Chronic Cough is here defined as lasting over 3 weeks without any improvement at all. It could be going on for months. Here we present the clinician’s condensed thought process when face-to-face with patients; see also Chronic Cough — Full Text for more in-depth discussion.
Causes of Chronic Cough
| Not From the Lung | Lung Diseases |
|---|---|
| โข Allergic Rhinitis (Allergies; Hay Fever) # โข Chronic Sinusitis โข Esophageal Reflux (GERD) (Heartburn) # โข Hypertension medication (โACE-Inhibitorsโ) # = Conditions which can sometimes go away & then recur [as opposed to an ongoing โcoughโ] xxx xxx | โข Asthma # โข Post-Viral Bronchospasm โข Pertussis โข Tuberculosis (TB) โข Certain Lung Infections (fungi, etc.) โข Chronic Bronchitis # โข Heart Failure โข Interstitial Lung Disease โข Hypersensitivity Pneumonitis # โข Uncommon Diseases of Lung or Trachea โข Lung Cancer |
All of the Lung Diseases above can occasionally cause shortness of breath (SOB), a potentially-serious symptom. See link for definition. If thereโs SOB, we know thereโs a lung disease, some of which can eventually be fatal; see symptom topic Shortness of Breath.
STEP #1 —- Consider most common causes; if likely, give treatment trial if:
- Patient hasย Nasal symptoms (runny nose, congestion, especially sneezing) ย โ a trial of allergy medicine for presumed Allergic Rhinitis.
- Patient has Heartburn (sour taste in throat) ย โ trial of antacid medicine for Esophageal Reflux.
- Patient has just begun an ACE-Inhibitor for Hypertension ย โ change the medication!!!
- Lung Exam suggesting Bronchospasm (wheezing or other sounds of bronchospasm heard by stethoscope ย โ a trial of medicine for Asthma. (also helps Post-Viral Bronchospasm)ย If patient a Smoker, may also try similar medications for diagnosis of Chronic Bronchitis.
- Bursts (paroxysms) of coughing, followed by vomiting ย โย may be Pertussis (tests not so useful; treatment not so useful once 2 weeks have gone by)
- None of Above:ย Test Peak Flow, give asthma treatment in office, repeat Peak Flow.ย If improved, trial of medicine for Asthma
- Chest X-Ray if:ย fever, night sweats, coughing up blood, to rule out TB or other Lung Infections
- If none of above, or if treatment trials don’t helpโฆ
STEP #2 (None of Above, OR Treatment Trials No Help) — Chest X-Ray (CXR)
- Abnormal CXR โ additional tests depend on type of abnormality, may include examination of sputum (phlegm), different types of CT scans, Pulmonary Function Tests
- Normal CXR โ different Treatment Trials anyway, for Allergic Rhinitis, Esophageal Reflux, and Asthma, one by one as necessary (see “STEP #1” for medication links). If child with many nasal symptoms, consider Chronic Sinusitis (see Nasal Congestion)
- If long-time / heavy Smoker โ CT Scan of Chest for Lung Cancer. Treatment Trial for Chronic Bronchitis.
- If Shortness of Breath โ See our topic on our diagnostic approach to Shortness of Breath (for Heart Failure and Interstitial Lung Disease)
STEP #3 — Normal CXR, & have tried different Treatment Trials without success
- Pulmonary Function Tests (PFTs) โ for diagnosing Asthma, Interstitial Lung Disease, and Uncommon Diseases of Lung or Trachea.
- If PFTs suggest: Asthma โ Treat it; If Interstitial Lung Disease โ obtain a High Resolution CT Scan, and referral to Pulmonologist; if Disease of Trachea โ referral to ENT Specialist
- If new Hoarseness or Voice Change lasting over 2 weeks โ refer to ENT Specialist to rule out Uncommon Diseases of Trachea or Larynx.
SPECIAL CASE — Hypersensitivity Pneumonitis (HP)
- Episodes of cough, shortness of breath, maybe fever / nausea that last 4 hours to a few days, go away, & come back, repeatedly
- If patient is a farmer, or has other job / hobby exposed to various dusts of animal or plant material, refer to Pulmonologist (mentioning this condition specifically)
- See link above for causes
STEP #4 — Everything Normal (CXR, PFTs, “High-Res CT”), No Symptoms above, & Nothing Helps
- Refer to a Specialist
- Pulmonologist — if we think lung diseases most likely);
- Ear-Nose-Throat (ENT; Otorhinolaryngologist) — if we think Upper Airway Cause; and/or
- Gastroenterologist — if we think GERD, and treatment doesn’t help
See Chronic Cough โ Full Text for more in-depth explanations and discussions.