History and examination

A thorough occupational history should be sought as work place sensitisers can lead to chronic cough. The same is true of dust/chemical exposure at home.

Physical examination should concentrate on the afferent sites identified as most commonly associated with cough.

Differential Diagnoses

Causes of chronic cough in patients with a normal chest radiograph

• Reflux disease
• Gastro-oesophageal reflux
• Laryngopharyngeal reflux
• Oesophageal dysmotility
• Asthma syndromes
• Cough variant asthma
• Eosinophilic bronchitis
• Rhinosinusitis
• Drug induced cough

Chest x-ray and spirometry are essential in the evaluation of chronic cough.

Chest x-ray and consideration of referral required for the following red flags:

• Haemoptysis
• Shortness of breath
• Fever
• Weight loss
• Pleuritic chest pain or pain not caused by coughing

If chest radiograph or clinical features suggest malignancy refer via 2 week wait service, but not otherwise

Manage red flags according to chest x-ray results

Review medication

• If no other obvious cause for cough and patient is on a drug known to cause cough (e.g. ACE inhibitor) consider changing to an alternative. NB-it can take up to 2 months for improvement in cough symptoms. Review after 8 weeks.

Manage ALL factors considered to be causing the cough SIMULTANEOUSLY – failure to do this often results in a poor or no response

If occupational, household, pet cause likely advise avoidance and review after 1 week. Consider referral to Occupational Health or Secondary Care

Significant sputum production suggests primary pulmonary pathology - consider referral to respiratory medicine

Smoking is one of the commonest causes of persistent cough, which appears to be dose related. To optimise the results from smoking cessation programmes it is advised that patients access motivational support from the Devon NHS Stop Smoking Service (01884 836 024). Review 8 weeks after quitting if still coughing re-consider irritability, reflux, sinusitis if not previously treated

Airway irritability e.g. coughing in relation to changes in air temperature or strong smells. 2 week trial of oral steroids (typically 30mg daily). If improvement - continue inhaled steroids at asthma dose. If no improvement stop treatment if aggravating factors treated simultaneously.

Reflux or meal posture related cough associated cough may occur in the absence of gastrointestinal symptoms. Failure to consider GORD as a cause for cough is a common reason for treatment failure. If symptoms of cough are worse with eating or lying, give 3 months intensive acid suppression with proton pump inhibitors (PPIs) (consider using bd) and alginates and review after 3 months. If improvement continue with maintenance dose therapy.

Review after 3 months if improvement continue maintenance dose therapy Add link to appropriate guideline

Rhinosinusitis is commonly associated with chronic cough. In the presence of prominent upper airway symptoms a trial of nasal topical corticosteroid for at least 3 months is recommended. If there is no response and other aggravating factors have been treated simultaneously, consider trying Montelukast at night for 3 months. If there is no response consider trying an oral antihistamine.

Review after 8 weeks if no improvement stop treatment if aggravating factors treated simultaneously.

Cough variant asthma - management of cough variant asthma should follow asthma guidelines, except at step 3 where there is no evidence for use of a long acting beta agonist. At step 3, evidence exists for the use of leukotriene receptor antagonists.

Cardiac cause - patients with heart disease can develop chronic cough particularly those with left ventricular impairment.

Further investigation or referral after assessing and managing these factors is unlikely to be of benefit unless there are new or changed symptoms.

Referral Criteria

Consider referral for red flag following chest x-ray (see red flag section)

Chest x-ray and spirometry are essential in the evaluation of chronic cough.

Referral Instructions

e-Referral Service:

• Specialty: Respiratory medicine
• Clinic Type: Not Otherwise Specified
• Service: DRSS-South Devon & Torbay-Respiratory Medicine-NHS Devon - 99P

Referral to ENT or Respiratory medicine unlikely to be of benefit unless red flags exist

Referral Forms

DRSS Referral Form

Torbay and South Devon seeking advice form

Evidence

British Thoracic Society (BTS) guideline - Recommendations for the management of cough in adults

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: August 2017