Cough
Cough - Summary
Cough is a reflex response to airway irritation. It is triggered by stimulation of airway cough receptors, either by irritants or by conditions that cause airway distortion.
Common airway irritants include:
Secretions.
Foreign bodies.
Infections.
Tumours.
Irritant gases, dust, or smoke.
Allergens.
Airway distortion is associated with conditions such as lung cancers, or pulmonary fibrosis caused by interstitial lung diseases such as sarcoidosis and idiopathic fibrosing alveolitis.
Upper respiratory tract infections are the most common causes of acute cough (less than 3 weeks' duration). Other causes include:
Acute bronchitis.
Pneumonia.
Acute exacerbations of asthma, chronic obstructive pulmonary disease (COPD), and bronchiectasis.
Pneumothorax.
Pulmonary embolism.
Foreign body aspiration.
Causes of subacute cough (3–8 weeks' duration).
Following an obvious respiratory infection, causes include: persistent pneumonia, persistent acute bronchitis, pertussis (whooping cough) and other types of post-infectious cough, when the infection has resolved but the cough persists through mechanisms that are not fully understood.
If there is no obvious respiratory infection, it is likely to be the early development of a chronic cough.
Causes of chronic cough (more than 8 weeks' duration) include:
Smoking-related causes, including smoker's cough, chronic bronchitis, and COPD.
Angiotensin-converting enzyme (ACE) inhibitors.
Asthma, cough variant asthma, and eosinophilic bronchitis.
Upper airway cough syndrome, most commonly caused by chronic rhinitis or chronic sinusitis.
Gastro-oesophageal reflux.
Uncommon causes of cough include:
Lung cancers.
Pulmonary tuberculosis.
Foreign body aspiration.
Bronchiectasis.
Interstitial lung disease.
Pertussis (whooping cough).
The cause should be determined where appropriate using history and examination. If the person has chest signs or respiratory symptoms in addition to cough, measurements of blood pressure, pulse rate, temperature, and oxygen saturation are required. If asthma is suspected, peak expiratory flow rate (PEFR) should be measured.
Emergency admission should be arranged if the person has:
A respiratory rate of more than 30 breaths per minute.
Tachycardia greater than 130 beats per minute.
Systolic blood pressure less than 90 mmHg, or diastolic blood pressure less than 60 mmHg (unless normal for them).
Oxygen saturation less than 92%, or central cyanosis (if no history of chronic hypoxia).
PEFR less than 33% of predicted.
Altered level of consciousness.
A large respiratory effort (particularly if becoming exhausted).
Clinical features of pulmonary embolism, pneumothorax, or aspiration of a foreign body.
Emergency admission should be considered depending on the severity and number of risk factors present, if the person does not meet the criteria above but:
Has an elevated respiratory rate.
Has tachycardia.
Has hypotension.
Has a high temperature (especially if higher than 38.5°C).
Has a PEFR less than 50% of predicted.
Is older than 65 years of age.
People who need urgent referral because they have suspected lung cancer, pulmonary tuberculosis, or foreign body aspiration should be identified.
Have I got the right topic?
This CKS topic is based on the British Thoracic Society's guideline Recommendations for the management of cough in adults [Morice et al, 2006] and the American College of Chest Physicians' guideline An empiric integrative approach to the management of cough [Pratter et al, 2006].
This CKS topic covers the assessment and management of adults presenting with cough as the predominant symptom.
This CKS topic does not cover the assessment of someone presenting with cough associated with significant breathlessness.
There are separate CKS topics on Asthma, Breathlessness, Chest infections - adult, Chronic obstructive pulmonary disease, Common cold, Cough - acute with chest signs in children, Influenza - seasonal, Lung cancer - suspected, Palliative cancer care - cough, Smoking cessation, Tuberculosis, and Whooping cough.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
July 2011 — minor update. More exact paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency [MHRA, 2011]. Prescriptions have been updated to reflect the revised dosing. Issued in July 2011.
May to September 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.
Update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 April 2010.
HTAs (Health Technology Assessments)
No new HTAs since 1 April 2010.
Economic appraisals
No new economic appraisals relevant to England since 1 April 2010.
Systematic reviews and meta-analyses
Systematic reviews published since the last revision of this topic:
Leconte, S., Ferrant, D., Dory, V., and Degryse, J. (2010) Validated methods of cough assessment: a systematic review of the literature. Respiration 81(2), 161-174. [Abstract]
Umoren, R., Odey, F., and Meremikwu, M.M. (2011) Steam inhalation or humidified oxygen for acute bronchiolitis in children up to three years of age (Cochrane Review). The Cochrane Library. Issue 1. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Primary evidence
Randomized controlled trials published since the last revision of this topic:
Ryan, N.M., Birring, S.S., and Gibson, P.G. (2012) Gabapentin for refractory chronic cough: a randomised, double-blind, placebo-controlled trial. Lancet 380(9853), 1583-1589. [Abstract]
New policies
No new national policies or guidelines since 1 April 2010.
New safety alerts
No new safety alerts since 1 April 2010.
Changes in product availability
No changes in product availability since 1 April 2010.
Goals and outcome measures
Goals
To support primary healthcare professionals:
To assess the person with cough and make a diagnosis when possible
To admit or refer people with cough as appropriate
To treat people with cough when appropriate
Background information
Definition
What is it?
Cough is a reflex response to airway irritation [Chung and Pavord, 2008]. It is triggered by stimulation of airway cough receptors, either by irritants or by conditions that cause airway distortion.
Common airway irritants include:
Secretions.
Foreign bodies.
Infections.
Tumours.
Irritant gases, dust, or smoke.
Allergens.
Airway distortion is associated with conditions such as lung cancers, or pulmonary fibrosis caused by interstitial lung diseases such as sarcoidosis and idiopathic fibrosing alveolitis.
Cough is defined as [Pratter et al, 2006]:
Acute when present for less than 3 weeks.
Sub-acute when present for 3–8 weeks.
Chronic when present for more than 8 weeks.
Causes
What causes it?
For the causes of cough associated with breathlessness, where breathlessness is the predominant symptom, see the CKS topic on Breathlessness.
Acute cough (less than 3 weeks' duration) [Morice et al, 2006]
Upper respiratory tract infections are the most common cause.
Other causes include:
Acute bronchitis.
Pneumonia.
Acute exacerbations of asthma, chronic obstructive pulmonary disease (COPD), and bronchiectasis.
Pneumothorax.
Pulmonary embolism.
Foreign body aspiration.
Sub-acute cough (3–8 weeks' duration) [Pratter et al, 2006]
Following an obvious respiratory infection, causes include:
Persistent pneumonia.
Persistent acute bronchitis.
Pertussis (whooping cough) and other types of post-infectious cough, when the infection has resolved but the cough persists through mechanisms that are not fully understood.
When cough does not follow an obvious respiratory infection, it is likely to be the early development of a chronic cough.
Chronic cough (more than 8 weeks' duration):
More than 99% of chronic coughs are caused by one or more of the following [Mello et al, 1996; Chung and Pavord, 2008]:
Smoking-related causes, including smoker's cough, chronic bronchitis, and COPD.
