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Infectious cause suspected Consider COVID-19 (wet or dry cough), flu in season, pertussis, TB. ✓hx/ex, incl triggers, environment, occupation, travel, ✓red flags 1 (dyspnea, hemoptysis, etc), r/o life-threatening dz (pneumonia, etc), ✓impact on life. 1 Sputum purulence/color change (green/yellow) doesn’t signify bacteria. 2 F/U all pts in 4-6wk 1 - R/O pneumonia. Unlikely if all these absent: HR rate >100, RR >24, T >38°C, abnl chest exam2 (healthy immunocompetent pts <70 yo)3
- If immunocompromise, ✓CXR. Consider TB, esp for HIV pts in high-prevalence areas, even if NL CXR4
- If hx obstructive airway dz: Consider asthma exac, COPD exac or acute exac chronic bronchitis. If hx bronchiectasis, consider acute exac, tx w/ airway clearance techniques, etc5
If acute bronchitis, defined as wet/dry cough (≤3wk per ACCP,6 ≤6wk per ACP)3 w/o clinical evidence of other dx,6 often w/ mild constitutional sx:3 - Don’t routinely test (CXR,2 spirometry, sputum micro, CRP, procalcitonin, etc) if immunocompetent.3,6 If cough persists/worsens, re-eval, ✓targeted tests (eg, CXR, sputum micro, PEF, CBC, CRP)6
- Tx: don’t use abx,3,6 antivirals. If worsening & suspect complicating bacterial infxn on re-eval, consider abx6
- Sx relief: Don’t use antitussives, mucokinetics, NSAIDs, per ACCP.6 Per ACP, sx relief hasn’t been shown to ↓illness duration; though dextromethorphan, codeine, 1st-gen antihistamines, decongestants,2,3 or guaifenesin,3 might offer benefit—weigh risk/benefit in light of limited data in support of specific agents.2,3 Don’t use asthma inhalers (except inhaled BD if wheezing);6 beta-2-agonists don’t help pts w/o asthma or COPD.3 Don’t use oral steroids in immunocompetent outpts6
If rhinosinusitis (>90% are viral): 2 consider watchful waiting, even if acute bacterial rhinosinusitis. Most resolve in 1wk, but sx 3 may last up to 33 days - Sx: nasal congestion/obstruction, purulent nasal d/c, maxillary tooth pain, face pain/pressure, fever, fatigue, cough, anosmia, ear pressure/fullness, HA, halitosis
- Mgmt: imaging not routine.2,3 Bacterial dz should meet criteria for severity, persistence, or worsening.2,3 Offer watchful waiting, even if bacterial.2 Tailor sx relief to individual rhinosinusitis sx
If URI/common cold, most recover in 7-10 days. Weigh risk/benefit of sx relief, given lack of evidence.2 Abx only for confirmed strep throat2,3 - Sx: cough, fever, rhinorrhea, congestion, postnasal drip, sore throat, HA, myalgia,2 malaise, sneeze3
- OTC sx relief. Don’t use OTC antitussives, expectorants, NSAIDs, antihistamines, mucolytics, or combos, per ACCP.7 ACP suggests sx relief (antitussives, analgesics); antihistamines alone have more side effects than benefits, yet relief seen in 1/4 pts on antihistamine/analgesic/decongestant combo.3 CDC suggests benefit to nasal sx, cough w/ combo 1st-gen antihistamine + decongestant (pseudoephedrine, phenylephrine); NSAIDs can help some sx2
- Prescription sx relief. Evidence lacking for intranasal steroids, opioids.2 Avoid codeine in <18 yo.7 ACP suggests inhaled ipratropium bromide, inhaled cromolyn sodium may help.3 ACCP was unable to make recommendations on acetylcysteine, carbocysteine7
- Vitamin/mineral/home remedies. Honey may improve cough vs placebo or diphenhydramine, but not better than dextromethorphan,7 per ACCP. Evidence lacking on vitamin/herbal remedies3 or nasal saline irrigation as cold tx.2 Insufficient evidence on zinc lozenges, per ACCP;7 although ACP suggests weighing risk/benefit of zinc <24h from sx onset
- If suspect Group A strep (persistent fever, anterior cervical LN, tonsil exudates, cough absence): ✓RADT +/- cx (cx not routine in adults);2 don’t use abx unless confirmed dx2,3
- If pertussis strongly suspected based on clinical picture (less severe, typical “whoop” less freq in adolescents/adults), strongly consider tx awaiting test results8
Footnotes 1 ACCP 2018. Irwin RS, et al. Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report. Chest. 2018. Jan;153(1):196-209. PubMed® abstract
• Red flag s/sx: hemoptysis, dyspnea (esp @ rest or nighttime), systemic sx (fever, wt↓ peripheral edema w/ wt↑), recurrent pneumonia, hoarseness, emesis, dysphagia, coinciding abnl resp exam/CXR
• Red flags for smoking hx: smoker >45 yo w/ new/changed cough or coexisting voice disturbance; as well as pts 55-80 yo w/ 30-pack-yr hx who smoke currently or quit w/in past 15y
• Potentially life-threatening dz: pneumonia, severe COPD/ asthma exac, PE, HF, etc
2 CDC. Antibiotic Prescribing and Use in Doctor’s Offices. Adult Treatment Recommendations. Last reviewed 10/3/17. Accessed 9/24/20
• Acute bronchitis. Colored sputum doesn’t signify bacteria. CXR not indicated for most pts. Evidence supporting sx relief is limited, but options incl dextromethorphan, codeine, 1st-gen antihistamines (diphenhydramine), decongestant (phenylephrine).
• Rhinosinusitis mgmt: 90%-98% are viral. Abx aren’t guaranteed to help even if bacterial, watchful waiting is encouraged for acute bacterial dz. Sinus x-ray not routine.
• Acute bacterial rhinosinusitis defined as 1+ of these:
1) severe >3-4 days, eg, T ≥39°C (102°F) w purulent nasal d/c or face pain
2) persistent >10 days w/o improving (eg, nasal d/c or daytime cough)
3) worsening 3-4 days, eg, worse/new-onset fever, daytime cough, nasal d/c that follows initial improvement or viral URI that lasted 5-6 days.
• Pneumonia in healthy adults rare w/o abnl hx/ex: HR ≥100, RR ≥24, T ≥38°C & abnl lung exam. Colored sputum doesn’t signify bacteria.
