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Home | Articles | Respiratory | Chronic Cough Pathway

Chronic Cough Pathway

Last updated 22nd March 2022
Referral Guideline
Primary Care Management
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Background

  1. Chronic cough is one which lasts for more than 8 weeks. It affects 10-20% of adults and accounts for 10% of respiratory referrals. Most patients have a dry or minimally productive cough ​a productive cough usually indicates primary lung pathology. The main abnormality in chronic cough is heightened cough reflex.
  2. A chronic non-productive cough with no other red flag symptoms is a very rare presentation of lung cancer and if there are no worrying features and CXR is normal then it is reasonable to treat as chronic cough in Primary care.

Who to Refer

Patients with red flags should be referred as usual:

Urgent Referral

  • Persistent haemoptysis
  • Abnormality on CXR
  • Weight loss / fatigue /
  • progressive
  • breathlessness
  • Hoarseness / chest or
  • shoulder pain

Routine Referral

Where primary care management has failed referral can be referred to respiratory

Primary Care Management

Points in History and Examination

  • Onset of cough sudden onset is suspicious of foreign body
  • Relation to infection patients often describe cough as starting with an infection but this may still be due to reflux
  • Sputum productive cough suggests pulmonary disease
  • Cough after eating or with talking is more likely to be due to reflux
  • Persistent throat clearing and nasal congestion point to rhinitis/post-nasal drip
  • Nocturnal cough, cough on exercise with wheeze/breathlessness point to asthma-like syndrome (cough variant asthma or eosinophilic bronchitis)
  • Occupational history may reveal exposure to sensitisers or irritants
  • Examine for signs lung disease, finger clubbing, ENT but will usually be unhelpful

Investigations

  • Do a CXR
  • Arrange spirometry with reversibility
  • Serial peak flows (although less likely to be helpful than in standard asthma)
  • Sputum for culture and AAFB (if productive)
  • Bloods for whooping cough serology and FBC (eosinophilia)

Management

  • Advise patient to avoid coughing
  • Stop ACEI if on it may take weeks to help
  • Stop smoking (obviously)
  • Trial of PPI plus alginate for at least 3 months
  • Trial steroid nasal spray
  • Consider trial oral steroids for 2 weeks if does not respond to this then not cough variant asthma
  • If still persists then revisit diagnosis and try another treatment or consider referral.
  • There little evidence for use of cough suppressants or antihistamines