para>Children with chronic cough not responsive to an inhaled β-agonist and without overt stressors should undergo spirometry (if age-appropriate) and foreign body evaluation (CXR).
Initial Tests (lab, imaging)
- Evaluation will be dictated by findings in the comprehensive history and physical.
- Evaluation of peak flow may be indicated.
- If considering neoplasm, heart failure, or infectious etiologies, CXR or B-type natriuretic peptide (BNP) may be indicated.
- In cases of failure to respond to initial trial of empiric therapy, CXR may also be beneficial.
Follow-Up Tests & Special Considerations
- Examples:
- If considering chronic obstructive pulmonary disease (COPD), asthma, or restrictive lung disease: spirometry
- If suspicious of cystic fibrosis: sweat chloride testing
- If suspicious of hypereosinophilic syndrome, tuberculosis, or malignancy: sputum for eosinophils and cytology
- If abnormal CXR, suspected neoplasm, or underlying pulmonary disorder, consider a chest CT.
- Consider pulmonary consultation.
- Refer to gastroenterologist for endoscopy.
Diagnostic Procedures/Other
If diagnosis suggested and inadequate response to initial measures, other procedures can be considered:
- Pulmonary function testing
- Purified protein derivative (PPD) skin testing
- Allergen testing
- 24-hour esophageal pH monitor
- Bronchoscopy, if history of hemoptysis or smoking with normal CXR
- Endoscopic or video fluoroscopic swallow evaluation or barium esophagram
- Sinus CT
- Ambulatory cough monitoring and cough challenge with citric acid, capsaicin, or other bronchodilator (at specialized cough clinic)
- Echocardiogram
Test Interpretation
Specific to underlying cause
TREATMENT
- With chronic cough, empiric treatment should be directed at the most common causes as clinically indicated (UACS, asthma, GERD) (2)[C].
- Oral antihistamine/decongestant therapy with a 1st-generation antihistamine or nasal steroid spray can be used as initial empiric treatment (2)[C].
- In patients with cough associated with the common cold, nonsedating antihistamines were not found to be effective in reducing cough (2)[C].
- In stable patients with chronic bronchitis, therapy with ipratropium bromide may reduce chronic cough (3)[C].
- Centrally acting antitussive drugs (dextromethorphan, hydrocodone) may be used for short-term symptomatic relief of coughing in patients with chronic bronchitis but have limited efficacy in cough due to upper respiratory infections (3)[C].
- For cough associated with lung cancer, narcotic cough suppressants are recommended (3)[C].
- The American Academy of Pediatrics does not recommend central cough suppressants for treating any kind of cough (2)[B].
- In children <14 years, when pediatric recommendations are not available, adult recommendations should be used with caution (2)[C].
- Some children with recurrent cough and no evidence of airway obstruction may benefit from an inhaled β-agonist (4)[C].
- In infants and children with nonspecific chronic cough, trials of empiric PPI therapy were not effective (5)[C].
GENERAL MEASURES
- In patients with chronic cough, considerations for potential etiology should include asthma (2)[B] or UACS (2)[C].
- With concomitant complaints of heartburn and regurgitation, GERD should be considered as a potential etiology (2)[C].
- 90% of patients will have resolution of cough after smoking cessation (2)[A].
- When indicated, ACE inhibitor therapy should be switched in patients in whom intolerable cough occurs (3)[A]. It may take several days or weeks for cough to resolve after stopping ACE inhibitor therapy.
- Empirically treat postnasal drip and GERD.
- Consider nonpharmacologic options, such as warm fluids, hard candy, or nasal drops. In infants and children, try clearing secretions with a bulb syringe.
- Attempt maximal therapy for single most likely cause for several weeks, then search for coexistent etiologies.
MEDICATION
- Treatments (nasal steroids, classic antihistamines, antacids, bronchodilators, inhaled corticosteroids, PPIs, antibiotics) should be directed at the specific cause of cough.
