Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Cough
Cough - Key Features
1. In patients presenting with an acute cough:
a) Include serious causes (e.g. pneumothorax, pulmonary embolism [PE]) in the differential diagnosis.
Consider life-threatening conditions: pneumothorax, PE, heart failure, exacerbation of asthma or COPD, pneumonia
Approach to cough:
|Divide patient population||Divide cough|
|Pediatric: less than 15 yr.
Adult: older than 15 yr.
|Acute: less than 3 weeks|
Subacute: 3-8 weeks
For subacute cough: if history of infection treat as post-infectious until cough becomes chronic (i.e. lasts longer than 8 weeks), if no history of infection, treat as chronic
In children with acute cough, consider croup, bronchiolitis, pertussis and treat
b) Diagnose a viral infection clinically, principally by taking an appropriate history.
No one sign, symptom or test rules out bacterial infection or rules in viral
However, if no red flag symptoms present, no CXR or further investigation is warranted until the cough persists into chronic phase.
|History||Red Flag Symptom|
Details of cough: Duration, ?productive, impact on function, other symptoms (fever, congestion, muscle aches, SOB, chest pain)
|Sudden fever - Suggestive of influenza, pneumonia, SARS|
Shortness of Breath, chest pain – r/o life threatening causes
|Physical Exam||Red Flag Signs|
Listen for cough in office, judge frequency, severity
|Unusually ill, abnormal vitals|
Shortness of breath, respiratory distress
c) Do not treat viral infections with antibiotics. (Consider antiviral therapy if appropriate.)
Acute bronchitis commonly lasts 7 to 10 days; up to 1 month in 25% of patients
Controversial, but may consider Abx if cough lasts >14 d
Abx do not increase/speed up resolution; but decreases “time feeling ill” by 0.5 days
Most people just want the cough to stop: Cough management options
|Non-pharma (possibly more effective)||Pharma (expert consensus only)|
|Decrease or quit smoking
Fluids (keep mucus thin)
|Beta agonists (only if wheezing)|
2. In pediatric patients with a persistent (or recurrent) cough, generate a broad differential diagnosis (e.g., gastroesophageal reflux disease [GERD], asthma, rhinitis, presence of a foreign body, pertussis)
In children, divide chronic cough into specific (dx recognizable from description of cough and/or other findings on hx or exam) and non-specific
Specific cough (Table 2)
|Type of cough||Diagnosis|
|Barking or brassy cough
|Croup, tracheomalacia, habit cough|
|Auscultatory findings (wheeze, crackles, differential breath sounds)
Cough characteristics (eg, cough with choking, cough quality, cough starting from birth)
|Asthma, bronchitis, congenital lung disease, foreign body aspiration, airway abnormality|
Congenital lung abnormalities
See ACCP Algorithm at end of document.
3. In patients with a persistent (e.g., for weeks) cough:
a) Consider non‐pulmonary causes (e.g., GERD, congestive heart failure, rhinitis), as well as other serious causes (e.g. cancer, PE) in the differential diagnosis. (Do not assume that the child has viral bronchitis).
Wide differential, often with multiple causes in the same person.
Start with hx and p/e as for acute cough, plus CXR. Be wary for constitutional symptoms suggestive of cancer or TB infection.
Three most common causes in adults: Post-nasal drip, asthma, GERD
b) Investigate appropriately.
4. Do not ascribe a persistent cough to an adverse drug effect (e.g. from an angiotensin‐converting enzyme inhibitor) without first considering other causes.
If cough caused by ACEi, expect resolution within 2 weeks of stopping.
5. In smokers with persistent cough, assess for chronic bronchitis (chronic obstructive pulmonary disease) and make a positive diagnosis when it is present. (Do not just diagnose a smoker’s cough.)
See COPD topic
- o Summary of American College of Chest Physician Guidelines; has chronic cough algorithm
Worral, G. Acute cough in children. CFP Mar 2011; 57(3): 315–318
Irwin, R. et al. Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines. Chest. 1 Jan 2006; 129(1 suppl):1S-292S
- o Really dense; stick with the AFP Summary
Chang, A and Glomb, W. Guidelines for Evaluating Chronic Cough in Pediatrics. Chest. Jan 2006; 129(1 suppl):260S-283S