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.

Assessment

History Pointers
  • 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.
Signs and Symptoms
  • 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.
  • Rare but important
    • Lung cancer.
    • Pulmonary fibrosis.
  • Rare
    • Inhaled foreign body, auricular pathology, tonsils.

Red Flags

Unexplained:

  • Chest pains
  • Haemoptysis
  • Weight loss
  • Clubbing
  • Smoking

Investigations

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

Management

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
Asthma
  • 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
Gastroesophageal Reflux
  • 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
Post Nasal Drip
Local administrative info

New Medicines Service ("NMS")

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.

Referral

Referral Criteria

  • 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.

Referral Instruction

To refer to secondary care

e-Referral Service Selection

  • Specialty: Respiratory
  • Clinic Type: Not otherwise specified
  • Service: DRSS-Western-Respiratory Medicine-Devon CCG-15N

Referral Forms

DRSS referral form

Supporting Information

Patient Information

British Lung Foundation

Asthma UK

Primary Care Respiratory Society

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group.

Publication date: 5 February 2016

Last updated: 12-11-2020

 

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