Angiotensin-converting enzyme (ACE) inhibitors.
Asthma, cough variant asthma, and eosinophilic bronchitis.
Upper airway cough syndrome, most commonly caused by chronic rhinitis or chronic sinusitis.
Gastro-oesophageal reflux.
Uncommon causes include:
Lung cancers.
Pulmonary tuberculosis.
Foreign body aspiration.
Bronchiectasis.
Interstitial lung disease.
Pertussis (whooping cough).
Diagnosis
Diagnosis
Diagnosis - cough less than 3 weeks
Diagnosis - cough less than 3 weeks' duration
Diagnosing the cause
How do I diagnose the cause of a cough of less than 3 weeks' duration?
If cough is associated with significant breathlessness, see the CKS topic on Breathlessness.
An upper respiratory tract infection is the most likely cause when:
There are no other respiratory symptoms such as breathlessness, pleuritic chest pain, haemoptysis, or wheeze, and
Examination of the chest is normal.
If the person has chest signs and/or respiratory symptoms in addition to cough:
Identify people who need emergency admission including people with clinical features of:
Pulmonary embolism, pneumothorax, or foreign body aspiration.
Severe illness, based on an assessment of their pulse rate, blood pressure, temperature, respiratory rate, peak expiratory flow rate, and oxygen saturation level (if pulse oximetry is available).
If the person has chest signs and/or respiratory symptoms in addition to cough and does not require emergency admission, look for clinical features of:
Lung cancer. Arrange a chest X-ray to be reported within 5 days if features of lung cancer are present.
If the person is older than 40 years of age with persistent haemoptysis and smokes, also arrange urgent referral to a respiratory physician.
If the person has a chest X-ray that is suggestive of lung cancer (including pleural effusion and slowly resolving consolidation) arrange urgent referral to a respiratory physician. If features of lung cancer are present, arrange a chest X-ray to be reported within 5 days.
Pneumonia. The diagnosis can be confirmed by chest X-ray, but it is not considered necessary if the person is well enough to be managed in the community.
Arrange a chest X-ray if the person is older than 50 years of age, smokes, and has clinical features of pneumonia, to look for signs of underlying lung cancer.
Acute bronchitis. The diagnosis is confirmed by clinical features alone.
Acute asthma. The diagnosis is confirmed by demonstrating variable airflow limitation by:
Serial peak expiratory flow rate measurements demonstrating greater than a 20% diurnal or day-to-day change, or
Where there is doubt, by a large response (more than 400 mL) to either bronchodilators or 30 mg of oral prednisolone daily for 14 days.
For further information, see the CKS topic on Asthma.
An acute exacerbation of chronic obstructive pulmonary disease (COPD) if the person is older than 35 years of age, and smokes or has smoked. The diagnosis is confirmed by:
Demonstrating air flow limitation by spirometry that is not fully reversible with treatment.
Air flow limitation is defined as a forced expiratory volume in 1 second (FEV1) of less than 80% of the predicted value and FEV1/forced vital capacity ratio less than 70%. For further information, see the CKS topic on Chronic obstructive pulmonary disease.
An acute exacerbation of bronchiectasis, especially in non-smokers with chronic productive cough or recurrent chest infections. The diagnosis is confirmed by:
Arranging a chest X-ray to exclude other causes for symptoms, and
Referring to a respiratory physician for confirmation of the diagnosis by high resolution CT scanning.
Pertussis, especially if the person has cough lasting more than 14 days with paroxysms of coughing or vomiting after coughing or cough associated with an inspiratory whoop, and if they have developed a cough within 3 weeks of being in contact with someone with confirmed pertussis. The diagnosis is confirmed by:
Taking nasopharyngeal aspirates or nasal swabs for culture if the person presents up to 2 weeks after the onset of the cough, or by taking blood for serology if the person presents more than 2 weeks after the onset of the cough.
Basis for recommendation
Basis for recommendation
Confirming acute bronchitis and pneumonia based on clinical features alone
The use of clinical features alone to distinguish acute bronchitis from pneumonia in people who are well enough to be manged in the community is based on expert opinion [British Thoracic Society, 2009] and an assessment of the evidence on the sensitivity of clinical features to distinguish acute bronchitis from pneumonia summarized in an expert review article [Braman, 2006].
Confirming asthma or chronic obstructive pulmonary disease (COPD)
Recommendations on how to confirm a diagnosis of asthma are based on expert opinion published in the British guideline on the management of asthma published by the Scottish Intercollegiate Guidelines Network and the British Thoracic Society [SIGN and BTS, 2008].
Recommendations on how to confirm a diagnosis of COPD are based on expert opinion published in the guideline Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care issued by the National Institute for Health and Clinical Excellence [National Clinical Guideline Centre, 2010].
Confirming bronchiectasis
In the Guideline for non-CF bronchiectasis, the British Thoracic Society recommends referring people with suspected bronchiectasis to a specialist to arrange a high resolution CT scan to confirm the diagnosis [British Thoracic Society, 2010]. This recommendation is based on evidence from observational studies and expert opinion that the chest X-ray appearance and clinical features of bronchiectasis are insufficiently sensitive and specific to reliably diagnose the condition.
Confirming pertussis
Recommendations are based expert opinion published in the UK guidelines for use of erythromycin chemoprophylaxis in persons exposed to pertussis [Dodhia et al, 2002].
Arranging a chest X-ray for people older than 50 years of age who smoke with clinical features of pneumonia
This recommendation is based on expert opinion published in BTS guidelines for the management of community acquired pneumonia in adults [British Thoracic Society, 2009]. A chest X-ray is recommended to look for features of lung cancer because, in the opinion of experts, this combination of features puts people at high risk of the disease.
Arranging a chest X-ray for people with haemoptysis and other clinical features of lung cancer
The National Institute for Health and Clinical Excellence in Referral guidelines for suspected cancer recommend investigating people with haemoptysis and other clinical features of lung cancer [NICE, 2005]. This recommendation is based on evidence from observational studies and expert opinion that these features are associated with a high risk of the disease.
Clinical features - acute cough causes
What are the clinical features of the common causes of acute cough?
Upper respiratory tract infections
Conditions include the common cold, influenza, pharyngitis, otitis media, and sinusitis.
Symptoms — may cause cough with or without sputum, general malaise, and possibly fever. Infection and symptoms, such as pain and discharge, may be localized to the nose, ears, throat, or sinuses.
Signs — no focal chest signs.
Acute bronchitis
Symptoms — cough with or without sputum, breathlessness, wheeze, or general malaise.
Signs — no chest signs other than wheeze and crackles. Crackles, if present, should clear with coughing — if they persist, diagnose pneumonia.
Pneumonia
Symptoms — cough associated with at least one other symptom of breathlessness, sputum, wheeze, or pleuritic pain.
Signs — any focal chest sign (such as dull percussion note, bronchial breathing, or coarse crackles) plus at least one systemic feature (such as fever/sweating, or myalgia), with or without a temperature greater than 38°C. There may be signs of an associated pleural effusion.
Acute asthma
Risk factors — personal history of rhinitis or eczema, or family history of atopy.