• Common cold/URI: fever, cough, rhinorrhea/congestion, postnasal drip, sore throat, HA, myalgias. Sx relief (weigh benefit/harm): decongestants (pseudoephedrine, phenylephrine) combo w/ 1st-gen antihistamine may help nasal sx, cough; NSAIDs can help some sx. Evidence lacking for antihistamine mono-tx, opioids, intranasal steroids, nasal saline irrigation as cold tx.
• Pharyngitis: Do RADT on pts w/ 2+ Centor criteria (fever, tonsil exudates, tender cervical LN, cough absence); don’t give abx if RADT (-); throat cx not routine in adults.
3 ACP/CDC 2016. Harris AM, et al. Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016. Mar 15;164(6):425-34. PubMed® abstract
Acute bacterial rhinosinusitis. Use abx only if any of these:
1) sx >10 days w/o improvement or
2) onset severe s/sx (eg, T >39°C) w/ purulent nasal d/c or face pain ≥3 consecutive days or
3) “double sickening” w/ typical viral illness x5 days initially improves, then sx worsen.
4 ACCP 2017. Rosen MJ, et al. Cough in Ambulatory Immunocompromised Adults: CHEST Expert Panel Report. Chest. 2017. Nov;152(5):1038-1042. PubMed® abstract
Immunocompromise may limit inflammatory response, so CXR may be NL despite pulm infxn.
5 ACCP 2018. Hill AT, et al. Treating Cough Due to Non-CF and CF Bronchiectasis With Nonpharmacological Airway Clearance: CHEST Expert Panel Report. Chest. 2018. Apr;153(4):986-993. PubMed® abstract
6 ACCP 2020. MP Smith, et al. Acute Cough Due to Acute Bronchitis in Immunocompetent Adult Outpatients: CHEST Expert Panel Report. Chest. 2020. May;157(5):1256-1265. PubMed® abstract
Acute bronchitis = no clinical evidence of these: common cold, pneumonia, sinusitis, asthma, COPD, acute exac of chronic of bronchitis, acute exac of bronchiectasis, etc; NL chest exam; no imaging abnormalities.
7 ACCP 2017. Malesker MA, et al. Pharmacologic and Nonpharmacologic Treatment for Acute Cough Associated With the Common Cold: CHEST Expert Panel Report. Chest. 2017. Nov;152(5):1021-1037. PubMed® abstract
8 CDC 2019. Pertussis (Whooping Cough). Centers for Disease Control and Prevention. Last reviewed 10/25/19. Accessed 10/1/20
• Test: nasopharyngeal swab or aspirate for PCR, cx; special handling required.
• Stage 1 Catarrhal: Insidious sx onset w/in 5-10 days of exposure (max 21 days). Coryza, low-grade fever, initially intermittent mild cough gradually increases in severity
• Stage 2 Paroxysmal: Cough persists x1-6wk. Multiple paroxysms of numerous rapid coughs (often at night) ending in whoop, thick mucus, posttussive emesis, long inspiratory effort, cyanosis, exhaustion. Whoop, emesis may be absent. Paroxysms disappear in 2-3wk.
• Stage 3 Convalescent: Nonparoxysmal cough may persist 2-6wk after paroxysms subside, though paroxysms may recur months later.
Noninfectious cause suspected Consider COVID-19 (wet or dry cough), flu in season. ✓hx/ex, incl triggers, (smoking; new drug, eg, ACEI), environment 1 (incl in athletes 2), occupation, travel, ✓red flags (hemoptysis, dyspnea, etc), 1 r/o life-threatening dz (severe COPD/ asthma exac, PE, etc), 1 ✓impact on life. 1 F/U all pts in 4-6wk 1 - Consider environmental exposures (resp irritants, pollutants, smoke, allergens, etc)1
- If immunocompromised, ✓CXR; if (-) & common cough causes excluded, test for dz assoc w/ immunocompromise3
- If hx obstructive airway dz: Consider asthma exac, COPD exac or acute exac chronic bronchitis. If hx bronchiectasis, consider acute exac, tx w/ airway clearance techniques, etc4
- If asthma suspected (incl cough-variant, exercise-induced), ✓spirometry pre/post-BD, methacholine challenge.1,5 Tx asthma per step tx; pre-tx exercise-induced bronchospasm w/ bronchodilators
- If NAEB suspected (steroid-responsive cough in nonsmoker w/o airway hyperresponsiveness):5 ✓blood/sputum eos, FENO, per ACCP; per ERS, sputum eos superior to blood; FENO threshold unclear.6 Tx w/ inhaled steroids5
- If postnasal drip/upper airway cough syndrome suspected (eg, from rhinosinus dz), tx involves 1st-gen6 antihistamine + decongestant1
Footnotes 1 ACCP 2018. Irwin RS, et al. Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report. Chest. 2018. Jan;153(1):196-209. PubMed® abstract
• Red flag s/sx: hemoptysis, dyspnea (esp @ rest or nighttime), systemic sx (fever, wt↓ peripheral edema w/ wt↑), recurrent pneumonia, hoarseness, emesis, dysphagia, coinciding abnl resp exam/CXR
• Red flags for smoking hx: smoker >45 yo w/ new/changed cough or coexisting voice disturbance; as well as pts 55-80 yo w/ 30-pack-yr hx who smoke currently or quit w/in past 15y
• Potentially life-threatening dz: pneumonia, severe COPD/ asthma exac, PE, HF, etc
2 ACCP 2017. Boulet LP, et al. Cough in the Athlete: CHEST Guideline and Expert Panel Report. Chest. 2017. Feb;151(2):441-454. PubMed® abstract
• Cough in athletes most commonly asthma, exercise-induced bronchospasm, or environment-related; seen esp after intense exercise, wherein ↑ventilatory volumes may ↑allergen/pollutant penetration & dehydrate airways; more prevalent in winter sports & swimmers. ✓timing w/ exercise (cough during vs after), sports environment, season.
• Eval for acute/recurrent cough: asthma, exercise-induced bronchospasm, UACS (postnasal drip from rhinosinus dz), sport-related environment exposure. Consider URI.
• Tests: ✓PFTs w/ bronchoprovocation challenge, airborne allergy eval, environment eval (resp irritants, pollutants, allergens, etc).
