1. 1
to cough management
Introduction
Cough can be an important
defense mechanism to help clear
excessive secretions and foreign
material from airways. But,
cough can also be an important
factor in the spread of infection.
1. Coughing is more often the
result of an involuntary reflex
response to stimulation of
cough receptors in the
airways.
2. An effective cough depends
on the ability to achieve high
gas flows and intrathoracic
pressures, enhancing the
removal of mucus adhering
to the airway wall. A variety
of protussive treatment
modalities may improve
cough mechanics.
3. It is the complications of
cough that lead patients to
seek medical attention.
4. There are two categories of
cough although they are not
mutually exclusive (Grade II-
2, III-3) and they are:
• Acute, lasting less than 3
weeks, [most frequently
due to the common cold
(Grade III)].and
• Chronic, lasting 3 to 8
weeks or longer [often
simultaneously due to
more than one condition
(Grade II-2, II-3), but can
be the sole clinical
manifestation of asthma
and gastroesophageal
reflux disease (GERD)
(Grade II-2). In the
nonsmoking population,
persistent cough is
reported to occur in 14 to
23 % of adults]. Although
in most patients chronic
cough has a single cause,
in up to one fourth of
patients, multiple
disorders contribute to
the cough.
• The most common
causes of chronic cough
in nonsmokers are
postnasal drip syndrome
(PNDS), asthma, and/or
GERD (Grade II-2, II-3),
whether or not the cough
is described as dry or
productive (Grade II-2).
PNDS, asthma, and/or
GERD are likely to be
causes(s) of chronic
cough in approximately
100% of the nonsmokers
who are not taking
angiotensin-converting
enzyme inhibitor (ACEI)
drugs and who have
normal or nearly normal
chest radiographs
showing no more than
stable inconsequential
scars (Grade II-2).
5. PNDS, either singly or in
combination with other
conditions, is the single most
common cause of chronic
cough for which patients seek
medical attention (Grade II-Approach
Foreword
There has been a rapidly
increasing volume of
research undertaken in
the field of acute and
chronic cough at both
basic scientific and
clinical levels. All this
leads the clinicians to
handle cough not only as
a defensive symptom
but also to treat it as a
disturbance. However,
no approach is going to
ensure the successful
management of cough
unless the approach is
scientific and sturctured.
Here is an approach to
assist the clinicians in
that direction.
Dr. B. K. Iyer
Consulting editor
Shelys Pharmaceuticals

2. 2
2). The symptoms and signs
of PNDS are nonspecific
(Grade II-2); therefore, a
definitive diagnosis of
PNDS-induced cough
cannot be made from history
and physical examination
alone. An approach to cough
management bearing in minf
the therapy for PNDS is a
crucial step in cough
management. The
combination of a first-generation
antihistamine
and a decongestant is
considered to be the most
consistently effective sole
form of therapy in treating
most patients with PNDS-induced
cough not due to
sinusitis (Grade II-2). Newer
generation, relatively
nonsedating antihistamines
are not as effective as first-generation
antihistamines in
treating PNDS secondary to
nonallergic conditions.
6. Asthma is a common cause
of chronic cough. A
diagnosis of cough-variant
asthma is suggested by the
presence of airway hyper-responsiveness,
and
confirmed only when the
cough resolves with asthma
medications.
7. GERD can cause cough by
aspiration, but it most likely
causes chronic cough in
patients with normal
radiographs by a vagally
mediated reflex mechanism
(Grade II, II-2). When
GERD is the cause of
chronic cough, GI symptoms
are often absent (Grade II-2).
When 24-h esophageal pH
monitoring cannot be done
for the precise diagnosis, an
empiric trial of antireflux
medication is appropriate
when GERD is suspected as
a cause of cough. Treatment
should also include diet and
lifestyle changes in addition
to drugs. Cough due to
GERD has been reported to
resolve with medical therapy
in 70 to 100% of patients;
mean time to recovery may
take as long as 169 to 179
days (Grade II-2).
8. Cough is a principal feature
of chronic bronchitis (CB)
and its treatment should
chiefly be directed to
reduction of sputum
production and airway
inflammation (eg, by
smoking cessation and
removal of environmental
irritants) (Grade II-2).
Ipratropium can decrease
sputum production and
cough (Grade I). Nonspecific
cough suppressants should
be avoided, and mucolytics
are of uncertain benefit.
Although the effectiveness of
systemic corticosteroids and
antibiotics on cough have not
been specifically studied,
they are likely to be helpful
in decreasing cough during
exacerbations of COPD
(Grade III).
9. Bronchiectasis is a cause of
chronic cough in a relatively
small number of patients; the
diagnosis is established by
clinical history, chest
radiograph, high-resolution
CT scan of the thorax, and
cough disappearance with
specific approaches
including physiotherapy,
drugs to stimulate
mucociliary clearance, and
systemic antibiotics (Grade
II-2).
10. Postinfectious cough is a
diagnosis of exclusion; it
should be considered when
a patient complains only of
cough after a respiratory tract
infection and has a normal
chest radiograph.