Symptoms — wheeze, breathlessness, cough. Symptoms are variable (often worse at night, first thing in the morning, and upon exercise or exposure to cold or allergens).
Signs — there may be none when the person is feeling well. During an acute episode, the respiratory rate is increased, and wheeze is usually present.
Peak expiratory flow rate (PEFR) is reduced during an acute episode. Acute asthma is:
Life-threatening — when PEFR is less than 33% of predicted, and is associated with tachycardia, hypotension, a silent chest, or impaired level of consciousness.
Severe — when PEFR is 33–50% of predicted, and is associated with a respiratory rate of more than 25 breaths per minute and an inability to complete full sentences.
Moderate — when PEFR is more than 50% of predicted, with a respiratory rate of less than 25 breaths per minute.
Acute exacerbation of chronic obstructive pulmonary disease (COPD)
History — typically, the person is older than 35 years of age, is a smoker or past smoker, and reports slowly progressive breathlessness often associated with wheezing or chest tightness, and a cough (producing purulent sputum).
Symptoms of acute exacerbation — new or worsening cough associated with worsening breathlessness, and wheeze.
Signs — wheeze, hyperinflated chest (in emphysema), crackles (when infection is present). There may be signs of right-side heart failure in people with severe disease, including swollen ankles and increased jugular venous pressure. The person's peripheries (the hands and feet) are often warm to the touch and a dusky colour (cyanosed), with distended veins.
Acute exacerbation of bronchiectasis
History of bronchiectasis — suspect if the person has a history of recurrent or chronic productive cough (present in 75–100% of adults with bronchiectasis), progressive breathlessness (72–83%), haemoptysis (51–45%), and non-pleuritic chest pain between exacerbations (31%).
Symptoms of an acute exacerbation — new or worsening cough that may be associated with worsening breathlessness and wheeze.
Signs — coarse crackles in early inspiration commonest in the lower lung fields (70% of adults), wheeze (34%), and large airway rhonchi (44%). Finger clubbing occurs infrequently.
Pulmonary embolism (PE)
Risk factors — immobilization, surgery, cancer, symptoms or signs of deep vein thrombosis (DVT).
Symptoms — acute-onset breathlessness (in 73% of people with PE), pleuritic pain (66%), cough (37%), haemoptysis (13%). Recurrent acute episodes may lead to chronic breathlessness.
Signs — tachypnoea of more than 20 breaths per minute (in 70% of people with PE), crackles (51%), tachycardia (30%), signs of DVT (11%).
Pneumothorax/tension pneumothorax
Risk factors — smoking, age, and body type (adults who are young, tall, and slim), previous pneumothorax, chronic respiratory disease (such as COPD or asthma), trauma to chest wall (including therapeutic procedures such as injections and aspirations).
Symptoms — collapse, sudden-onset pleuritic pain, breathlessness.
Signs — reduced chest wall movements, reduced breath sounds, reduced vocal fremitus, and increased resonance of the percussion note on the affected side. Tension pneumothorax can result in rapid development of severe symptoms associated with tracheal deviation away from the pneumothorax, tachycardia, and hypotension.
Aspiration of a foreign body
Symptoms — sudden onset of cough that may be associated with history suggestive of an inhaled foreign body.
Signs — sudden onset of cough, distress, or stridor if the foreign body lodges in the upper airway. There may be signs of lung or lobar collapse if there is a foreign body in the lower airways. Signs of lung or lobar collapse include reduced chest wall movement on affected side, dull percussion note with bronchial breathing, and reduced or diminished breath sounds.
Lung cancer
Risk factors — smoking, primary cancers at other sites, asbestos exposure, COPD.
Symptoms — haemoptysis or persistent and unexplained cough, chest or shoulder pain, breathlessness, weight loss, hoarseness.
Signs — finger clubbing, cervical or supraclavicular lymphadenopathy, signs of superior vena cava obstruction, stridor.
Pertussis
History — suspect in an adult with a cough:
Lasting more than 14 days with paroxysms of coughing or vomiting after coughing or a cough associated with an inspiratory whoop. Paroxysms increase in frequency and severity as the condition progresses and usually persists for 2–6 weeks. Occasionally the cough may persist for several months. A prolonged cough may be the only symptom in adults.
That develops within 2 weeks of being in contact with someone with confirmed pertussis.
Signs — normal chest examination.
Basis for recommendation
Basis for recommendation
Clinical features of upper respiratory tract infections
These are based on the expert opinion from clinical experience reported in the Oxford textbook of medicine [Little, 2010].
Clinical features of acute bronchitis
These are based on an assessment of the evidence on the sensitivity of clinical features to distinguish acute bronchitis from pneumonia summarized in an expert review article [Braman, 2006].
Diagnostic criteria for clinical features of pneumonia
These are based on an assessment of the evidence on the sensitivity of clinical features to diagnose pneumonia summarized in the British Thoracic Society guideline BTS guidelines for the management of community acquired pneumonia in adults [British Thoracic Society, 2009].
Clinical features of asthma
These are based on expert opinion from clinical experience and observational studies reported in the British guideline on the management of asthma issued by the British Thoracic Society and Scottish Intercollegiate Guidelines Network [SIGN and BTS, 2008].
Clinical features of chronic obstructive pulmonary disease
These are based on expert opinion from clinical experience reported in the guideline Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care [NICE, 2010].
Clinical features of bronchiectasis
These are based on observational studies of the prevalence of clinical features associated with confirmed bronchiectasis reported in the Guideline for non-CF Bronchiectasis from the British Thoracic Society [British Thoracic Society, 2010].
Clinical features of pulmonary embolism
These are based on evidence from a diagnostic study of the clinical features associated with confirmed pulmonary embolism [Stein et al, 1991].
Clinical features of pneumothorax
These are based on expert observation reported in the Oxford textbook of medicine [Davies et al, 2010].
Clinical features of foreign body aspiration
Clinical features of upper airway obstruction are based on expert opinion from clinical experience reported in the Oxford textbook of medicine [Stradling and Craig, 2010].
Clinical features of lung or lobar collapse are based on expert opinion from clinical experience reported in Clinical medicine [Frew and Holgate, 2005].
Clinical features of lung cancer
These are based on expert opinion of the National Institute for Health and Clinical Excellence reported in the Referral guidelines for suspected cancer: lung cancer [NICE, 2005].
Clinical features of pertussis
These are based on expert observation reported in the UK guidelines for use of erythromycin chemoprophylaxis in persons exposed to pertussis [Dodhia et al, 2002].
Diagnosis - cough 3-8 weeks
Diagnosis - cough 3-8 weeks' duration
Diagnosing the cause
How do I diagnose the cause of sub-acute cough of 3-8 weeks' duration?
If cough is associated with significant breathlessness, see the CKS topic on Breathlessness. For advice on when to arrange urgent referral — see Urgent referral.
If the person has a cough that started with an obvious respiratory infection:
Identify people with clinical features of pneumonia or acute bronchitis.
Identify people with pertussis (whooping cough):
Suspect in an adult with cough lasting more than 14 days with paroxysms of coughing or vomiting after coughing or an inspiratory whoop, and in adults presenting with cough who have been in contact with someone with confirmed pertussis in the preceding 3 weeks.