• Tx: Consider tx trial directed at most likely cause, in light of particular sport & environment. ✓evolving anti-doping regs if prohibitions relevant.
3 ACCP 2017. Rosen MJ, et al. Cough in Ambulatory Immunocompromised Adults: CHEST Expert Panel Report. Chest. 2017. Nov;152(5):1038-1042. PubMed® abstract
Immunocompromise may limit inflammatory response, so CXR may be NL despite pulm infxn. Obliterative bronchiolitis typically occurs ≤1y post bone marrow txp w/ cough & dyspnea; CXR often NL. CA pts w/ NL CXR may have mets on endobronchial bx (eg, Kaposi sarcoma in AIDS).
4 ACCP 2018. Hill AT, et al. Treating Cough Due to Non-CF and CF Bronchiectasis With Nonpharmacological Airway Clearance: CHEST Expert Panel Report. Chest. 2018. Apr;153(4):986-993. PubMed® abstract
5 ACCP 2020. Cote A, et al. Managing Chronic Cough Due to Asthma and NAEB in Adults and Adolescents: CHEST Guideline and Expert Panel Report. Chest. 2020. Jul;158(1):68-96. PubMed® abstract
Noninvasive airway inflammation markers (blood/sputum eos, FENO) can predict steroid responsiveness (moderate evidence).
• Asthma/cough-variant asthma. If incomplete response to inhaled steroids, re-eval for other causes; then try ↑dose, consider leukotriene receptor antagonist trial, consider combo inhaled steroids w/ beta-2-agonist.
• NAEB = corticosteroid-responsive cough in nonsmoker w/ airway eosinophilia but w/o airway hyperresponsiveness. Tx w/ inhaled steroids; if incomplete response, consider other causes, then ↑dose & consider leukotriene receptor antagonist trial.
6 ERS 2020. Morice AH, et al. ERS Guidelines on the Diagnosis and Treatment of Chronic Cough in Adults and Children. European Respiratory Society. Eur Resp J. 2020. Jan 2;55:1901136. PubMed® abstract
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Consider COVID-19 (wet or dry cough), flu in season. ✓hx/ex, incl smoking, exposures, travel, ✓red flags (hemoptysis, SOB, systemic sx, etc), 1 r/o life-threatening dz (pneumonia, etc). 1 ✓impact on life. F/U all pts in 4-6wk 1 Consider ongoing infxn (eg, TB, pertussis) before eval for common postinfxn cough: - If immunocompromise, ✓CXR. Consider TB, esp for HIV pts in hi-prevalence areas, even if NL CXR2
- If pertussis strongly suspected based on clinical picture (less severe, typical “whoop” less freq in adolescents/adults), strongly consider tx awaiting test results3
- If hx obstructive airway dz: Consider asthma exac, COPD exac or acute exac chronic bronchitis. If hx bronchiectasis, consider acute exac, tx w/ airway clearance techniques, etc4
- If acute bronchitis, wet or dry cough (≤6wk, per ACP;5 ≤3wk, per ACCP6): Tests not routine, don’t use abx.5,6 Sx relief guidance varies; ACCP doesn’t recommend antitussives, mucokinetics, NSAIDs;6 ACP suggests weighing risk/benefit5
Consider common causes of postinfectious cough, incl new-onset & exac of chronic conditions.1,7 Tx provoking factors (postnasal drip, asthma, GERD), then consider empiric tx trial (eg, inhaled steroids/other agents)7 - UACS/postnasal drip exac: Tx underlying cause (eg, rhinitis, sinusitis, etc); if postviral or no apparent cause, consider empiric 1st-gen antihistamine + decongestant combo7
- Asthma sx (incl cough-variant): ✓spirometry pre/post-BD, methacholine challenge, tx w/ inhaled steroids1,8
- If hx chronic obstructive airway dz, consider exacerbation,7 manage as acute exac chronic bronchitis/COPD. If exac of bronchiectasis, incl airway clearance techniques in tx4
- NAEB sx (steroid-responsive cough in nonsmoker w/o airway hyperresponsiveness): ✓blood/sputum eos, FENO, tx w/ inhaled steroids.8 Avoid causal allergens/sensitizers;7 tx w/ inhaled steroids8
- GERD sx: Lifestyle change (wt↓ if overwt, elevate bed head, avoid meals <3h of bedtime). Don’t use PPI if cough is only sx7
Footnotes 1 ACCP 2018. Irwin RS, et al. Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report. Chest. 2018. Jan;153(1):196-209. PubMed® abstract
• Red flag s/sx: hemoptysis, dyspnea (esp @ rest or nighttime), systemic sx (fever, wt↓, peripheral edema w/ wt↑), recurrent pneumonia, hoarseness, emesis, dysphagia, coinciding abnl resp exam/CXR
• Red flags for smoking hx: smoker >45 yo w/ new/changed cough or coexisting voice disturbance; as well as pts 55-80 yo w/ 30-pack-yr hx who smoke currently or quit w/in past 15y
• Potentially life-threatening dz: pneumonia, severe COPD/ asthma exac, PE, HF, etc
2 ACCP 2017. Rosen MJ, et al. Cough in Ambulatory Immunocompromised Adults: CHEST Expert Panel Report. Chest. 2017. Nov;152(5):1038-1042. PubMed® abstract
Immunocompromise may limit inflammatory response, so CXR may be NL despite pulm infxn. If CXR(-) & common cough causes are excluded, test for dz assoc w/ immunocompromise.
3 CDC 2019. Pertussis (Whooping Cough). Centers for Disease Control and Prevention. Last reviewed 10/25/19. Accessed 10/1/20
• Test: nasopharyngeal swab or aspirate for PCR, cx; special handling required.
• Stage 1 Catarrhal: Insidious sx onset w/in 5-10 days of exposure (max 21 days). Coryza, low-grade fever, initially intermittent mild cough gradually increases in severity
• Stage 2 Paroxysmal: Cough persists x1-6wk. Multiple paroxysms of numerous rapid coughs (often at night) ending in whoop, thick mucus, posttussive emesis, long inspiratory effort, cyanosis, exhaustion. Whoop, emesis may be absent. Paroxysms disappear in 2-3wk.
• Stage 3 Convalescent: Nonparoxysmal cough may persist 2-6wk after paroxysms subside, though paroxysms may recur months later.
