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|
|• Allergic Rhinitis (Allergies; Hay Fever) #|
• Chronic Sinusitis
• Esophageal Reflux (GERD) (Heartburn) #
• Hypertension medication (“ACE-Inhibitors”)
# = Conditions which can sometimes go away & then recur [as opposed to an ongoing “cough”]
|• Asthma #|
• Post-Viral Bronchospasm
• Tuberculosis (TB)
• Certain Lung Infections (fungi, etc.)
• Chronic Bronchitis #
• Heart Failure
• Interstitial Lung Disease
• Hypersensitivity Pneumonitis #
• Uncommon Diseases of Lung or Trachea
• Lung Cancer
All of the Lung Diseases above can occasionally cause shortness of breath (SOB), a potentially-serious symptom. See link for definition. If there’s SOB, we know there’s 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 has Nasal symptoms (runny nose, congestion, especially sneezing) → a trial of allergy medicine for presumed Allergic Rhinitis.
- Patient has Heartburn (sour taste in throat) → trial of antacid medicine for Esophageal Reflux.
- Patient has just begun an ACE-Inhibitor for Hypertension → change the medication!!!
- Lung Exam suggesting Bronchospasm (wheezing or other sounds of bronchospasm heard by stethoscope → a trial of medicine for Asthma. (also helps Post-Viral Bronchospasm) If patient a Smoker, may also try similar medications for diagnosis of Chronic Bronchitis.
- Bursts (paroxysms) of coughing, followed by vomiting → may be Pertussis (tests not so useful; treatment not so useful once 2 weeks have gone by)
- None of Above: Test Peak Flow, give asthma treatment in office, repeat Peak Flow. If improved, trial of medicine for Asthma
- Chest X-Ray if: fever, night sweats, coughing up blood, to rule out TB or other Lung Infections
- If none of above, or if treatment trials don’t help…
STEP #2 (None of Above, OR Treatment Trials No Help) — Chest X-Ray (CXR)
- Abnormal CXR → additional tests depend on type of abnormality, may include examination of sputum (phlegm), different types of CT scans, Pulmonary Function Tests
- Normal CXR → 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 → CT Scan of Chest for Lung Cancer. Treatment Trial for Chronic Bronchitis.
- If Shortness of Breath → 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) → for diagnosing Asthma, Interstitial Lung Disease, and Uncommon Diseases of Lung or Trachea.
- If PFTs suggest: Asthma → Treat it; If Interstitial Lung Disease → obtain a High Resolution CT Scan, and referral to Pulmonologist; if Disease of Trachea → referral to ENT Specialist
- If new Hoarseness or Voice Change lasting over 2 weeks → 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 — Full Text for more in-depth explanations and discussions.