Postinfectious cough
ultimately resolves over time
but can be controlled by
cough preparations and
maybe, antibacterials, if
needed. Another important
aspect to bear in mind is
eosinophilic bronchitis
developing due to allergy, in
which case therapy has to be
more clearly specific. It
would make sense to note
that worm infestation gives
rise to eosinophilia which in
turn gives rise to cough.
11. Coughs that develop for the
first time and last for months
in susceptible groups are
suggestive of bronchogenic
carcinoma. Present or prior
cigarette smoking or
occupational exposures
increase the risk.
12. Cough due to ACEIs is a
class effect of these drugs
and is not dose-related. The
cough is typically
nonproductive and is
associated with an irritating,
tickling, or scratchy
sensation in the throat. ACEI

3. 3
induced cough may appear
hours to weeks or months
after ACEI is started (Grade
II). Cough due to ACEIs will
disappear or substantially
improve within 4 weeks of
discontinuing the drug
(Grade I). Definitive
treatment of ACEI-induced
cough is discontinuation of
the drug.
13. Habit cough and
psychogenic cough are
diagnoses of exclusion
(Grade III).
14. Chronic interstitial lung
disease is an uncommon
cause of cough. However,
the most common causes of
chronic cough should be
investigated before
antitussives are prescribed
(Grade III).
15. In children, asthma, URTI &
LRTI, and GERD are the
most common causes of
acute and chronic cough.
Less common causes of
cough in children are
congenital anomalies,
aspiration and environmental
exposures. The approach to
managing chronic cough in
children is similar to the
approach in adults (Grade
III). A chest radiograph
should be obtained in nearly
all children with chronic
cough to rule out lower
respiratory tract and cardiac
pathology (Grade III). The
recommended diagnostic
approach to cough in
children is history, physical
examination, and
determination of a most
likely etiology (Grade III).
16. Pharmacologic treatment of
cough is either:
• (a) antitussive, to
prevent, control, or
eliminate cough, or
• (b) protussive, to make
cough more effective.
Antitussives
Antitussive therapy is indicated
when cough serves no useful
function such as clearing the
airways. Specific antitussive
therapy is directed at the etiology
or mechanism causing cough (eg.
cigarette smoking, postnasal
drip). Nonspecific antitussive
therapy is directed at the
symptom rather than the etiology
or mechanism. Because of the
high probability of being able to
determine the causes of cough
and prescribe specific treatment
that can be successful, there is a
limited role for nonspecific
antitussive treatment (Grade II-
2, II-3). It is indicated (Grade III)
when specific therapy has not
had a chance to work or will not
work (eg. inoperable lung
cancer).
Protussives
Protussive therapy is indicated
when cough performs a useful
function and needs to be
encouraged (eg. in
bronchiectasis, CF). Hypertonic
saline in CF appears promising.
An Empiric Treatment
Algorithm
STEP ONE
For first 1 week, adopt empiric
treatment for postnasal drip using
an older-generation
antihistamine-decongestant
combination. If bacterial
infection is identified, the patient
should be treated with an empiric
trial of antibiotics such as
amoxicillin-clavulanate
potassium or azithromycin, or a
second- or third-generation oral
cephalosporin. When all of these
measures fail, the patient may
require aspiration or irrigation of
the sinuses.
STEP TWO
Patients who continue to cough
despite the treatments in step 1
should be evaluated for asthma.
Physicians should bear in mind
that patients with asthma may
present with only a chronic, non
productive cough termed
“cough-variant asthma.”
Objective evaluation by
spirometry must be done. A
reduced peak expiratory flow rate
and a reduced ratio of forced
expiratory volume in one second
(FEV1) to forced vital capacity
(FVC) is diagnostic of
obstructive lung disease.
Following bronchodilator
therapy, an increase of at least 15
percent in the FEV1 may be
expected in the patient with
asthma. Patients diagnosed with
asthma should be treated
prophylactically with inhaled
cromolyn sodium, and with beta-agonist
and/or steroid inhalers
and oral corticosteroids, as
required.
STEP THREE
Chest and sinus radiographs
should be performed at this stage,
if they are not already done. Any
clinically significant abnormality

4. should be evaluated and treated.
STEP FOUR
Patients in whom a diagnosis has
not been reached by this time and
who remain symptomatic should
be given an empiric gastric-acid
suppression test, along with
antireflux measures for treatment
of possible GERD. Patients who
respond to this empiric therapy
should receive aggressive
therapy with a proton-pump
inhibitor for at least 8 weeks.
STEP FIVE
Patients who still continue to
cough at this stage should receive
bronchoscopic examination. If
this procedure does not produce
a diagnosis, a repeat course of
antiasthmatic therapy with a beta
agonist and steroids should be
tried.
STEP SIX
If cough still persists, the
physician should institute a
careful search for less common
causes but it would be unusual
for cough to be the only
presenting symptom in patients
with serious underlying disease.
