Pathway - management of chronic cough with no obvious trigger

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Background

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.

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.

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.

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.

Points in history

  • 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

Examination

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

  • For more detailed information refer to the BTS cough guideline - LINK

Editorial Information

Last reviewed: 27/06/2022

Next review date: 30/06/2024

Author(s): Stuart Little.

Version: 1