4 ACCP 2018. Hill AT, et al. Treating Cough Due to Non-CF and CF Bronchiectasis With Nonpharmacological Airway Clearance: CHEST Expert Panel Report. Chest. 2018. Apr;153(4):986-993. PubMed® abstract
5 ACP/CDC 2016. Harris AM, et al. Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016. Mar 15;164(6):425-34. PubMed® abstract
• Sx relief hasn’t been shown to ↓illness duration; though dextromethorphan, codeine, 1st-gen antihistamines, decongestants or guaifenesin might offer benefit—weigh risk/benefit in light of limited data in support of specific agents.
6 ACCP 2020. MP Smith, et al. Acute Cough Due to Acute Bronchitis in Immunocompetent Adult Outpatients: CHEST Expert Panel Report. Chest. 2020. May;157(5):1256-1265. PubMed® abstract
• Acute bronchitis = no clinical evidence of these: common cold, pneumonia, sinusitis, asthma, COPD, acute exac of chronic of bronchitis, acute exac of bronchiectasis, etc; NL chest exam; no imaging abnormalities
• Don’t routinely test (spirometry, sputum micro, CRP, procalcitonin, etc) if immunocompetent. If cough persists/worsens, re-eval, ✓targeted tests (eg, CXR, sputum micro, PEF, CBC, CRP).
• Tx: Don’t use abx, antivirals. If worsening & suspect complicating bacterial infxn on re-eval, consider abx.
• Sx relief: Don’t use antitussives, mucokinetics, NSAIDs. Don’t use asthma inhalers (except inhaled BD if wheezing). Don’t use oral steroids in immunocompetent outpts.
7 ACCP 2006. Irwin RS, et al. Diagnosis and Management of Cough Executive Summary: ACCP Evidence-Based Clinical Practice Guidelines. Chest. 2006. Jan;129:1S-23S. PubMed® abstract
8 ACCP 2020. Cote A, et al. Managing Chronic Cough Due to Asthma and NAEB in Adults and Adolescents: CHEST Guideline and Expert Panel Report. Chest. 2020. Jul;158(1):68-96. PubMed® abstract
• Noninvasive airway inflammation markers (blood/sputum eos, FENO) can predict steroid responsiveness (moderate evidence).
• Asthma tx. If incomplete response to inhaled steroids for asthma/cough-variant asthma, re-eval for other causes; then try ↑dose, consider leukotriene antagonist trial, consider combo inhaled steroids w/ beta-2-agonist.
• NAEB: Tx w/ inhaled steroids; if incomplete response, consider other causes, then ↑dose & consider leukotriene antagonist trial.
Manage as chronic cough. Consider COVID-19 (wet or dry cough), consider pertussis. ✓hx/ex, incl smoking, triggers, environment 1 (incl in athletes 2) occupation, travel, ✓red flags (hemoptysis, SOB, systemic sx, etc), 1 r/o life-threatening dz (severe COPD/ asthma, HF, etc 1), ✓impact on life 1 If cause unclear, ✓CXR, spirometry3 (selectively CT,1,3 occupational eval, bronch, etc1) & consider 4- to 6-wk1 sequential3 tx trials for most common causes: asthma, nonasthmatic eosinophilic bronchitis (NAEB), postnasal drip, GERD1/esophageal dysmotility.3 If inadequate response to optimal tx trial(s), f/u 4-6 more wks & consider other causes1 - If smoking or drug effect (ACEI, sitagliptin,1 bisphosphonates or CCBs may worsen reflux; prostanoid eye drops3): D/C ≥4wk, then reassess.1 Ceasing smoking may transiently ↑cough3
- Hx obstructive airway dz. Chronic bronchitis:4 Stop smoking/exposures; insufficient evidence for abx, bronchodilators, mucolytics, etc;4 optimize COPD or asthma tx. Bronchiectasis: Use airway clearance techniques5
- If cough hypersensitivity (cold air, perfume, smoke, bleach) manage exposures3
- If immunocompromised w/ CXR(-) & common cough causes excluded, test for dz assoc w/immunocompromise6
- Consider TB in endemic area/hi-risk pt, even if CXR NL,1 consider sputum AFB3
- If pertussis strongly suspected based on clinical picture (less severe, typical “whoop” less freq in adolescents/adults), strongly consider tx awaiting test results7
Consider 4- to 6-wk1 sequential3 tx trials for most common chronic cough causes, based on findings:1 - Postnasal drip/UACS: Consider nasopharyngoscopy, sinus imaging, allergy eval, or empiric tx, per AACP;1 ERS recommends against sinus CT. Tx w/ 1st-gen3 antihistamine + decongestant1,3
- Asthma (incl cough variant): ✓spirometry pre/post-BD, methacholine challenge, allergy eval—or empiric tx w/ inhaled steroids.1,8 If incomplete response, re-eval causes, ↑dose, consider leukotriene receptor antagonist trial (2- to 4-wk trial in adults, per ERS3), consider combo inhaled steroids w/ beta-2-agonist8
- NAEB:8 ✓sputum eos, FENO, allergy eval,1 avoid triggers3—or empiric tx of inhaled steroids1 (hi-dose, per ERS3). FENO thresholds uncertain for chronic cough, per ERS.3 If incomplete response to inhaled steroids (may take 1mo3), re-eval cause; ↑dose, consider leukotriene receptor antagonist trial8
- Don’t trial inhaled steroids if spirometry/methacholine challenge show no asthma & sputum eos & FENO (-) for eosinophilic inflammation, per ACCP.9 ERS suggests that pts w/ fixed airflow obstruction trial inhaled steroids + long-acting bronchodilator combo x2-4wk; d/c if no response @ endpoint3
- GERD. ↓wt if overwt, elevate bed head, avoid meals <3h of bedtime. If heartburn + regurg, control sx w/ PPI, H2RA, alginate, or antacids. If cough alone w/o heartburn/regurg, don’t use PPI alone w/o lifestyle change. Reflux cough may take up to 3mo to respond; if refractory, ✓manometry & pH-metry.10 Don’t do 24-hr pH monitor if no peptic sx.3 If (-) w/u for acid reflux, don’t use PPIs;3,9 even w/ acid reflux, PPIs only modestly effective for cough3
- Esophageal dysmotility. Reflux & aspiration can cause voice change, nasal sx, dysgeusia.3 Tests incl endoscopic &/or video fluoroscopic swallow eval, Ba esophagram/swallow, per ACCP.1 ERS notes Ba swallow has poor sensitivity.3 Insufficient evidence on promotility drugs, but if chronic refractory bronchitis could consider, per ERS3
Footnotes 1 ACCP 2018. Irwin RS, et al. Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report. Chest. 2018. Jan;153(1):196-209. PubMed® abstract
• Red flag s/sx: hemoptysis, dyspnea (esp @ rest or nighttime), systemic sx (fever, wt↓, peripheral edema w/ wt↑), recurrent pneumonia, hoarseness, emesis, dysphagia, coinciding abnl resp exam/CXR
• Red flags for smoking hx: smoker >45 yo w/ new/changed cough or coexisting voice disturbance; as well as pts 55-80 yo w/ 30-pack-yr hx who smoke currently or quit w/in past 15y
• Potentially life-threatening dz: pneumonia, severe COPD/ asthma exac, PE, HF, etc
2 ACCP 2017. Boulet LP, et al. Cough in the Athlete: CHEST Guideline and Expert Panel Report. Chest. 2017. Feb;151(2):441-454. PubMed® abstract
• Cough in athletes most commonly asthma, exercise-induced bronchospasm, or environment-related; seen esp after intense exercise, wherein ↑ventilatory volumes may ↑allergen/pollutant penetration & dehydrate airways. More prevalent in winter sports & swimmers. ✓timing w/ exercise (cough during vs after), sports environment, season.