Patients with lung cancer,
4
interstitial lung disease, chronic
lung infections or aneurysm
could be expected to be identified
by chest radiographs &/or
bronchoscopy. A CT scan of the
chest would be appropriate in
these patients, and lymph-node
biopsy may be necessary in
diagnosing sarcoidosis or
bronchogenic carcinoma. In the
absence of clinical signs of
congestive heart failure, two-dimensional
echocardiography
may aid in diagnosis.
Any child who coughs and has a
history of recurrent pneumonia
and/or failure to thrive should
have a sweat chloride test for
cystic fibrosis. Finally,
immunosuppression caused by
HIV infection and opportunistic
chest infection must be
suspected.
If all of this evaluation and
treatment fails, a careful history
should be repeated, with
emphasis on occupational or
home exposure to an airway
irritant. If no pathology can be
found, psychogenic cough must
be considered.
REFERENCES
1. Braunwald E. Cough and hemoptysis. In:
Harrison’s Principles of internal medicine. 13th
ed. New York: McGraw-Hill, 1994:171-8.
2. CHEST, VOLUME 114 / NUMBER 2 /
AUGUST, 1998 Supplement by Richard S.
Irwin, et al;
3. Zervanos NJ, Shute KM.Acute,disruptive
cough:symptomatic therapy for a nagging
problem.Post Graduate Med 1994;95(2):153-
168
4. Irwin RS, Corrao WM, Pratter MR. Chronic
persistent cough in the adult: the spectrum and
frequency of causes and successful outcome
of specific therapy. Am Rev Respir Dis
1981;123(4 Pt 1):413-7.
5. Braman SS, Corrao WM. Chronic cough.
Diagnosis and treatment. Prim Care
1985;12:217-25.
6. Braman SS, Corrao WM. Cough: differential
diagnosis and treatment. Clin Chest Med
1987;8:177-88.
7. Pratter MR, Bartter T, Akers S, DuBois J. An
algorithmic approach to chronic cough. Ann
Produced and presented as a free medical
service to the medical profession
Intern Med 1993;119:977-83.
8. Bucca C, Rolla G, Brussino L, De Rose V,
Bugiani M. Are asthma-like symptoms due to
bronchial or extrathoracic airway dysfunction?
Lancet 1995;346: 791-5.
9. Israili ZH, Hall WD. Cough and angioneurotic
edema associated with angiotensin-converting
enzyme inhibitor therapy. A review of the
literature and pathophysiology. Ann Intern Med
1992; 117:234-42.
10. Empey DW, Laitinen LA, Jacobs L, Gold WM,
Nadel JA. Mechanisms of bronchial
hyperreactivity in normal subjects after upper
respiratory tract infection. Am Rev Respir Dis
1976;113:131-9.
11. Standards for the diagnosis and care of patients
with chronic obstructive pulmonary disease
(COPD) and asthma. This official statement of
the American Thoracic Society was adopted
by the ATS Board of Directors, November 1986.
Am Rev Respir Dis 1987;136:225-44.
12. Definition and classification of chronic bronchitis
for clinical and epidemiological purposes. A
report to the Medical Research Council by their
Committee on the Aetiology of Chronic
Bronchitis. Lancet 1965;1(389):775-8.
13. Irwin RS, Curley FJ. The treatment of cough. A
comprehensive review. Chest 199l;99:1477-84.
14. Irwin RS, Curley FJ, Bennett FM. Appropriate
use of antitussives and protussives. A practical
review. Drugs 1993;46:80-91.
15. Ingram RH. Chronic bronchitis, emphysema
and airways obstruction. In: Harrison’s
Principles of internal medicine. 13th ed. New
York: McGraw-Hill, 1994:1197-205.
16. Irwin RS, Pratter MR, Holland PS, Corwin RW,
Hughes JP. Postnasal drip causes cough and
is associated with reversible upper airway
obstruction. Chest 1984;85(3):346-52.
17. Irwin RS, Curley FJ, French CL. Chronic cough.
The spectrum and frequency of causes, key
components of the diagnostic evaluation, and
outcome of specific therapy. Am Rev Respir
Dis 1990;141:640-7.
18. Irwin RS, French CL, Curley FJ, et al. Chronic
cough due to gastroesophageal reflux. Chest
1993;104(5): 1511-17.
19. Schindlbeck NE, Heinrich C, Konig A,
Dendorfer A, Pace F, Muller-Lissner SA.
Optimal thresholds, sensitivity, and specificity
of long-term pH-metry for the detection of
gastroesophageal reflux disease.
Gastroenterology 1987;93:85-90.
20. Corrao WM, Braman SS, Irwin RS. Chronic
cough as the sole presenting manifestation of
bronchial asthma. NEJM, 1979;300:633-7.
Produced and presented by Shelys Pharmaceuticals, New Bagomoyo road, P.O.Box 3016, Dar es
Salaam, Tanzania and edited on their behalf by Dr. B. K. Iyer, Consulting clinical co-ordinator