An approach

To cough

We will discuss both acute and chronic cough in one general discussion but we
will highlight along the way where these two differ
The best diagnostic framework for the etiologies of cough is a combination of
anatomic region and organ system.

❖ first category
It is referred to as HEENT (Head, ears, eyes, nose, throat) but in this context we
will relabel it as upper airway
And in the upper airway we have 4 main categories :
1- Acute upper respiratory infection : which is also known as common cold and
it’s caused by viruses
2- Upper airway cough syndrome ( this is the old name) but now it’s called post-
nasal drip : it includes a variety chronic condition which have overlapping
presentation and treatments which are :
a) Allergic rhinitis (hay fever)
b) Non-allergic rhinitis
c) Chronic sinusitis
These conditions causes sub acute to chronic nasal congestion ,runny nose,
sneezing,sinus pressure and of course cough!
3- Post-viral cough : which when a viral infection triggers a temporary version of
either upper airway cough syndrome or cough variant asthma
4- Laryngeal cancer : the most rare one

❖ Second category
It is pulmonary and conditions here include
1- Acute bronchitis : which is usually caused by viruses and has alote of clinical
overlap with upper respiratory infections
The small minority of acute bronchitis that’s caused by bacteria are due to
pertussis, mycoplasma, and chlamydia pneumonia
2- Pneumonia : not just bacterial but also fungal and mycobacterial
3- Cough variant asthma : which is just like asthma but the predominant symptom
is an episodic allergy mediated cough rather than wheezing or dyspnea
4- Chronic bronchitis (COPD)
5- Bronchiectasis
6- Lung cancer
7- Interstitial lung disease
8- Aspiration
9- Foreign body aspiration: which is most commonly seen in children

❖ Third category
It is the GI tract and it includes :
1- Laryngopharyngeal reflux /GERD : In Laryngopharyngeal reflux the gastric
contents reflux above the esophagus up above the upper esophageal sphincter
into the larynx and pharynx where is in GERD the gastric contents reflux past
the lower esophageal sphincter and remain in the esophagus and both situations
can cause cough

❖ Fourth category
It is the miscellaneous and it includes
1- ACE inhibitor side effect : the reported incidence is between 1% and as high as
up to 1/3 of the patients on the medication
2- Heart failure
3- Mitral valve disease
In the last 2 mentioned causes rarely present with only cough as the
predominant symptoms the presentation is usually dyspnea and cough or lower
extremity edema and cough not often as cough by itself
4- Ciliary dyskinesia : it is a genetic condition in which the airway lack the
normal mucuciliary clearness and a variaty of hereditary immunodeficiencies
5- Somatic cough syndrome (previously psychogenic cough)
6- Tic cough (previously habit cough)

The above mentioned are not all equally common and they cause either acite or
chronic cough
The most common cause of acute cough are upper respiratory tract infections, post
viral cough, acute bronchitis and pneumonia
The most common causes of chronic cough are upper airway cough syndrome,
asthma, laryngopharyngeal reflux/GERD, ACE inhibitors and among smokers
COPD

Evaluation
1- History
We will ask about
• Duration and timing of cough
• Characterization of cough as productive VS. non productive
Ask the patient to cough several times.
Cough associated with recurrent laryngeal nerve palsy has a hollow
sound because the vocal cords are unable to close completely; this has
been described as a bovine cough.
A muffled, wheezy, ineffective cough suggests obstructive pulmonary
disease.
A very loose productive cough suggests excessive bronchial secretions
due to chronic bronchitis, pneumonia or bronchiectasis.
A dry, irritating cough may occur with chest infection, asthma or
carcinoma of the bronchus and sometimes with left ventricular failure or
interstitial lung disease (ILD).
It is also typical of the cough produced by ACE inhibitor drugs.
A barking or croupy cough that have a muffled quality may suggest a
problem with the upper airway—the pharynx and larynx, or pertussis
infection.
Cough caused by tracheal compression by a tumour may be loud and
brassy.
A cough that is worse at night is suggestive of asthma or heart failure,
coughing that comes on immediately after eating or drinking may be due
to incoordinate swallowing or oesophageal reflux or, rarely, a tracheo-
oesophageal fistula.
• Presence of other symptoms such as fever, dyspnea, chest pain,
hemoptysis, heart burn, rhinorrea, nasal congestion or weight loss
• Sputum : It is an important to enquire about the type of sputum produced
and then to look at it, if it is available.
A large volume of purulent (yellow or green) sputum suggests the
diagnosis of bronchiectasis or lobar pneumonia.
 Foul-smelling dark-coloured sputum may indicate the presence of a lung
abscess with anaerobic organisms.
Pink frothy secretions from the trachea, which occur in pulmonary
oedema, should not be confused with sputum.
It is best to rely on the patient’s assessment of the taste of the sputum,
which, not unexpectedly, is foul in conditions like bronchiectasis or lung
abscess.
• Chronic lung disease
• Immunosuppression
• Smoking
• Use of an ACE inhibitors

