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Chronic Cough

Kathryn Robinett, MD, Neda Frayha, MD, and Paul Simmons, MD
00:00
23:27

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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.

Pearls:

  • 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-viral
    • GERD
    • Post-nasal drip (now known as upper airway cough syndrome)
    • Asthma
    • COPD
    • 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
  • Diagnostics:
    • If no improvement at 8 weeks:
      • CBC
      • 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)
      • Codeine
    • 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

REFERENCES:

  1. Irwin RS, Ownbey R, Cagle PT, et al. Interpreting the histopathology of chronic cough. Chest 2006; 130:362-370. 
  2. Michaudet C, Malaty J. Chronic cough: evaluation and management. Am Fam Physician. 2017 Nov 1;96(9):575-580. PMID: 29094873
  3. Smith JA, Woodcock A. Chronic cough. N Engl J Med. 2016 Oct 20;375(16):1544-1551. PMID: 27797316.
  4. Achilleos A. Evidence-based evaluation and management of chronic cough. Med Clin North Am. 2016 Sept;100(5):1033-45. PMID: 27542423

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