• Eval for acute/recurrent cough: asthma, exercise-induced bronchospasm, UACS (postnasal drip from rhinosinus dz), sport-related environment exposure. Consider URI.
• Tests: ✓PFTs w/ bronchoprovocation challenge, airborne allergy eval, environment eval (resp irritants, pollutants, allergens, etc).
• Tx: Consider tx trial directed at most likely cause, in light of particular sport & environment. ✓evolving anti-doping regs if prohibitions relevant.
3 ERS 2020. Morice AH, et al. ERS Guidelines on the Diagnosis and Treatment of Chronic Cough in Adults and Children. European Respiratory Society. Eur Resp J. 2020. Jan 2;55:1901136. PubMed® abstract
• Chest CT: Don’t do if NL CXR/exam.
• Rhinoscopy can detect polyps, mucus, but not routinely used, since nasal findings aren’t necessarily directly linked with cough.
• Reflux & aspiration. Repeated aspiration may cause sx of frequent “chest” infxn, bronchitis—even bronchiectasis. GI tract aspiration causes inflammation that can be eosinophilic or neutrophilic, causing asthmatic cough & mucus secretion.
• Promotility drugs (metoclopramide; domperidone; promotility macrolides eg, azithromycin): insufficient evidence. If chronic bronchitis refractory to other tx, might consider a 1-mo trial of macrolide, in light of antimicrobial stewardship guidance.
• If interstitial lung dz: Antitussives often not effective.
4 ACCP 2020. Malesker MA, et al. Chronic Cough Due to Stable Chronic Bronchitis: CHEST Expert Panel Report. Chest. 2020; 158(2):705-718. PubMed® abstract
• Chronic bronchitis = cough & sputum most days ≥3mo x ≥2y in a row (other resp/CV causes excluded).
• Risks: smoking/dust/irritant/pollutants
• Tx: Stop smoking, stop pollutants/other irritant exposures; insufficient evidence for abx, bronchodilators, mucolytics, or PEEP.
5 ACCP 2018. Hill AT, et al. Treating Cough Due to Non-CF and CF Bronchiectasis With Nonpharmacological Airway Clearance: CHEST Expert Panel Report. Chest. 2018. Apr;153(4):986-993. PubMed® abstract
6 ACCP 2017. Rosen MJ, et al. Cough in Ambulatory Immunocompromised Adults: CHEST Expert Panel Report. Chest. 2017. Nov;152(5):1038-1042. PubMed® abstract
Immunocompromise may limit inflammatory response, so CXR may be NL despite pulm infxn. If CXR(-) & common cough causes are excluded, test for dz assoc w/ immunocompromise. Obliterative bronchiolitis typically occurs ≤1y post bone marrow txp w/ cough & dyspnea; CXR often NL. CA pts w/ NL CXR may have mets on endobronchial bx (eg, Kaposi sarcoma in AIDS).
7 CDC 2019. Pertussis (Whooping Cough). Centers for Disease Control and Prevention. Last reviewed 10/25/19. Accessed 10/1/20
• Test: nasopharyngeal swab or aspirate for PCR, cx; special handling required.
• Stage 1 Catarrhal: Insidious sx onset w/in 5-10 days of exposure (max 21 days). Coryza, low-grade fever, initially intermittent mild cough gradually increases in severity
• Stage 2 Paroxysmal: Cough persists x1-6wk. Multiple paroxysms of numerous rapid coughs (often at night) ending in whoop, thick mucus, posttussive emesis, long inspiratory effort, cyanosis, exhaustion. Whoop, emesis may be absent. Paroxysms disappear in 2-3wk.
• Stage 3 Convalescent: Nonparoxysmal cough may persist 2-6wk after paroxysms subside, though paroxysms may recur months later.
8 ACCP 2020. Cote A, et al. Managing Chronic Cough Due to Asthma and NAEB in Adults and Adolescents: CHEST Guideline and Expert Panel Report. Chest. 2020. Jul;158(1):68-96. PubMed® abstract
• NAEB = corticosteroid-responsive cough in nonsmoker w/ airway eosinophilia but w/o airway hyperresponsiveness.
• Noninvasive airway inflammation markers (blood/sputum eos, FENO) can predict steroid responsiveness (moderate evidence).
9 ACCP 2016. Gibson P, et al. Treatment of Unexplained Chronic Cough: CHEST Guideline and Expert Panel Report. Chest. 2016. Jan;149(1):27-44. PubMed® abstract
• Unexplained = >8wk after tests, incl for asthma, eosinophilic bronchitis (sputum eos/FENO)—or inhaled steroid trial; as well as supervised tx trial(s)
• Inhaled steroids target eosinophilic inflammation in rhinitis, asthma, NAEB.