- If history and physical exam suggest GERD, may want to trial H2 blocker or PPI therapy prior to further diagnostic testing.
- A comparative effectiveness review of 49 studies with common opioid and nonanesthetic antitussives stated there is some efficiency for treating cough in adults, but evidence is limited (6)[C].
- The FDA issued a public health advisory stating that OTC cough and cold medicines, including antitussives, expectorants, nasal decongestants, antihistamines, or combinations, should not be given to children <2 years. Subsequently, manufacturers have changed labeling to state "do not use" in children <4 years. National estimates have shown a decline in emergency department visits in children <2 years related to adverse events from cough and cold medicine ingestion (7).
- Routine empiric treatment of children with chronic cough with leukotriene receptor antagonists lacks evidence and cannot be recommended (8)[C]. A small pilot study with montelukast in adults demonstrated some symptom relief after 2 weeks of treatment (9)[A].
First Line
- In adults, oral antihistamine/decongestant therapy can be empiric treatment. Multiple formulations are available OTC in combination with other ingredients. Advise patients to review labels carefully or consult pharmacist:
- Chlorpheniramine 2 mg/phenylephrine 5 mg/acetaminophen 325 mg (Tylenol Allergy Multi-Symptom) 2 caplets or gel caps PO q4h (maximum 12 caplets or gel caps in 24 hours; for patients >12 years)
- Nasal steroids: fluticasone, budesonide, others, 1 spray BID
- Central cough suppressants for short-term symptomatic relief of nonproductive cough
- Dextromethorphan 10 to 20 mg PO q4h for patients >12 years; use 5 to 10 mg PO q4h for patients 6 to 12 years
- Concomitant use of dextromethorphan and agents with serotonergic activity (e.g., SSRIs) should be avoided due to risk of serotonin syndrome.
- Narcotics: codeine 15 to 30 mg PO q6h; hydrocodone/acetaminophen (Vicodin) 5 mg PO q6h; hydrocodone/chlorpheniramine (Tussionex Pennkinetic) 10 mg (5 mL) PO q12h for patients ≥12 years (no benefit in children; no good efficacy data in adults)
Second Line
- A peripherally acting antitussive agent has been used:
- In patients >10 years, benzonatate (Tessalon Perles) 100 to 200 mg PO TID as needed (maximum 600 mg/day)
- Results from a small randomized placebo-controlled trial (n = 27) demonstrated subjective cough score improvement in patients using slow-release morphine sulfate. Patients had failed with other antitussive therapies. Side effects included constipation and drowsiness, and there were no discontinuations due to adverse events (10)[A].
- Morphine was administered 5 to 10 mg PO BID.
- An analysis of studies evaluating inhaled corticosteroid use in chronic cough for patients without additional indication such as asthma did not show consistent benefits (11)[C].
ISSUES FOR REFERRAL
Patients with chronic cough may benefit from evaluation by pulmonary, gastroenterology, ear-nose-and-throat (ENT), and/or allergy specialists.
SURGERY/OTHER PROCEDURES
Fundoplication may be effective for cough secondary to refractory GERD.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Consider stepwise withdrawal of medications after resolution of cough.
Patient Monitoring
Frequent follow-up is necessary to assess the effectiveness of treatment
DIET
Dietary modification: Patients with GERD may benefit by avoiding ethanol, caffeine, nicotine, citrus, tomatoes, chocolate, and fatty foods.
PATIENT EDUCATION
- Reassure patient that most cases of chronic cough are not life-threatening and that the condition can usually be managed effectively.
- Counsel that several weeks to a month may be needed for significant reduction or elimination of cough
- Prepare the patient for the possibility of multiple diagnostic tests and therapeutic regimens because the treatment is very often empiric.
PROGNOSIS
- >80% of patients can be effectively diagnosed and treated using a systematic approach.
