tobacco pneumonia, pertussis
Chronic use New onset of a chronic condition,
cough Less common e.g., UACS, bronchiectasis, cystic fibrosis,
COPD ciliary dyskinesia, interstitial lung disease
Bronchiectasis Irritation, e.g., due to environmental triggers, tobacco
Pulmonary tuberculosis smoke
Interstitial lung Tic cough [12]
disease (e.g., sarcoidosis, silicosis) Somatic cough disorder [12]
Chronic hypersensitivity Infants
pneumonitis Congenital defects
Lung cancer Cardiac anomalies
Obstructive sleep apnea

In endemic areas, consider pulmonary tuberculosis in all patients with a cough of

any duration. [2]

Consider pertussis in patients with risk factors, e.g., underimmunization and/or

contact with an infected individual. [12]
NOTES FEEDBACK

Management approach
Initial management [2][15]
Conduct a thorough clinical evaluation for cough, and if possible, identify specific cough
etiology.
Categorize cough by the duration of symptoms (see “Classification”).
Assess for red flags for cough.
Evaluate and treat life-threatening causes of cough immediately if present.
Order routine diagnostic studies for chronic cough or if red flags for cough are present (see
“Diagnostics”).
https://next.amboss.com/us/article/3L0Sxg#Z9867437122918bd982da8fd411588908 4/12
10/2/2021 Cough - AMBOSS

Subsequent management [2][15]

If specific cough etiology is identified:
Order additional or confirmatory testing as directed by clinical suspicion (see
“Diagnostics”).
Begin targeted therapy and consider adding symptomatic therapy as needed (see
“Treatment”).
If the cause remains uncertain after initial evaluation:
Follow the recommended approach for cough by duration (see “Acute and subacute cough”
and “Chronic cough”).
Consider empiric symptomatic therapy (see “Treatment”).
Acute and subacute cough is most commonly due to self-limiting viral illnesses.
Routine diagnostic studies are typically unnecessary unless red flags for
cough are present or required for specific suspected cough etiologies.
NOTES FEEDBACK

Clinical evaluation
A detailed history and physical examination are essential to help narrow down the
possible causes of cough and guide initial investigations and management. [2][15]
History of present illness
Duration of cough (weeks): Ascertaining the symptom duration is a recommended first step
in evaluating adults presenting with cough (see “Classification”). [2][15]
Other cough characteristics
Presence of sputum
Productive cough
Nonproductive cough
Onset
Sudden
Gradual
Quality: classic cough presentations in children [1][12]
Brassy or barking cough
Staccato cough (in infants)
Paroxysmal cough
Inspiratory whoop
Aggravating factors
Symptom variation depending on the weather and/or season
Supine position
Exercise
https://next.amboss.com/us/article/3L0Sxg#Z9867437122918bd982da8fd411588908 5/12
10/2/2021 Cough - AMBOSS

Daytime or nighttime worsening of symptoms

Associated symptoms
Viral symptoms, e.g., rhinorrhea, odynophagia, myalgia, fever
Allergic symptoms, e.g., itching or watery eyes, rhinorrhea, nasal congestion, throat clearing
Posttussive vomiting
Chest pain or heartburn
Cough exacerbated by exercise and at nighttime is characteristic of cough-
variant asthma.

Coughing paroxysms, inspiratory whoop, and posttussive emesis are

characteristic of pertussis. [16]
Other key historical features
Comorbidities
Personal or family history of atopy
History of chronic disease
Cardiac conditions
Respiratory conditions
Immunodeficiency
Neurological or developmental impairment
Vaccination status: absent or incomplete immunization, e.g., against Streptococcus
pneumoniae, Haemophilus influenzae type b, pertussis, influenza
Medication
ACE inhibitors [13]
Sitagliptin [2]
Beta blockers
Exposures
Infectious contacts
Radiation sources
Lifetime tobacco smoke exposure
Occupational exposure to irritants, e.g., chemicals, organic or inorganic dust [17]
Travel history [18]
Travel to endemic areas
At-risk activities
Means of transportation
Red flags for cough [2][13]
These red flag features may indicate a life-threatening cause of cough and typically warrant
rapid evaluation and treatment.
Smoking history, in particular:
https://next.amboss.com/us/article/3L0Sxg#Z9867437122918bd982da8fd411588908 6/12
10/2/2021 Cough - AMBOSS

Current smokers > 45 years of age with a new or worsening cough and/or voice changes
Patients 55–80 years old with ≥ 30 pack-years who either currently smoke or quit
smoking ≤ 15 years ago
Symptoms
Fever
Weight loss
Severe dyspnea (especially at nighttime or when at rest)
Hoarseness
Weight gain with peripheral edema
Dysphagia
Vomiting
Hemoptysis [1]
Recurrent pneumonia
Excessive sputum production
Physical examination
Abnormal pulmonary examination, e.g.,
Wheeze
Crackles
Abnormal cardiovascular examination, e.g., pulsus paradoxus
An abnormal screening chest x-ray in a patient with cough is also a red flag (see
“Diagnostics”).
NOTES FEEDBACK