• If less common pulmonary cause suspected: HRCT, bronchoscopy, occupational eval
• If cardiac cause suspected: ECG, Holter, echo, etc
10 ACCP 2016. Kahrilas PJ, et al. Chronic Cough Due to Gastroesophageal Reflux in Adults: CHEST Guideline and Expert Panel Report. Chest. 2016. Dec;150(6):1341-1360. PubMed® abstract
If suspect GERD cough, wt↓ if overwt, elevate bed head, avoid meals <3h of bedtime. If heartburn + regurg, control those sx w/ PPI, H2RA, alginate, or antacids. If cough alone w/o heartburn/regurg, don’t use PPI alone, use GERD lifestyle change +/- PPI. Reflux cough may take up to 3mo to respond; if refractory to antireflux, ✓esophageal manometry & pH-metry.
• If suspected reflux cough refractory to 3-mo antireflux tx in pt under eval for antireflux/bariatric surgery: Do esophageal manometry & pH-metry to ✓ for major motility dz & eval reflux. Esophageal manometry evaluates motility dz & accurately positions pH electrode for pH study. Hold PPI x7 days (hold H2RA x3 days) prior.
• If major motility dz (eg, achalasia, no peristalsis, distal esophageal spasm, hypercontractility): Don’t do antireflux surgery.
• If chronic presumed reflux cough fails medical tx in pt w/ adequate peristalsis but abnl esophageal acid exposure on pH-metry, antireflux (or bariatric) surgery suggested.
-
Awaiting investigations &/or tx trial(s) Consider COVID-19 (wet or dry cough), consider pertussis. ✓hx/ex, incl smoking, triggers, environment 1 (incl in athletes 2) occupation, travel, ✓red flags (hemoptysis, SOB, systemic sx, etc), 1 r/o life-threatening dz (severe COPD/ asthma, HF, etc 1), ✓impact on life 1 If cause unclear, ✓CXR, spirometry3 (selectively CT,1,3 occupational eval, bronch, etc1) & consider 4- to 6-wk1 sequential3 tx trials for most common causes: asthma, nonasthmatic eosinophilic bronchitis (NAEB), postnasal drip, GERD1/esophageal dysmotility.3 If inadequate response to optimal tx trial(s), f/u 4-6 more wks & consider other causes1 - If smoking or drug effect (ACEI, sitagliptin,1 bisphosphonates or CCBs may worsen reflux; prostanoid eye drops3): D/C ≥4wk then reassess.1 Ceasing smoking may transiently ↑cough3
- Hx obstructive airway dz. Chronic bronchitis:4 Stop smoking/exposures; insufficient evidence for abx, bronchodilators, mucolytics, etc;4 optimize COPD or asthma tx. Bronchiectasis: Use airway clearance techniques5
- If cough hypersensitivity (cold air, perfume, smoke, bleach) manage exposures3
- If immunocompromised w/ CXR(-) & common cough causes excluded, test for dz assoc w/immunocompromise6
- Consider TB in endemic area/hi-risk pt, even if CXR NL,1 consider sputum AFB3
- If pertussis strongly suspected based on clinical picture (less severe, typical “whoop” less freq in adolescents/adults), strongly consider tx awaiting test results7
Consider 4- to 6-wk1 sequential3 tx trials for most common chronic cough causes, based on findings:1 - Postnasal drip/upper airway cough syndrome: Consider nasopharyngoscopy, sinus imaging, allergy eval, or empiric tx, per AACP;1 ERS recommends against sinus CT. Tx w/ 1st-gen3 antihistamine + decongestant1,3
- Asthma (incl cough variant): ✓spirometry pre/post-BD, methacholine challenge, allergy eval—or empiric tx w/ inhaled steroids.1,8 If incomplete response, re-eval causes, ↑dose, consider leukotriene receptor antagonist trial (2- to 4-wk trial in adults, per ERS3), consider combo inhaled steroids w/ beta-2-agonist8
- NAEB:8 ✓sputum eos, FENO, allergy eval,1 avoid triggers3—or empiric tx of inhaled steroids1 (hi-dose, per ERS3). FENO thresholds uncertain for chronic cough, per ERS.3 If incomplete response to inhaled steroids (may take 1mo3), re-eval cause; ↑dose, consider leukotriene receptor antagonist trial8
- Don’t trial inhaled steroids if spirometry/methacholine challenge show no asthma & sputum eos & FENO (-) for eosinophilic inflammation, per ACCP.9 ERS suggests that pts w/ fixed airflow obstruction trial inhaled steroids + long-acting bronchodilator combo x2-4wk; d/c if no response @ endpoint3
- GERD. ↓wt if overwt, elevate bed head, avoid meals <3h of bedtime. If heartburn + regurg, control sx w/ PPI, H2RA, alginate, or antacids. If cough alone w/o heartburn/regurg, don’t use PPI alone w/o lifestyle change. Reflux cough may take up to 3mo to respond; if refractory, ✓manometry & pH-metry.10 Don’t do 24-hr pH monitor if no peptic sx.3 If (-) w/u for acid reflux, don’t use PPIs;3,9 even w/ acid reflux, PPIs only modestly effective for cough3
- Esophageal dysmotility. Reflux & aspiration can cause voice change, nasal sx, dysgeusia.3 Tests incl: endoscopic &/or video fluoroscopic swallow eval, Ba esophagram/swallow, per ACCP.1 ERS notes Ba swallow has poor sensitivity.3 Insufficient evidence on promotility drugs, but if chronic refractory bronchitis could consider, per ERS3
Footnotes 1 ACCP 2018. Irwin RS, et al. Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report. Chest. 2018. Jan;153(1):196-209. PubMed® abstract
• Red flag s/sx: hemoptysis, dyspnea (esp @ rest or nighttime), systemic sx (fever, wt↓, peripheral edema w/ wt↑), recurrent pneumonia, hoarseness, emesis, dysphagia, coinciding abnl resp exam/CXR
• Red flags for smoking hx: smoker >45 yo w/ new/changed cough or coexisting voice disturbance; as well as pts 55-80 yo w/ 30-pack-yr hx who smoke currently or quit w/in past 15y
• Potentially life-threatening dz: pneumonia, severe COPD/ asthma exac, PE, HF, etc
2 ACCP 2017. Boulet LP, et al. Cough in the Athlete: CHEST Guideline and Expert Panel Report. Chest. 2017. Feb;151(2):441-454. PubMed® abstract
• Cough in athletes most commonly asthma, exercise-induced bronchospasm, or environment-related; seen esp after intense exercise, wherein ↑ventilatory volumes may ↑allergen/pollutant penetration & dehydrate airways. More prevalent in winter sports & swimmers. ✓timing w/ exercise (cough during vs after), sports environment, season.
