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A cough lasting longer than 8 weeks can be a major frustration for our patients (and everyone around them). In this segment, pulmonologist and cough expert Dr. Kathryn Robinett walks Neda and Paul through a real-world approach to chronic cough and drops tons of beautiful, shimmery knowledge pearls along the way.
- Don’t be afraid to treat chronic cough empirically and simultaneously. If it persists despite treatment and basic work-up beyond 12 weeks, refer to pulm or ENT.
- Cough definitions:
- Chronic > 8 weeks
- Subacute 3-8 weeks
- Acute < 3 weeks
- Common causes of chronic cough:
- Post-nasal drip (now known as upper airway cough syndrome)
- Rare causes:
- Lung cancer
- Interstitial lung disease
- Eosinophilic bronchitis
- Occupational (notices it gets better when on vacation away from work or worse returning to work or new job with exposures)
- Overall approach:
- Very few guidelines
- Varies by provider
- Coughing begets coughing so an empiric for a total of 8 weeks of cough approach with multiple treatments to stop the cough isn’t wrong
- If no improvement at 8 weeks:
- Chest X-ray
- If no improvement at 4 weeks with empiric treatment:
- Full PFTs
- CT chest, non-contrast, high resolution but most CT scans are so good these days the standard is fine
- Referral to pulmonology
- Treatment options:
- Prednisone taper - 40 mg x 4 days, 30mg x 4 days, 20mg x 4 days, 10mg x 4 days
- PPI x 4 weeks
- Esophageal pH testing it not very helpful in cough because you may have normal pH but have GERD-related chronic cough
- Short-acting beta agonist +/- inhaled corticosteroid (not helpful if on oral steroids)
- Cough suppressants:
- Benzonatate (Tessalon perles)
- Nasal steroid
- If improvement:
- Peel off treatments starting with cough suppressants, leaving treatment for postnasal drip, GERD and asthma.
- Peel off remaining treatment based on level of suspicion for the underlying cause
- Other rarer causes:
- Chronic cough hypersensitivity syndrome - nerves and lungs become overly sensitive after viral URI resulting in chronic cough
- Vocal cord dysfunction - referral to ENT
- Cough as a tic - treated with behavioral therapy, speech therapy
- Irwin RS, Ownbey R, Cagle PT, et al. Interpreting the histopathology of chronic cough. Chest 2006; 130:362-370.
- Michaudet C, Malaty J. Chronic cough: evaluation and management. Am Fam Physician. 2017 Nov 1;96(9):575-580. PMID: 29094873
- Smith JA, Woodcock A. Chronic cough. N Engl J Med. 2016 Oct 20;375(16):1544-1551. PMID: 27797316.
- Achilleos A. Evidence-based evaluation and management of chronic cough. Med Clin North Am. 2016 Sept;100(5):1033-45. PMID: 27542423