Confirm the diagnosis by taking blood for serology.
Identify people with post-infectious cough (who do not have specific features suggestive of pertussis). The following features should all be present:
Absence of malaise.
A persistent dry cough.
A normal respiratory examination.
If the person has sub-acute cough that did not start with an obvious respiratory tract infection, look for a cause of chronic cough.
Basis for recommendation
Basis for recommendation
Diagnostic approach to people with sub-acute cough
These recommendations are based on expert opinion published in guidelines by the American College of Chest Physicians [Pratter et al, 2006].
Identifying people with pertussis
These recommendations are based on expert opinion reported in the UK guidelines for use of erythromycin chemoprophylaxis in persons exposed to pertussis [Dodhia et al, 2002].
Diagnosis - cough more than 8 weeks
Diagnosis - cough more than 8 weeks' duration
Initial assessment
How should I assess someone presenting with chronic cough of more than 8 weeks' duration?
If cough is associated with significant breathlessness, see the CKS topic on Breathlessness.
Identify people who need urgent referral because they have suspected lung cancer, pulmonary tuberculosis, or foreign body aspiration.
If the person is taking an angiotensin-converting enzyme (ACE) inhibitor — stop the treatment and prescribe an alternative. For further information on alternative treatments, see the CKS topics on Heart failure - chronic or Hypertension - not diabetic.
The diagnosis is confirmed by resolution or marked improvement of the cough after stopping the treatment.
For most people the cough resolves within 1 month, but occasionally it may persist for several months.
If the person smokes:
Advise them to stop smoking and offer them support to do so. For further information, see the CKS topic on Smoking cessation.
Smoker's cough is confirmed by resolution or marked improvement of the cough following smoking cessation. Usually cough resolves within 4 weeks, but it may take longer.
Identify whether the person has clinical features of Chronic obstructive pulmonary disease (COPD). The diagnosis is confirmed by:
Spirometry demonstrating airflow limitation that is not fully reversible with treatment.
Air flow limitation is defined as a forced expiratory volume in 1 second (FEV1) of less than 80% of the predicted value and FEV1/forced vital capacity ratio less than 70%. For further information, see the CKS topic on Chronic obstructive pulmonary disease.
A chest X-ray to exclude other causes for symptoms, such as lung cancer.
If the person has clinical features of chronic sinusitis or allergic rhinitis suggesting a diagnosis of upper airway cough syndrome (post-nasal drip), arrange a 2 week trial of a nasal corticosteroid.
The diagnosis is confirmed by resolution or marked improvement of the cough within 2 weeks.
If the person has clinical features of asthma:
Arrange serial peak expiratory flow rate (PEFR) measurements morning and night and prescribe a 2 week trial of an inhaled corticosteroid and a bronchodilator.
The diagnosis is confirmed by:
Serial PEFR measurements demonstrating airflow limitation that is variable or, where there is doubt, by a large response (more than 400 mL) to either bronchodilators or 30 mg of oral prednisolone daily for 14 days, and
Resolution or marked improvement of the cough with treatment.
For further information, see the CKS topic on Asthma.
If the person has dyspepsia, or a cough that is worse during or after eating, when bending, or has other clinical features of gastro-oesophageal reflux disease (GORD):
Arrange an 8 week trial of a proton pump inhibitor such as omeprazole 20–40 mg twice daily (or equivalent). If the cough only partially resolves, add in a prokinetic agent such as metoclopramide 10 mg three times daily.
The diagnosis is confirmed by resolution or marked improvement of the cough within 4 months of starting treatment.
If the person has a chronic productive cough, look for features of bronchiectasis and arrange a chest X-ray and spirometry.
If clinical features of bronchiectasis are present and the chest X-ray and spirometry do not indicate another cause refer to a specialist to arrange high-resolution CT scanning to confirm the diagnosis.
If the person has a chronic dry cough:
Look for features of interstitial lung disease and if present arrange a chest X-ray and spirometry.
Refer the person for specialist investigations if they have spirometry with a restrictive pattern and/or a chest X-ray suggestive of an underlying cause for interstitial lung disease (such as sarcoidosis or asbestosis).
Look for clinical features of pertussis (whooping cough) especially if the person has a cough lasting more than 14 days with paroxysms of coughing or vomiting after coughing or a cough associated with an inspiratory whoop, and in people who develop a cough within 3 weeks of being in contact with someone with confirmed pertussis. The diagnosis is confirmed by taking blood for serology.
If the person has a persistent unexplained cough, arrange a chest X-ray, and spirometry.
If there is no cause suggested from the history, examination, and investigations, see Further assessment.
Basis for recommendation
Basis for recommendation
Approach for diagnosing the cause of chronic cough
The recommendations about diagnosing the cause of chronic cough from clinical features are based on expert opinion published by:
The American College of Chest Physicians in the guideline An empiric integrative approach to the management of cough [Pratter et al, 2006].
The British Thoracic Society guideline in the guideline Recommendations for the management of cough in adults [Morice et al, 2006].
The recommendations for chest radiography and spirometry are based on expert opinion published by the American College of Chest Physicians in the guideline An empiric integrative approach to the management of cough [Pratter et al, 2006].
The British Thoracic Society recommend a chest X-ray and spirometry for all people with chronic cough. However, CKS only recommends these investigations when they form part of the usual assessment of the suspected underlying cause recommended in national guidelines. On this basis, CKS does not recommend chest X-ray or spirometry for people suspected of having angiotensin-converting enzyme (ACE) inhibitor cough, asthma, upper airway cough syndrome, or gastro-oesophageal reflux disease.
Confirming asthma or chronic obstructive pulmonary disease (COPD)
Recommendations on how to confirm a diagnosis of asthma are based on expert opinion published in the British guideline on the management of asthma published by the Scottish Intercollegiate Guidelines Network and the British Thoracic Society [SIGN and BTS, 2008].
Recommendations on how to confirm a diagnosis of COPD are based on expert opinion published in the guideline Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care issued by the National Institute for Health and Clinical Excellence [National Clinical Guideline Centre, 2010].
Confirming bronchiectasis
In the Guideline for non-CF bronchiectasis the British Thoracic Society recommend referring people with suspected bronchiectasis to a specialist to arrange a high-resolution CT scan to confirm the diagnosis [British Thoracic Society, 2010]. This recommendation is based on evidence from observational studies and expert opinion that the chest X-ray appearance and clinical features of bronchiectasis are insufficiently sensitive and specific to reliably diagnose the condition.
Confirming pertussis
Recommendations are based on expert opinion published in the UK guidelines for use of erythromycin chemoprophylaxis in persons exposed to pertussis [Dodhia et al, 2002].
Further assessment
How do I assess someone with chronic cough, when no cause is suggested from the history, examination, spirometry, chest X-ray, and blood tests?
If the person has chronic cough with no cause suggested from the history, examination, spirometry, chest X-ray, and blood tests — arrange a sequential trial of drug treatment:
Upper airway cough syndrome — prescribe a nasal corticosteroid and review after 2 weeks of treatment.