• Eval for acute/recurrent cough: asthma, exercise-induced bronchospasm, UACS (postnasal drip from rhinosinus dz), sport-related environment exposure. Consider URI.
• Tests: ✓PFTs w/ bronchoprovocation challenge, airborne allergy eval, environment eval (resp irritants, pollutants, allergens, etc).
• Tx: Consider tx trial directed at most likely cause, in light of particular sport & environment. ✓evolving anti-doping regs if prohibitions relevant.
3 ERS 2020. Morice AH, et al. ERS Guidelines on the Diagnosis and Treatment of Chronic Cough in Adults and Children. European Respiratory Society. Eur Resp J. 2020. Jan 2;55:1901136. PubMed® abstract
• Chest CT: Don’t do if NL CXR/exam.
• Rhinoscopy can detect polyps, mucus, but not routinely used, since nasal findings aren’t necessarily directly linked with cough.
• Reflux & aspiration. Repeated aspiration may cause sx of frequent “chest” infxn, bronchitis—even bronchiectasis. GI tract aspiration causes inflammation that can be eosinophilic or neutrophilic, causing asthmatic cough & mucus secretion.
• Promotility drugs (metoclopramide; domperidone; promotility macrolides eg, azithromycin): insufficient evidence. If chronic bronchitis refractory to other tx, might consider a 1-mo trial of macrolide, in light of antimicrobial stewardship guidance.
• If interstitial lung dz: Antitussives often not effective.
4 ACCP 2020. Malesker MA, et al. Chronic Cough Due to Stable Chronic Bronchitis: CHEST Expert Panel Report. Chest. 2020; 158(2):705-718. PubMed® abstract
• Chronic bronchitis = cough & sputum most days ≥3mo x ≥2y in a row (other resp/CV causes excluded).
• Risks: smoking/dust/irritant/pollutants
• Tx: stop smoking, stop pollutants/other irritant exposures; insufficient evidence for abx, bronchodilators, mucolytics, or PEEP
5 ACCP 2018. Hill AT, et al. Treating Cough Due to Non-CF and CF Bronchiectasis With Nonpharmacological Airway Clearance: CHEST Expert Panel Report. Chest. 2018. Apr;153(4):986-993. PubMed® abstract
6 ACCP 2017. Rosen MJ, et al. Cough in Ambulatory Immunocompromised Adults: CHEST Expert Panel Report. Chest. 2017. Nov;152(5):1038-1042. PubMed® abstract
Immunocompromise may limit inflammatory response, so CXR may be NL despite pulm infxn. If CXR(-) & common cough causes are excluded, test for dz assoc w/immunocompromise. Obliterative bronchiolitis typically occurs ≤1y post bone marrow txp w/ cough & dyspnea; CXR often NL. CA pts w/ NL CXR may have mets on endobronchial bx (eg, Kaposi sarcoma in AIDS).
7 CDC 2019. Pertussis (Whooping Cough). Centers for Disease Control and Prevention. Last reviewed 10/25/19. Accessed 10/1/20
• Test: nasopharyngeal swab or aspirate for PCR, cx; special handling required.
• Stage 1 Catarrhal: Insidious sx onset w/in 5-10 days of exposure (max 21 days). Coryza, low-grade fever, initially intermittent mild cough gradually increases in severity
• Stage 2 Paroxysmal: Cough persists x1-6wk. Multiple paroxysms of numerous rapid coughs (often at night) ending in whoop, thick mucus, posttussive emesis, long inspiratory effort, cyanosis, exhaustion. Whoop, emesis may be absent. Paroxysms disappear in 2-3wk.
• Stage 3 Convalescent: Nonparoxysmal cough may persist 2-6wk after paroxysms subside, though paroxysms may recur months later.
8 ACCP 2020. Cote A, et al. Managing Chronic Cough Due to Asthma and NAEB in Adults and Adolescents: CHEST Guideline and Expert Panel Report. Chest. 2020. Jul;158(1):68-96. PubMed® abstract
• NAEB = corticosteroid-responsive cough in nonsmoker w/ airway eosinophilia but w/o airway hyperresponsiveness.
• Noninvasive airway inflammation markers (blood/sputum eos, FENO) can predict steroid responsiveness (moderate evidence).
9 ACCP 2016. Gibson P, et al. Treatment of Unexplained Chronic Cough: CHEST Guideline and Expert Panel Report. Chest. 2016. Jan;149(1):27-44. PubMed® abstract
• Unexplained = >8wk after tests, incl for asthma, eosinophilic bronchitis (sputum eos/FENO)—or inhaled steroid trial; as well as supervised tx trial(s)
• Inhaled steroids target eosinophilic inflammation in rhinitis, asthma, NAEB.
• If less common pulmonary cause suspected: HRCT, bronchoscopy, occupational eval
• If cardiac cause suspected: ECG, Holter, echo, etc
10 ACCP 2016. Kahrilas PJ, et al. Chronic Cough Due to Gastroesophageal Reflux in Adults: CHEST Guideline and Expert Panel Report. Chest. 2016. Dec;150(6):1341-1360. PubMed® abstract
If suspect GERD cough, wt↓ if overwt, elevate bed head, avoid meals <3h of bedtime. If heartburn + regurg, control those sx w/ PPI, H2RA, alginate, or antacids. If cough alone w/o heartburn/regurg, don’t use PPI alone, use GERD lifestyle change +/- PPI. Reflux cough may take up to 3mo to respond; if refractory to antireflux, ✓esophageal manometry & pH-metry.
• If suspected reflux cough refractory to 3-mo antireflux tx in pt under eval for antireflux/bariatric surgery: Do esophageal manometry & pH-metry to ✓ for major motility dz & eval reflux. Esophageal manometry evaluates motility dz & accurately positions pH electrode for pH study. Hold PPI x7 days (hold H2RA x3 days) prior.
• If major motility dz (eg, achalasia, no peristalsis, distal esophageal spasm, hypercontractility): Don’t do antireflux surgery.
• If chronic presumed reflux cough fails medical tx in pt w/ adequate peristalsis but abnl esophageal acid exposure on pH-metry, antireflux (or bariatric) surgery suggested.