2- Assess the vitals

• BP, pulse rate, temperature, RR

3- Focused physical exam

• HEENT exam
• Pulmonary examination
• Cardiac auscultation ( including JVP)

4- Key Lab tests

They are usually not helpful in most cases of a cough especially the chronic
ones but consider checking
• CBC (if infection is suspected)
• Chest X-ray

Now we will enter the diagnostic algorithm with the an initial question of wether
or not to order a chest X-ray
Abnormalities on X-ray include
1- Focal alveolar opacification
consistent with pneumonia Or
aspiration
2- Diffuse interstitial opacity
consistent with ILD
3- Hyperinflation and flatlining of
the diaphragm consistent with
COPD
4- Lung masses consistent with
cancer

But for most patients with cough

particularly those with chronic cough
the chest X-ray will be unremarkable
this will make serious pathology
relatively unlikely but not impossible
but despite that they should be
diagnosed correctly

Some of the etiologies listed below have confirmatory tests but in practice most
doctors often recommend instead a diagnostic trail of empiric treatment based on
the clinical present factors
This is usually because the empiric treatment that is used is benign and the
confirmatory test are either expensive or have sub optimal positive and negative
predictive values

1. Duration < 1 week, accompanied by other URI symptoms → Probable viral

URI and we give symptomatic treatment but the only consideration here is nasal
swab for influenza if during flu season particularly if there’s fever

2. <3 weeks, no other notable symptoms → Prob. acute bronchitis; symptomatic

treatment (no Ab is given) antibiotics only if pertussis
3. Acute, smoker or known history of COPD → Possible COPD exacerbation and
if there’s no more likely diagnosis consider prednisone, bronchodilators
( albuterol , ipratribiom), +/- abx

4. Subacute, preceded by now-resolved URI symptoms → Probable post-viral

cough, but also consider pertussis

5. Chronic, with nasal congestion, rhinorrhea, sneezing, et.— > Treat empirically
for upper airway cough syndrome (antihistamine, decongestant and/or nasal
steroids depending on the sub type)

6. Chronic most prominent at night, symptoms of heartburn → Treat empirically

for laryngopharyngeal reflux/GERD w PPIS & activity modification (weight
loss, smoking cessation, reducing alcohol and not eating 3 hrs befor bed

7. Chronic, with hoarseness → laryngopharyngeal reflux but hoarseness lasting

for weeks can also suggest pharyngeal or vocal cord tumors and need ENT
referral for consideration of laryngoscopy

8. Chronic, non-productive, triggered by exercise or cold temp, wheezing → Treat

empirically for cough variant asthma with albuterol & steroid inhalers

9. Chronic, smoker, diminished lung sounds, hyperresonance > Check PFTS to

evaluate for COPD

10. Use of ACE inhibitor, non-productive → Consider switch to an angiotensin Il

receptor blocker

If the patient fails to improve despite a course of treatment consider chest X-ray if
not already taken and to try aither a course of empiric treatment for the next most
probable diagnosis or to procede with more testing such as Methacholine
Challenge test for asthma and esophageal PH monitoring ti diagnose reflux
depending on the severity of cough an ent referral may be appropriate
One last point if the patient is presented with hemoptysis that warrant a similar yet
distinct diagnostic work up as they may have serious pathology
Key takeaway points

• The most common etiologies of an acute cough are an upper respiratory

infection, post-viral cough, acute bronchitis, and pneumonia.
• The most common etiologies of a chronic cough are upper airway cough
syndrome, colloquially known as post-nasal drip, cough-variant asthma, COPD,
laryngopharyngeal reflux/GERD, and an ACE inhibitor side effect.
• There is a lack of consensus regarding the naming and categorization of many
cough etiologies.
• Patients presenting with a cough should have a chest X-ray if either the cough is
chronic, or if it's associated with a red flag for serious pathology.
• If serious pathology is felt to be unlikely, empiric treatment of the most
probable diagnosis is an acceptable alternative to cumbersome, costly,
insensitive, or non-specific diagnostic testing.

Additional tables from different textbooks for revision