The diagnosis is confirmed by resolution or marked improvement of the cough within 2 weeks.
Asthma — prescribe a topical corticosteroid and review after 2 weeks of treatment.
The diagnosis of asthma, cough variant asthma, or eosinophilic bronchitis is confirmed by resolution or marked improvement of the cough within 2 weeks.
Gastro-oeophageal reflux disease — prescribe a proton pump inhibitor such as omeprazole 20 to 40 mg twice daily (or equivalent) and review after 8 weeks.
The diagnosis is confirmed by resolution or marked improvement of the cough within 8 weeks.
If the person has a chronic cough that partially responds to a trial of therapy, consider if there is more than one cause of the cough.
If the person has a chronic cough that has no identifiable cause following the above assessment — arrange referral to a respiratory physician (preferably to a specialist who runs a cough clinic).
Basis for recommendation
Basis for recommendation
Determining the cause by a sequential trial of drug treatment
Recommendations are based on expert opinion published by:
The American College of Chest Physicians in the guideline An empiric integrative approach to the management of cough [Pratter et al, 2006].
The British Thoracic Society guideline in Recommendations for the management of cough in adults [Morice et al, 2006].
Clinical features - non-pulmonary causes
What are the clinical features of the non-pulmonary causes of chronic cough?
Angiotensin-converting enzyme (ACE) inhibitor induced cough
History — cough may start almost immediately after the person starts an ACE inhibitor or after a dose increase, or it may occur after several years of treatment. Cough settles after the person stops the ACE inhibitor, but may take up to 4 months to completely resolve.
Symptoms — bouts of coughing associated with the perception of airway irritation. Between coughing bouts, the person is asymptomatic.
Signs — no signs of chest disease.
Gastro-oesophageal reflux disease
Symptoms.
Cough that may or may not be associated with symptoms of gastro-oesophageal reflux. Symptoms of gastro-oesophageal reflux commonly occur after eating a large meal or with bending.
Cough that is worse during or after eating, with talking, and with bending.
Signs — no signs of chest disease.
Upper airway cough syndrome (also called post-nasal drip) caused by:
Chronic sinusitis
Symptoms — chronic (more than 12 weeks) nasal blockage or nasal discharge with facial pain or pressure over the affected sinus. A reduced sense of smell is common. Pain may radiate into the upper teeth.
Signs — There may be tenderness to palpation of the effected sinus.
Allergic rhinitis
History — allergic rhinitis is more likely if there is a personal or family history of atopy (asthma, eczema, or allergic rhinitis).
Symptoms — nasal itching, sneezing, discharge, and blockage. Symptoms may be associated with exposure to a known allergen such as house dust mite, animal dander, or pollens.
Basis for recommendation
Basis for recommendation
Angiotensin-converting enzyme (ACE) inhibitor induced cough
This information is based on expert opinion from clinical experience published in a review article [Morice, 2007].
Gastro-oesophageal reflux disease
This information is based on expert opinion from clinical experience published in a review article [Morice, 2007].
Upper airway cough syndrome
The association between upper airway disease and chronic cough is based on expert opinion [Morice et al, 2006; Morice, 2007].
The information on the clinical features of chronic sinusitis is based on expert observation reported in the European position paper on rhinosinusitis and nasal polyps [Fokkens et al, 2007] and the UK guideline for the management of rhinosinusitis and nasal polyposis [Scadding et al, 2007].
The information on the clinical features of allergic rhinitis is based on expert opinion from clinical experience published in a review article [Quillen and Feller, 2006].
Clinical features - pulmonary causes
What are the clinical features of the pulmonary causes of chronic cough?
Asthma
Risk factors — personal and family history of atopy.
Symptoms — wheeze, breathlessness, and cough. Symptoms are variable, often worse at night, with exercise, or with exposure to cold or allergens.
Signs — wheeze is present during an acute episode, except when asthma is extremely severe when the chest may be silent.
The peak expiratory flow rate (PEFR) is reduced during an acute episode. Acute asthma is:
Life-threatening when the PEFR is less than 33% of predicted.
Severe when the PEFR is 33–50% of predicted.
Moderate when the PEFR is more than 50% of predicted.
Cough variant asthma
Clinical features — chronic cough with a normal chest examination, and normal spirometry.
May be confirmed by demonstrating hyper-responsiveness to airway provocation, sputum eosinophilia (only available to a specialist), and symptomatic improvement with a trial of an inhaled topical corticosteroid.
Eosinophilic bronchitis
Clinical features: chronic cough, normal chest examination, normal spirometry, and normal response to airway provocation test (only available to a specialist).
May be confirmed by demonstrating sputum eosinophilia (only available to a specialist), and symptom improvement with a trial of an inhaled corticosteroid.
Smoker's cough and chronic bronchitis
Smoker's cough
Symptoms — morning cough with little sputum.
Signs — normal chest examination.
Chronic bronchitis
Symptoms — chronic productive cough on most days for 3 months in each of two consecutive years, if the person does not have another cause for chronic cough.
Signs — normal chest examination.
Chronic obstructive pulmonary disease
History — slow progressive breathlessness in a person older than 35 years of age who smokes or who has smoked.
Symptoms — persistent progressive breathlessness usually associated with wheezing or chest tightness. Acute exacerbations of symptoms are common, and usually caused by respiratory tract infections.
Signs — wheeze, hyperinflated chest, may have signs of right sided heart failure such as swollen ankles and increased jugular venous pressure.
Bronchiectasis
History — suspect in people with a history of recurrent or chronic productive cough, especially if they do not smoke.
Symptoms — cough with daily sputum production (present in 75–100% of adults with bronchiectasis), progressive breathlessness (72–83%), haemoptysis (51–45%), non-pleuritic chest pain between exacerbations (31%).
Signs — coarse crackles in early inspiration most common in the lower lung fields (70% of adults), wheeze (34%), large airway rhonchi (44%). Finger clubbing occurs infrequently.
Interstitial lung disease (ILD)
Causes — include idiopathic pulmonary fibrosis, sarcoidosis, pneumoconioses, ILD associated with drug therapy, ILD associated with connective tissue disease, and hypersensitivity pneumonitis/extrinsic allergic alveolitis (following sensitization to inhaled environmental allergens, for example from birds, hay, or mushrooms).
Symptoms — cough and slowly progressive breathlessness. When it is caused by extrinsic allergic alveolitis there may be a history of recurrent episodes of flu-like illness following exposure to the responsible allergen. There may be symptoms of the underlying cause (for example joint pains when the ILD is associated with connective tissue disease).
Signs — there may be none in sarcoidosis. When present, there may be fine end inspiratory crepitations (indicative of fibrosis), finger clubbing, cyanosis, and signs of right heart failure.
Pertussis
History — suspect in an adult with a cough:
Lasting more than 14 days with paroxysms of coughing or vomiting after coughing or a cough associated with an inspiratory whoop. Paroxysms increase in frequency and severity as the condition progresses and usually persist for 2–6 weeks. Occasionally the cough may persist for several months. A prolonged cough may be the only symptom in adults.
That develops within 2 weeks of being in contact with someone with confirmed pertussis.