Unexplained after investigations & tx trial(s) If tests complete (spirometry, CXR, etc) & inadequate response to optimized tx trials (asthma, nonasthmatic eosinophilic bronchitis, postnasal drip, GERD, if relevant): ✓red flags,1 ✓triggers, smoking, environment (incl in athletes),2 occupational exposures, etc, ✓impact on life, before considering options1 - R/O asthma (spirometry, methacholine challenge) & NAEB (sputum eos, FENO)—or that inhaled steroids trialed.3 If these tests all (-), don’t trial inhaled steroids3
- If asthma or NAEB dx’d but inadequate response to inhaled steroids: Re-eval cause; then try ↑dose, consider leukotriene receptor antagonist trial; for asthma, also consider combo inhaled steroids w/ beta-2-agonist.4 Avoid triggers5
- GERD, dysmotility. If (-) w/u for acid reflux, don’t use PPIs.3 Insufficient evidence on promotility drugs, per ERS, but if chronic bronchitis refractory to other tx, could consider5
- If upper airway sx: Laryngoscopy not routine but could detect inducible laryngeal obstruction that could respond to cough control tx5
- Further imaging: Don’t do chest CT if NL CXR/exam, but if no clear dx or refractory to tx, HRCT may identify subtle interstitial lung dz. Don’t do sinus CT, per ERS5
Consider options for difficult-to-tx cough: multimodal speech path, gabapentin, cough clinic referral, or clinical trial.3 F/U in 4-6 wks, per ACCP;1 ERS suggests continuing successful tx x3mo, then attempting w/d3 - Stop triggers (eg, smoking, ACEI).1,5 Quitting smoking may ↑cough transiently5
- If any tx partially effective, maintain it1
- Multimodal speech path/cough control tx trial recommended, by experienced practitioners3,5
- If choosing empiric gabapentin trial, 1st discuss contraindications, risk/benefit; start 300 mg daily escalating to max tolerable dose of 1800 mg daily (divided into 2 doses). Reassess risk/benefit @ 6 mo before continuing, per ACCP.3 ERS supports gabapentin or pregabalin trial in adults, but cites adverse effects, lower response rate than opioids5
- Weigh risk/benefit of opioids. Consider trial of low-dose slow-release morphine (5-10 mg bid) in adults—response seen in 1wk, but only 1/2 of pts may respond; d/c if no response in 1-2wk, per ERS.5 Codeine not recommended due to less predictability, drug metabolism issues, side effects
Footnotes 1 ACCP 2018. Irwin RS, et al. Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report. Chest. 2018. Jan;153(1):196-209. PubMed® abstract
• Red flag s/sx: hemoptysis, dyspnea (esp @ rest or nighttime), systemic sx (fever, wt↓, peripheral edema w/ wt↑), recurrent pneumonia, hoarseness, emesis, dysphagia, coinciding abnl resp exam/CXR
• Red flags for smoking hx: smoker >45 yo w/ new/changed cough or coexisting voice disturbance; as well as pts 55-80 yo w/ 30-pack-yr hx who smoke currently or quit w/in past 15y
• Potentially life-threatening dz: pneumonia, severe COPD/ asthma exac, PE, HF, etc
2 ACCP 2017. Boulet LP, et al. Cough in the Athlete: CHEST Guideline and Expert Panel Report. Chest. 2017. Feb;151(2):441-454. PubMed® abstract
• Cough in athletes most commonly asthma, exercise-induced bronchospasm, or environment-related; seen esp after intense exercise, wherein ↑ventilatory volumes may ↑allergen/pollutant penetration & dehydrate airways. More prevalent in winter sports & swimmers. ✓timing w/ exercise (cough during vs after), sports environment, season.
• Eval for acute/recurrent cough: asthma, exercise-induced bronchospasm, UACS (postnasal drip from rhinosinus dz), sport-related environment exposure. Consider URI.
• Tests: ✓PFTs w/ bronchoprovocation challenge, airborne allergy eval, environment eval (resp irritants, pollutants, allergens, etc).
• Tx: Consider tx trial directed at most likely cause, in light of particular sport & environment. ✓evolving anti-doping regs if prohibitions relevant.
3 ACCP 2016. Gibson P, et al. Treatment of Unexplained Chronic Cough: CHEST Guideline and Expert Panel Report. Chest. 2016 Jan;149(1):27-44. PubMed® abstract
• Unexplained = >8wk after tests, incl for asthma, eosinophilic bronchitis (sputum eos/FENO)—or inhaled steroid trial; as well as supervised tx trial(s)
• Inhaled steroids target eosinophilic inflammation in rhinitis, asthma, NAEB.
• If less common pulmonary cause suspected: HRCT, bronchoscopy, occupational eval
• If cardiac cause suspected: ECG, Holter, echo, etc
4 ACCP 2020. Cote A, et al. Managing Chronic Cough Due to Asthma and NAEB in Adults and Adolescents: CHEST Guideline and Expert Panel Report. Chest. 2020. Jul;158(1):68-96. PubMed® abstract
• NAEB = corticosteroid-responsive cough in nonsmoker w/ airway eosinophilia but w/o airway hyperresponsiveness.
• Noninvasive airway inflammation markers (blood/sputum eos, FENO) can predict steroid responsiveness (moderate evidence).
5 ERS 2020. Morice AH, et al. ERS Guidelines on the Diagnosis and Treatment of Chronic Cough in Adults and Children. European Respiratory Society. Eur Resp J. 2020. Jan 2;55:1901136. PubMed® abstract
• Chest CT: Don’t do if NL CXR/exam.
• Rhinoscopy can detect polyps, mucus, but not routinely used, since nasal findings aren’t necessarily directly linked with cough.
• Reflux & aspiration. Reflux & aspiration may cause voice change, nasal sx, dysgeusia. Repeated aspiration may cause sx of frequent “chest” infxn, bronchitis—even bronchiectasis. GI tract aspiration causes inflammation that can be eosinophilic or neutrophilic, causing asthmatic cough & mucus secretion.
• Promotility drugs (metoclopramide; domperidone; promotility macrolides eg, azithromycin): insufficient evidence. If chronic bronchitis refractory to other tx, might consider a 1-mo trial of macrolide, in light of antimicrobial stewardship guidance.
• If interstitial lung dz: Antitussives often not effective.
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