Dry Cough

Scope

Management and referral guidelines for Persistent (more than 3-6 weeks) dry cough affecting quality of life.

A dry or minimally productive cough is a common reason for referral, but many cases can be managed with few needing complex investigations.

Ask the patient: if they perceive their cough to start in their throat or their chest?
Nocturnal cough, airway sensitivity - commoner in asthma.
Cough after meals, after talking, on bending, shortly after rising - commoner with GORD.
Metallic taste, wheeze after coughing, hoarseness post-cough commoner with GORD.

Common causes of dry cough are:
- Post infected irritability may take 8-10 weeks to resolve.
- Asthma (cough-variant asthma sufferers may have a little wheeze / SOB).
- COPD.
- Reflux (may not be accompanied by dyspepsia / heartburn in non-acid reflux. Of note, there is a higher probability of GORD in patients with BMI greater than 30
- Post-nasal drip (cough stimulus is often referred to the throat).
- Medication e.g. ACE inhibitors (some author say resolution of cough can be months).
- Excessive throat clearing / straining of voice (common in teachers, call centre workers), sometimes referred to as 'vicious circle cough'.
- Occupational exposures may sometimes trigger dry cough.

Unexplained:

CXR and spirometry to exclude significant diagnoses. If abnormal refer accordingly.

If no clear diagnosis an empirical trial of treatment based on clinical suspicion:

A focused history will assist e.g. nocturnal cough, airway sensitivity - commoner in asthma
Cough after meals, after talking, on bending, shortly after rising - commoner with reflux
Metallic taste, wheeze after coughing, hoarseness post-cough commoner with reflux
Our clinical approach reviews the probability of the above common conditions and excludes the rarer with smoking and occupational history, a chest X-ray and spirograph
We then address the most likely condition with an empiric therapeutic trial, sometimes trials of both types of therapy in succession

For possible asthma try an inhaled corticosteroid via spacer with bronchodilator if required (see formulary sections 3.2 Corticoseroids and 3.1 Bronchodilators)
Monitor using peak flow chart and review in 4-6 weeks
Review history for trigger factors including occupational exposures
Formulary asthma guidelines
If no response consider trials of treatment for Gastroesophageal Reflux or Post Nasal Drip

Try a Proton Pump Inhibitor at 18:00 (see 1.3 Antisecretory drugs and mucosal protectants). A pro-motility agent is required in non-acid reflux
Lifestyle advice is also helpful
If no response consider trials of treatment for asthma or post nasal drip

For post nasal drip a trial of nasal steroid +/- topical nasal decongestant spray +/- antihistamine
If no response consider trials of treatment for gastroesophageal reflux or asthma

A free community service to provide early support to patients to maximise the benefits of the medication they have been prescribed.

A free community pharmacy service to help patients use their medications more effectively.

In your referral letter please document the following:
- Smoking history
- History and response to treatments already instigated
- Results of investigations
If cough resistant to above management, consider referral for consultant assessment.