Signs — normal chest examination.
Basis for recommendation
Basis for recommendation
Clinical features of asthma
This information is based on a expert opinion from clinical experience observation supported by observational studies reported in the British guideline on the management of asthma issued by the British Thoracic Society and Scottish Intercollegiate Guidelines Network [SIGN and BTS, 2008].
Clinical features of cough variant asthma
This information is based on a expert opinion from clinical experience reported in expert review articles [Dicpinigaitis, 2004; Morice, 2007].
Clinical features of eosinophilic bronchitis
This information is based on a expert opinion from clinical experience reported in expert review articles [Dicpinigaitis, 2004; Morice, 2007].
Clinical features of smoker's cough
This information is based on a expert opinion from clinical experience reported in Clinical medicine [Frew and Holgate, 2005].
Clinical features of chronic bronchitis
This information is based on a expert opinion from clinical experience reported in the Oxford textbook of medicine [MacNee, 2010].
Clinical features of chronic obstructive pulmonary disease
This information is based on a expert opinion from clinical experience reported in the guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care [NICE, 2010].
Clinical features of bronchiectasis
This information is based on observational studies of the prevalence of clinical features associated with confirmed bronchiectasis reported in the Guideline for non-CF Bronchiectasis from the British Thoracic Society [British Thoracic Society, 2010].
Clinical features of interstitial lung disease
This information is based on a expert opinion from clinical experience reported in the Oxford textbook of medicine [Baughman and Lower, 2010; Hendrick and Spickett, 2010; Seaton, 2010].
Clinical features of pertussis
These are based on expert observation reported in the UK guidelines for use of erythromycin chemoprophylaxis in persons exposed to pertussis [Dodhia et al, 2002].
Management
Management
Scenario : Management - cough less than 3 weeks: covers the management of acute cough, including the indications for emergency admission and referral.
Scenario : Management - cough 3-8 weeks: covers the management of sub-acute cough, including the indications for urgent referral.
Scenario : Management - cough more than 8 weeks: covers the management of chronic cough, including the indications for urgent referral.
Scenario : Management - cough less than 3 weeks
Scenario : Management - cough less than 3 weeks' duration
Emergency admission
When should I arrange emergency admission for someone with acute cough?
If the person has chest signs or respiratory symptoms in addition to cough, measure blood pressure, pulse rate, temperature, and oxygen saturation. If asthma is suspected, measure peak expiratory flow rate (PEFR).
Arrange emergency admission if the person has:
A respiratory rate of more than 30 breaths per minute.
Tachycardia greater than 130 beats per minute.
Systolic blood pressure less than 90 mmHg, or diastolic blood pressure less than 60 mmHg (unless this is normal for them).
Oxygen saturation less than 92%, or central cyanosis (if the person has no history of chronic hypoxia).
PEFR less than 33% of predicted.
Altered level of consciousness.
A large respiratory effort (particularly if the person is becoming exhausted).
Clinical features of pulmonary embolism, pneumothorax, or aspiration of a foreign body.
Consider arranging emergency admission, depending on the severity and number of risk factors present, if the person has any of the following:
Elevated respiratory rate (but if it is more than 30 breaths per minute, arrange emergency admission).
Tachycardia (but if it is more than 130 beats per minute, arrange emergency admission).
Hypotension (but if blood pressure is less than 90 mmHg systolic or 60 mmHg diastolic, arrange emergency admission).
High temperature (especially if it is higher than 38.5°C).
PEFR less than 50% of predicted (but if it is less than 33%, arrange emergency admission).
Older than 65 years of age.
Basis for recommendation
Basis for recommendation
Blood pressure, pulse rate, respiratory rate, temperature, and level of consciousness
The modified early warning system (MEWS), recommended by the British Thoracic Society (BTS), assesses and classifies the seriousness of the condition of an acutely unwell person (on the basis of their blood pressure, pulse, temperature, breathing rate, and level of consciousness) to determine their need for urgent medical care [British Thoracic Society, 2008].
MEWS is based on evidence (from a prospective cohort study of 673 medical admissions) of the association between vital signs and level of consciousness, and the risk of death, risk of cardiac arrest, and need for treatment in a high-dependency or intensive care unit [Subbe et al, 2001].
The CRB-65 scoring system, recommended by BTS, assesses the risk of harm for people with community-acquired pneumonia, based on the presence of: Confusion (recent); Respiratory rate of 30 breaths/min or greater; Blood pressure (systolic less than 90 mmHg, or diastolic less than 60 mmHg or less); and age (65 years of age or older) [Lim et al, 2009].
The CRB-65 assessment is based on evidence of the risk of death from a cohort study that prospectively followed 1000 people who had been admitted to hospital with a primary diagnosis of community-acquired pneumonia [Lim et al, 2003].
The Scottish Intercollegiate Guidelines Network (SIGN) and BTS British guideline on the management of asthma recommends assessing the risk of harm for people with acute asthma based on respiratory rate, blood pressure, pulse rate, and level of consciousness (as well as their peak expiratory flow rate, oxygen saturation, presence of central cyanosis and signs of exhaustion) [SIGN and BTS, 2008].
This assessment is based on evidence, from confidential enquires into over 200 asthma deaths in the UK, of the association between these clinical features and the risk of death in people presenting with acute severe asthma.
CKS takes the view that the similarity of the recommended methods of assessing risk in widely differing conditions can be taken as evidence that these methods of assessment can reasonably be extrapolated to all people who are acutely ill, whatever the cause, and to people with breathlessness where the cause is unknown.
Oxygen saturation less than 92%
The BTS guidelines for the management of community acquired pneumonia in adults recommend that pulse oximetry should be available to general practitioners to assess severity of illness and oxygen requirement in people with community-acquired pneumonia and other acute respiratory illnesses [British Thoracic Society, 2009].
The SIGN and BTS guideline on the management of asthma recommends that people with asthma and an oxygen saturation less than 92% should be admitted to hospital, as they are at high risk of death [SIGN and BTS, 2008].
Central cyanosis
Central cyanosis is reported to be present when the concentration of deoxygenated haemoglobin is more than 50 g/L. This corresponds to an arterial oxygen saturation of less than 90% in people who are not anaemic [Douglas and Bevan, 2009].
The SIGN and BTS British guideline on the management of asthma recommends that people with asthma and oxygen saturation of less than 92% should be admitted to hospital as they are at high risk of death [SIGN and BTS, 2008].
Peak expiratory flow rate (PEFR)
The SIGN and BTS British guideline on the management of asthma recommends that people with asthma and PEFR less than 30% of predicted, have life-threatening asthma; and recommends emergency admission [SIGN and BTS, 2008].
The guideline also recommends that, for people with known asthma and PEFR less than 50% of predicted, the decision to admit should be based on their response to treatment and the risk of subsequent deterioration (based on their previous history).
These recommendations are based on evidence from confidential enquires into over 200 asthma deaths in the UK that identified clinical features associated with an increased risk of death.
Other indications for admission
Suspected pulmonary embolism, pneumothorax, and foreign body aspiration are known to be associated with a high risk of death or serious morbidity [Zoorob and Campbell, 2003].
