Evaluation and management of chronic cough in adults
Background:
Chronic cough (CC), a cough that lasts > 8 weeks, has an overall prevalence of 5‐11% in adults, peaking between 60 and 80 years of age. Of the 15% of patients who remain undiagnosed or refractory to treatment, two thirds are women.
Objective:
The objective was to present an updated evidence-based algorithmic approach for evaluating and managing CC, with emphasis on treatment modalities for refractory CC.
Methods:
A literature search was conducted of medical literature data bases for guidelines, position papers, systematic reviews, and clinical trials from January 2022 to June 2023, on the evaluation and management of CC.
Results:
The initial assessment should be limited to a detailed history, physical examination, chest radiograph, spirometry, exhaled nitric oxide, blood eosinophil count, and measurement of cough severity and quality of life by using validated instruments. The top diagnoses to consider are asthma, chronic obstructive pulmonary disease, nonasthmatic eosinophilic bronchitis, gastroesophageal reflux disease, and upper airway cough syndrome. Additional studies are only obtained when red flags are present or the patient fails to respond after avoidance of high-risk factors, e.g., smoking and angiotensin-converting enzyme inhibitors, and 4‐6 weeks of empiric treatment for the most likely respiratory and gastrointestinal diseases. When diagnostic tests and/or specific directed treatments fail to control CC, low-dose morphine (preferred), gabapentin, pregabalin, and/or cough control therapy are recommended. Non-narcotic purinergic 2×3 (P2×3) receptor antagonists, gafapixant and campilixant, are currently being studied for CC.
Conclusion:
For the evaluation and management of patients with CC, clinicians should use an algorithmic approach and identify “red flags,” reduce high-risk factors, and use empiric treatment for the five top diagnoses before extensive diagnostic testing. Current treatment for refractory cough is limited to symptomatic management.
Chronic cough (CC), a cough that lasts > 8 weeks, has an overall prevalence of 5‐11% in adults, peaking between 60 and 80 years of age. Of the 15% of patients who remain undiagnosed or refractory to treatment, two thirds are women.
Objective:
The objective was to present an updated evidence-based algorithmic approach for evaluating and managing CC, with emphasis on treatment modalities for refractory CC.
Methods:
A literature search was conducted of medical literature data bases for guidelines, position papers, systematic reviews, and clinical trials from January 2022 to June 2023, on the evaluation and management of CC.
Results:
The initial assessment should be limited to a detailed history, physical examination, chest radiograph, spirometry, exhaled nitric oxide, blood eosinophil count, and measurement of cough severity and quality of life by using validated instruments. The top diagnoses to consider are asthma, chronic obstructive pulmonary disease, nonasthmatic eosinophilic bronchitis, gastroesophageal reflux disease, and upper airway cough syndrome. Additional studies are only obtained when red flags are present or the patient fails to respond after avoidance of high-risk factors, e.g., smoking and angiotensin-converting enzyme inhibitors, and 4‐6 weeks of empiric treatment for the most likely respiratory and gastrointestinal diseases. When diagnostic tests and/or specific directed treatments fail to control CC, low-dose morphine (preferred), gabapentin, pregabalin, and/or cough control therapy are recommended. Non-narcotic purinergic 2×3 (P2×3) receptor antagonists, gafapixant and campilixant, are currently being studied for CC.
Conclusion:
For the evaluation and management of patients with CC, clinicians should use an algorithmic approach and identify “red flags,” reduce high-risk factors, and use empiric treatment for the five top diagnoses before extensive diagnostic testing. Current treatment for refractory cough is limited to symptomatic management.
Keywords: Leicester cough questionnaire; Newcastle Laryngeal Hypersensitivity Questionnaire; Patient Health Questionnaire 9-item scale; angiotensin converting enzyme inhibitors; antihistamines; asthma; azithromycin; campilixant; capsacian; chronic cough; chronic obstructive pulmonary disease; cough hypersensitivity syndrome; eliapixant; gastroesophageal reflux disease; gefapixant; intranasal corticosteroids; laryngeal and/or pharyngeal hyperresponsiveness; morphine; non-asthmatic eosinophilic bronchitis; opioids; orvepitant; post-nasal drip; purinergic receptor; refractory chronic cough; sivopixant; systemic corticosteroids; topical corticosteroids; transient receptor potential; upper airway cough syndrome; vagal C fibers
Document Type: Research Article
Publication date: November 15, 2023
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