Acute and subacute cough

The following recommendations apply to adults and are consistent with the 2006 and 2018
CHEST guidelines on diagnosis and management of cough. [2][15]
Suspected life-threatening causes of cough: Begin immediate empiric therapy and expedite
targeted diagnostics and treatment.
Suspected self-limiting infectious (e.g., URTI, acute bronchitis) or postinfectious cause:
Consider conservative approach. [19][20]
Suspected non-self-limiting infection (e.g., pneumonia, TB, pertussis): Confirm diagnosis
and begin targeted therapy. [16]
Newly diagnosed chronic condition or exacerbation thereof
(e.g., UACS, asthma, GERD, NAEB, COPD, bronchiectasis): Begin targeted management.
Subacute cough of suspected noninfectious origin: See “Chronic cough.”
Consider tailored symptomatic therapy and supportive care in all patients in addition
to targeted therapy (see “Treatment”).

https://next.amboss.com/us/article/3L0Sxg#Z9867437122918bd982da8fd411588908 7/12
10/2/2021 Cough - AMBOSS

Diagnostic studies for acute or subacute cough are not routinely indicated in
patients without red flags for cough. [2][13][15]

Postinfectious cough is the most common cause of subacute cough and often
resolves without treatment. If it is interfering with the patient's sleep and/or daily
activities, consider the use of antitussives.
NOTES FEEDBACK

Chronic cough
The following recommendations apply to adults and are consistent with the 2006 and 2018
CHEST guidelines on diagnosis and management of cough. [2][13][15]
Follow the diagnostic and therapeutic approach for suspected causes of cough based on
detailed clinical evaluation for cough.
Obtain CXR as part of the routine evaluation (if not already performed). [2][12]
Eliminate any known modifiable triggers , e.g.:
Recommend smoking cessation and avoiding second-hand smoke.
Stop or substitute offending medications (e.g., ACE inhibitors, NSAIDs, beta blockers).
Recommend avoiding environmental and/or occupational exposures.
Focus the evaluation on the most common causes of chronic cough in adults and consider
sequential diagnostics and/or empiric treatment. [15]
MAXIMIZE TABLE TABLE QUIZ
Most common causes of chronic cough in adults
Initial management
Assess for possible underlying illnesses, e.g., allergic rhinitis, chronic sinusitis, pertussis, and
UACS treat if identified. [15]
Consider empiric treatment with a first-generation antihistamine and decongestant. [2][13]
Consider intranasal steroids, nasal saline, or oral antihistamines.
Pulmonary function testing, e.g., bronchial challenge test, spirometry [15]
Asthma Allergy testing [2]
Consider a trial of asthma treatment. [13][15]

NAEB Consider sputum studies and/or a fractional exhaled nitric oxide test. [15]
Consider a trial of inhaled corticosteroids. [13][15]
GERD Trial pharmacological treatment of GERD. [15]

https://next.amboss.com/us/article/3L0Sxg#Z9867437122918bd982da8fd411588908 8/12
10/2/2021 Cough - AMBOSS

In endemic areas, screen all patients with cough for tuberculosis regardless of
cough duration. [12]

Also consider new-onset COPD, interstitial lung disease, and lung cancer,
especially in patients with red flags for cough.
NOTES FEEDBACK

Life-threatening causes of cough

The following conditions should be considered in all adults who present with a cough
accompanied by signs of respiratory distress, hemodynamic instability, and/or red flags for
cough (see also “Dyspnea”):
Severe asthma exacerbation or life-threatening asthma exacerbation
Pneumonia with respiratory failure
Severe acute exacerbation of chronic obstructive pulmonary disease (AECOPD)
Pulmonary embolism (PE)
Acute heart failure (AHF)
Foreign body aspiration (FBA)
Acute inhalation injury
Pneumothorax
Acute pericarditis
Acute chest syndrome
Anaphylaxis
Lung cancer
If the patient is unstable, follow the ABCDE approach and consider
immediate oxygen therapy, airway management, and/or mechanical ventilation.
NOTES FEEDBACK

Diagnostics
Diagnostic studies for acute or subacute cough are not routinely indicated in
patients without red flags for cough. [2][13][15]
Initial investigations [2][22][23][24][25]
Chest x-ray
https://next.amboss.com/us/article/3L0Sxg#Z9867437122918bd982da8fd411588908 9/12
10/2/2021 Cough - AMBOSS