- Cough from any cause may take weeks to months until resolution, and resolution depends greatly on efficacy of treatment directed at underlying etiology.
COMPLICATIONS
- Cardiovascular: arrhythmias, syncope
- Stress urinary incontinence
- Abdominal and intercostal muscle strain
- GI: emesis, hemorrhage, herniation
- Neurologic: dizziness, headache, seizures
- Respiratory: pneumothorax, laryngeal, or tracheobronchial trauma
- Skin: petechiae, purpura, disruption of surgical wounds
- Medication side effects
- Other: negative impact on quality of life
REFERENCES
11 Morice AH, Millqvist E, Belvisi MG, et al. Expert opinion on the cough hypersensitivity syndrome in respiratory medicine. Eur Respir J. 2014; 44(5):1132-1148.22 Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1)(Suppl):1S-23S.33 Bolser DC. Cough suppressant and pharmacologic protussive therapy: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1)(Suppl):238S-249S.44 Gupta A, McKean M, Chang AB. Management of chronic non-specific cough in childhood: an evidence-based review. Arch Dis Child Educ Pract Ed. 2007;92(2):33-39.55 Chang AB, Lasserson TJ, Gaffney J, et al. Gastro-oesophageal reflux treatment for prolonged non-specific cough in children and adults. Cochrane Database Syst Rev. 2011;(1):CD004823.66 Yancy WSJr, McCrory DC, Coeytaux RR, et al. Efficacy and tolerability of treatments for chronic cough: a systematic review and meta-analysis. Chest. 2013;144(6):1827-1838.77 Hampton LM, Nguyen DB, Edwards JR, et al. Cough and cold medication adverse events after market withdrawal and labeling revision. Pediatrics. 2013;132(6):1047-1054.88 Chang AB, Winter D, Acworth JP. Leukotriene receptor antagonist for prolonged non-specific cough in children. Cochrane Database Syst Rev. 2006;(2):CD005602.99 Mincheva RK, Kralimarkova TZ, Rasheva M, et al. A real-life observational pilot study to evaluate the effects of two-week treatment with montelukast in patients with chronic cough. Cough. 2014;10(1):2.1010 Morice AH, Menon MS, Mulrennan SA, et al. Opiate therapy in chronic cough. Am J Respir Crit Care Med. 2007;175(4):312-315.1111 Johnstone KJ, Chang AB, Fong KM, et al. Inhaled corticosteroids for subacute and chronic cough in adults. Cochrane Database Syst Rev. 2013;(3):CD009305.
ADDITIONAL READING
Dicpinigaitis PV, Morice AH, Birring SS, et al. Antitussive drugs-past, present, and future. Pharmacol Rev. 2014;66(2):468-512.
SEE ALSO
- Asthma; Bronchiectasis; Congestive Heart Failure; Eosinophilic Pneumonias; Gastroesophageal Reflux Disease; Laryngeal Cancer; Lung, Primary Malignancies; Pertussis; Pulmonary Edema; Rhinitis, Allergic; Sinusitis; Tuberculosis
- Algorithm: Cough, Chronic
CODES
ICD10
- R05 Cough
- J44.9 Chronic obstructive pulmonary disease, unspecified
- J41.0 Simple chronic bronchitis
ICD9
- 786.2 Cough
- 496 Chronic airway obstruction, not elsewhere classified
- 491.0 Simple chronic bronchitis
SNOMED
- 68154008 Chronic cough (finding)
- 13645005 Chronic obstructive lung disease (disorder)
- 46802002 smokers cough (disorder)
CLINICAL PEARLS
- Chronic cough is defined as a cough that persists for >8 weeks in adults.
- In patients with chronic cough, most frequent etiologies include a history of smoking, asthma, UACS, and GERD.
- The FDA issued a public health advisory stating that OTC cough and cold medicines should not be given to children <2 years. OTC cough expectorant and suppressant product labels state "do not use" in children <4 years.