Stridor
Stridor is a sign of upper airway obstruction. It carries a high risk of death or serious morbidity. Experts recommend immediate admission [Zoorob and Campbell, 2003].
Waiting for emergency admission
How should I manage someone with acute cough waiting for emergency admission?
If the person has an oxygen saturation of less than 92%, give oxygen and continuously monitor their oxygen saturation levels while waiting for transfer to hospital.
ONLY USE A 28% VENTURI MASK AT 4 L/MIN FOR PEOPLE WITH SUSPECTED CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), morbid obesity, a chest wall deformity, or a neuromuscular disorder. This is because they are at risk of hypercapnic respiratory failure.
For other people who are acutely ill, use a simple face mask. Adjust the flow rate to 5–10 L/min to achieve a target oxygen saturation of 94–98%.
Identify and treat if the person has clinical features of acute severe asthma (peak expiratory flow less than 50% of predicted) or an acute exacerbation of COPD.
Give a bronchodilator (for example nebulized salbutamol 5 mg, or repeated doses of a metered-dose inhaler via a spacing device).
Give prednisolone 30 mg orally (if available).
Repeat the bronchodilator treatment as necessary.
For further information, see the CKS topics on Asthma and Chronic obstructive pulmonary disease.
Basis for recommendation
Basis for recommendation
Oxygen therapy
Recommendations are based on expert opinion published in the BTS guideline for emergency oxygen use in adult patients [O'Driscoll et al, 2008].
Management of acute severe asthma
Recommendations are based on expert opinion published in the British Guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2008].
Management of an acute exacerbation of chronic obstructive pulmonary disease
Recommendations are based on expert opinion published in Chronic obstructive pulmonary disease: national clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care [National Collaborating Centre for Chronic Conditions, 2004].
Emergency admission not required
How should I manage someone with acute cough who does not need emergency admission?
For people with:
An upper respiratory tract infection — advise them:
To use paracetamol or ibuprofen as required to reduce pain or symptoms of malaise.
To rest and drink sufficient fluids to prevent dehydration.
To stop smoking if they smoke; offer support and treatment to stop. For further information see the CKS topic on Smoking cessation.
To seek medical advice if symptoms deteriorate significantly or other symptoms develop.
That antibiotics are not likely to be helpful.
That cough medicines may help, but they are not thought to be any more effective than simple remedies such as a honey and lemon drink.
Acute asthma — see the CKS topic on Asthma.
An acute exacerbation of chronic obstructive pulmonary disease — see the CKS topic on Chronic obstructive pulmonary disease.
Bronchiectasis — see the CKS topic on Bronchiectasis.
Pneumonia or bronchitis — see the CKS topic on Chest infections - adult.
Suspected lung cancer — see the CKS topic on Lung cancer - suspected.
Basis for recommendation
Basis for recommendation
Management of upper respiratory tract infections
Advice to people with an upper respiratory tract infection is based on expert opinion published in the British Thoracic Society guideline Recommendations for the management of cough in adults [Morice et al, 2006].
Management of other conditions
The basis for the management of other conditions are found within the individual CKS topics.
Scenario : Management - cough 3-8 weeks
Scenario : Management - cough 3-8 weeks' duration
Urgent referral
When should I arrange urgent referral to a respiratory physician for someone with sub-acute cough?
Identify whether the person has clinical features of:
Lung cancer, including:
Haemoptysis, or
Any of the following symptoms and signs that are unexplained and persist for longer than 3 weeks: chest and/or shoulder pain, breathlessness, weight loss, chest signs, hoarseness, finger clubbing, cervical/ supraclavicular lymphadenopathy.
Pulmonary tuberculosis, including:
Chronic cough which may be associated with sputum, breathlessness, or haemoptysis.
Weight loss, fever, night sweats, anorexia, and general malaise.
Finger clubbing.
Foreign body aspiration, including:
Sudden onset of cough that may be associated with history suggestive of an inhaled foreign body.
Stridor, if the foreign body is in the upper airway. There may be signs of lung or lobar collapse if the foreign body is in the lower airways. Signs of lung or lobar collapse include reduced chest wall movement on the affected side, a dull percussion note with bronchial breathing, reduced or diminished breath sounds.
If the person has clinical features of lung cancer:
Arrange a chest X-ray to be reported within 5 days.
Arrange urgent referral to respiratory physician:
For people older than 40 years of age with persistent haemoptysis who smoke.
For people with a chest X-ray that is suggestive of lung cancer (including pleural effusion or slowly resolving consolidation).
If the person has clinical features of pulmonary tuberculosis:
Arrange a chest X-ray and, if possible, send three sputum samples (ideally one sample should be taken in the early morning) for microscopy to look for acid-fast bacilli and for mycobacterial culture.
Refer to a specialist for diagnosis and management (ideally within 2 weeks). Do not delay referral to a specialist by waiting for investigation results if symptoms are highly suggestive of active tuberculosis.
If the person has a suspected foreign body aspiration, arrange urgent referral or emergency admission (depending on clinical judgement) to a respiratory physician for bronchoscopy.
Basis for recommendation
Basis for recommendation
Identify people with features of lung cancer, pulmonary tuberculosis, or foreign body aspiration
An initial assessment to identify people with a serious cause for cough is widely recommended by experts including the British Thoracic Society in their guideline Recommendations for the management of cough in adults [Morice et al, 2006], and the American College of Chest Physicians in their guideline An Empiric integrative approach to the management of cough [Pratter et al, 2006].
Clinical features of lung cancer
This information is based on the National Institute for Health and Clinical Excellence guideline Referral guidelines for suspected cancer: lung cancer [NICE, 2005].
Clinical features of pulmonary tuberculosis
This information is based on expert opinion from review articles [MeReC, 2003; Campbell and Bah-Sow, 2006; Griffiths and Martineau, 2007].
Clinical features of foreign body aspiration
This information is based on expert opinion from clinical experience published in the Oxford textbook of medicine [Stradling and Craig, 2010].
Recommendations on referral
National guidelines state that people with suspected active tuberculosis (TB) should be seen by a TB specialist for diagnosis, treatment, and follow up [Joint Tuberculosis Committee of the British Thoracic Society, 1998]. The Chief Medical Officer's action plan, published in 2004, recommended that people with suspected TB should be seen within 2 weeks [DH, 2004].
The National Institute for Health and Clinical Excellence in Referral guidelines for suspected cancer recommend that people with haemoptysis and other clinical features of lung cancer are urgently investigated and referred [NICE, 2005].
Bronchoscopy is recommended for all people with a suspected foreign body aspiration by the British Thoracic Society in the guideline Recommendations for the management of cough in adults [Morice et al, 2006]. BTS do not discuss the urgency of referral. CKS recommends urgent referral based on good clinical practice.
Urgent referral not required
How should I manage someone with sub-acute cough who does not need urgent referral?
If the person has pneumonia or acute bronchitis, see the CKS topic on Chest infections - adult.
If the person has post-infectious cough:
Explain that the cough may persist for several months.
Advise them to re-attend for assessment if the cough does not improve after 2 months.
If the person has a sub-acute cough that did not start with an obvious respiratory tract infection, assess and manage as for chronic cough.