Obtain routinely for investigating chronic cough, suspected pneumonia, or suspected TB.
Obtain urgently if red flags for cough are present (e.g., high risk of lung cancer).
Otherwise, consider as directed by clinical evaluation of cough.
Laboratory studies: Consider in patients with red flags for cough, signs of respiratory
distress, suspected sepsis/bacteremia, or risk factors for specific infections.
CBC
ABG
Microbiology of respiratory infections
Cultures: e.g., sputum culture, blood culture
TB testing: e.g., tuberculin skin test, sputum examination for acid-fast bacilli
Pertussis testing: e.g., nasopharyngeal swab, deep nasopharyngeal aspirate, culture
and/or PCR
Viral testing: e.g., nasopharyngeal PCR for influenza, RSV, COVID-19
Pulmonary function tests: Consider based on clinical suspicion of chronic lung disease.
[12]
Spirometry: to differentiate between obstructive lung disease (e.g., asthma, COPD)
and restrictive lung disease (e.g., interstitial lung disease)
Bronchial challenge test (metacholine challenge test; bronchodilator reversibility test): to
differentiate asthma from other obstructive lung diseases
Single-breath diffusing capacity: to differentiate between intrapulmonary (e.g., interstitial
lung disease) and extrapulmonary causes (e.g., pleural effusion) of restrictive lung disease
Additional investigations [2][22][23][24][25]
Consider the following on a case-by-case basis depending on clinical evaluation for cough,
duration, and results of initial investigations.
Imaging
X-ray of paranasal sinuses: Consider in patients with UACS secondary to
suspected sinusitis.
Consider CT chest for:
Suspected bronchiectasis
Recurrent pneumonia
CXR findings suggestive of lung cancer (e.g., mass, hilar lymphadenopathy)
Inconclusive chest x-ray findings in patients with foreign body aspiration
Endobronchial investigations
Bronchoalveolar lavage (BAL)
Description: A minimally invasive technique that is performed during flexible
bronchoscopy in order to evaluate the immunologic, inflammatory, and infectious processes
at the level of the alveoli in diffuse lung disease.
Indications
Inconclusive noninvasive diagnostic tests (e.g., in bronchiectasis, asbestosis)
Suspected infectious etiology in patients who are unable to expectorate sputum for
examination (e.g., tuberculosis, PCP, histoplasmosis, aspergillosis)
Consider bronchoscopy for:
https://next.amboss.com/us/article/3L0Sxg#Z9867437122918bd982da8fd411588908 10/12
10/2/2021 Cough - AMBOSS

Foreign body aspiration

Lung cancer
Suspected tracheoesophageal fistula
Others
BNP levels, ECG, and ECHO: e.g., for suspected heart failure
Endoscopy, 24-hour esophageal pH monitoring, and/or barium swallow: e.g., for
suspected GERD/achalasia that is not responsive to a trial of PPIs
Assessment of environmental and occupational exposures
NOTES FEEDBACK

Treatment
Approach
Treat specific underlying cough etiologies.
Evaluate the patient's response with routine follow-up.
Reconsider the working diagnosis if treatment is unsuccessful.
Consider supportive measures and symptomatic treatment, e.g., in acute viral cough.
Antibiotics are not recommended for the routine treatment of cough unless there
is a proven indication, e.g., in pneumonia or acute bacterial sinusitis.
Supportive measures
Recommend rest and adequate hydration.
Advise patients to avoid lung irritants, e.g., smoke, incense. [26][27]
Nonpharmacological measures may be beneficial, e.g.: [14]
Nasal saline for nasal congestion
Honey [28][29][30]
A humidifier
Symptomatic treatment for cough [19][20][31][32]
Expectorants, e.g., guaifenesin (immediate release or extended release)
Increases bronchial fluid content to loosen mucus (no cough suppression)
May be considered for productive coughs
Cough suppressants (antitussives)
Generally not effective [19][20]
May be considered for nonproductive coughs that interfere with sleep
Centrally acting: Suppress the cough reflex arc at the level of the central nervous
system(see “Opioids“ for more information).
Dextromethorphan (immediate release or extended release)
Codeine (off-label)
https://next.amboss.com/us/article/3L0Sxg#Z9867437122918bd982da8fd411588908 11/12
10/2/2021 Cough - AMBOSS

Peripherally acting: Suppress peripheral triggers of the cough reflex arc by anesthetizing
respiratory stretch receptors, e.g., benzonatate
Antitussive medications decrease coughing and, therefore, should only be used
in nonproductive cough, as coughing is needed for the expectoration of mucus.
They are not indicated in productive coughs or coughs caused by an infection.
Symptomatic treatment for specific types of cough
Mucolytics, e.g., N-acetylcysteine
Thins mucus by cleaving disulfide bridges between mucus glycoproteins
May be used in hyperviscous chronic bronchopulmonary diseases (e.g., COPD, cystic
fibrosis)
Chest physiotherapy
Loosens and mobilizes airway mucus through physical percussion, vibrations, and postural
drainage
May be beneficial for patients with ineffective cough (e.g., neuromuscular disorders) and/or
bronchopulmonary diseases with increased sputum viscosity (e.g., cystic
fibrosis, bronchiectasis, pneumonia)
Treatment of associated symptoms
Antihistamines: Consider if an allergic component is suspected, e.g., in allergic rhinitis.
Bronchodilators (e.g., beta agonists): indicated for the treatment of asthma and COPD
Steroids
Intranasal or inhaled steroids: used in allergic rhinitis, asthma, and NAEB
Systemic steroids: used in patients with acute inflammation and/or edema, e.g.,
in anaphylaxis, AECOPD, acute asthma exacerbation, croup
Decongestants (e.g., oxymetazoline, pseudoephedrine): may be used to treat nasal
congestion [33]
NSAIDs: may be used to treat myalgia, headache, and fever

https://next.amboss.com/us/article/3L0Sxg#Z9867437122918bd982da8fd411588908 12/12