Basis for recommendation
Basis for recommendation
The recommendations for the management of post-infectious cough are based on expert opinion from the American College of Chest Physicians' guideline, An empiric integrative approach to the management of cough [Pratter et al, 2006].
Scenario : Management - cough more than 8 weeks
Scenario : Management - cough more than 8 weeks' duration
Urgent referral
When should I arrange urgent referral to a respiratory physician for someone with chronic cough?
Identify whether the person has clinical features of:
Lung cancer, including:
Haemoptysis, or
Any of the following symptoms and signs that are unexplained and persist for longer than 3 weeks; chest and/or shoulder pain, breathlessness, weight loss, chest signs, hoarseness, finger clubbing, cervical/ supraclavicular lymphadenopathy.
Pulmonary tuberculosis, including:
Chronic cough which may be associated with sputum, breathlessness, or haemoptysis.
Weight loss, fever, night sweats, anorexia, and general malaise.
Foreign body aspiration, including:
Recurrent pneumonia in the same lobe, which may indicate an aspirated foreign body.
Sudden onset of cough that may be associated with history suggestive of an inhaled foreign body.
Stridor, if the foreign body is in the upper airway. There may be signs of lung or lobar collapse if the foreign body is in the lower airways. Signs of lung or lobar collapse include reduced chest wall movement on the affected side, a dull percussion note, and reduced or diminished breath sounds.
If the person has clinical features of lung cancer:
Arrange a chest X-ray to be reported within 5 days.
Arrange urgent referral to a respiratory physician:
If the person is older than 40 years of age with persistent haemoptysis, and they smoke.
If the person has a chest X-ray that is suggestive of lung cancer (including pleural effusion or slowly resolving consolidation).
If the person has clinical features of pulmonary tuberculosis:
Arrange a chest X-ray and, if possible, send three sputum samples (ideally one sample should be taken in the early morning) for microscopy to look for acid-fast bacilli and for mycobacterial culture.
Refer to a specialist for diagnosis and management (ideally within 2 weeks). Do not delay referral to a specialist by waiting for investigation results if symptoms are highly suggestive of active tuberculosis.
If the person has a suspected foreign body aspiration, arrange urgent referral to a respiratory physician for bronchoscopy.
Basis for recommendation
Basis for recommendation
Identify people with features of lung cancer, pulmonary tuberculosis, or foreign body aspiration
An initial assessment to identify whether the person has a serious cause for cough is widely recommended by experts including the British Thoracic Society (BTS) in their guideline Recommendations for the management of cough in adults [Morice et al, 2006] and the American College of Chest Physicians in their guideline An empiric integrative approach to the management of cough [Pratter et al, 2006].
Clinical features of lung cancer
This information is based on the National Institute for Health and Clinical Excellence guideline Referral guidelines for suspected cancer: lung cancer [NICE, 2005].
Clinical features of pulmonary tuberculosis
This information is based on expert opinion from review articles [MeReC, 2003; Campbell and Bah-Sow, 2006; Griffiths and Martineau, 2007].
Clinical features of foreign body aspiration
This information is based on expert opinion from clinical experience published in the Oxford textbook of medicine [Stradling and Craig, 2010].
Recommendations on referral
National guidelines state that if the person has suspected active tuberculosis (TB) they should be seen by a TB specialist for diagnosis, treatment, and follow up [Joint Tuberculosis Committee of the British Thoracic Society, 1998]. The Chief Medical Officer's action plan, published in 2004, recommended that people with suspected TB should be seen within 2 weeks [DH, 2004].
The National Institute for Health and Clinical Excellence in Referral guidelines for suspected cancer recommends that people with haemoptysis and other clinical features of lung cancer [NICE, 2005] are urgently investigated and referred.
Bronchoscopy is recommended for all people with a suspected foreign body aspiration by the British Thoracic Society in the guideline Recommendations for the management of cough in adults [Morice et al, 2006]. The BTS does not discuss the urgency of referral. CKS recommends urgent referral based on good clinical practice.
Managing the cause
How do I manage the underlying cause of chronic cough?
If the person has an identified cause for chronic cough — manage the underlying cause. If the person has:
Asthma — see the CKS topic on Asthma.
Cough variant asthma and eosinophilic bronchitis, manage with inhaled corticosteroid adjusting the treatment as for asthma — see the CKS topic on Asthma.
Smokers cough or chronic bronchitis, offer to help them stop smoking — see the CKS topic on Smoking cessation.
Chronic obstructive pulmonary disease — see the CKS topic on Chronic obstructive pulmonary disease.
Upper airways cough syndrome (post-nasal drip) — see the CKS topics on Sinusitis or Allergic rhinitis.
Gastro-oesophageal reflux disease (GORD) — see the CKS topic on Dyspepsia - proven GORD.
A cough caused by an angiotensin converting enzyme (ACE) inhibitor, stop the ACE inhibitor and prescribe an appropriate alternative — see the CKS topics on Hypertension - not diabetic or Heart failure - chronic.
If the person has chronic cough with a cause that cannot be identified following an assessment that includes a chest X-ray and spirometry — refer to a respiratory physician.
Basis for recommendation
Basis for recommendation
Referral for specialist assessment if a cause for chronic cough cannot be identified is recommended by the British Thoracic Society in the guideline Recommendations for the management of cough in adults [Morice et al, 2006].
Evidence
Evidence
Supporting evidence
Recommendations in this topic are largely based on the British Thoracic Society guideline Recommendations for the management of cough in adults [Morice et al, 2006] and the American College of Chest Physicians guideline An empiric integrative approach to the management of cough [Pratter et al, 2006]. These guidelines are based almost entirely on expert opinion derived from clinical experience.
The evidence on the emergency management of asthma, chronic obstructive pulmonary disease, pneumonia in adults, and the emergency use of oxygen can be found in guidelines from the British Thoracic Society and the Scottish Intercollegiate Guidelines Network [SIGN and BTS, 2008], the National Institute for Health and Clinical Excellence [National Collaborating Centre for Chronic Conditions, 2004], and the British Thoracic Society [British Thoracic Society, 2001; O'Driscoll et al, 2008].
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of cough with additional searches for evidence in the following areas:
Differential diagnosis of cough
The search excluded children.
Search dates
Date unrestricted – April 2010
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
exp Cough/, cough.tw., tussis.tw., tussive.tw.
post nasal drip.tw., bronchial carcinoma.tw., upper respiratory tract infection.tw., upper respiratory tract tumour.tw., upper respiratory tract tumor.tw., eosinophilic bronchitis.tw., exp Air Pollutants, Occupational/, exp Occupational Diseases/, exp Air Pollutants/,
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
National Guidelines Clearinghouse
British Columbia Medical Association
Institute for Clinical Systems Improvement
Guidelines International Network
National Library of Guidelines
National Health and Medical Research Council (Australia)
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Driver and Vehicle Licensing Agency
NHS Plus (occupational health practice)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
DynaMed
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
Sources of medicines information
The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.
British National Formulary (BNF)
electronic Medicines Compendium (eMC)
European Medicines Agency (EMEA)
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