Chronic cough

Overview

Chronic cough is defined as cough persisting for more than eight weeks*. It is a common complaint, thought to affect 5-10% of the adult population and can be notoriously difficult to treat.

For any patient with chronic cough it is imperative to exclude a serious underlying cause, identify any cardio-respiratory disease which may account for symptoms, and once excluded, to consider targeted trials of treatment for asthma related cough, upper airway cough syndrome and/or reflux related cough (see final section on this page for details).

All information is summarised in the accompanying Cough management flow chart (Appendix A).

Chronic cough is significantly detrimental to patients’ quality of life as well as an established socio-economic burden. Quantifying the impact of chronic cough is key to patient engagement, decision making and treatment (Leicester Cough Questionnaire, Appendix B, max score 21, higher scores = better quality of life)

Assessment in Primary Care

This requires a thorough history and examination to determine/assess:
1. Cough duration, triggers, whether it is productive of sputum
2. Presence of red flag symptoms for malignancy including weight loss, haemoptysis, or persistent chest pain
3. Presence chronic cardio-respiratory disease; shortness of breath, bilateral crackles on examination
4. Identification of associated nasal, throat or gastrointestinal symptoms
5. Drug history, in particular the use of angiotensin converting enzyme inhibitors, calcium channel blockers and/or bisphosphonates
6. Occupational history
7. Smoking history

Where appropriate;
- Offer smoking cessation advice
- Lifestyle advice/ weight management in the setting of gastro-oesophageal reflux
- Stop ACE inhibitor/other relevant drugs and consider alternative
- Suggest avoidance of precipitating factors (consider occupation, pets)

Investigations

• Chest X-ray - consider in all patients with chronic cough or with red flags.
• Bloods tests - to include NTproBNP if patient is breathless or other symptoms or signs of heart failure. 
• CT scan chest - if indicated by CXR or normal CXR but respiratory disease still suspected.
• Echocardiogram - if structural heart disease suspected.
• Spirometry - it is recommended that all patients require spirometry (and reversibility if obstructive pattern). However, it is recognised that access to spirometry in primary care may still be difficult as a result of the COVID pandemic so a pragmatic approach can be taken. Clinicians should therefore continue down the flowchart with trials of treatment etc, whilst the patient is awaiting spirometry as soon as that is practically possible for any given practice.

* For patients with cough of < 8 weeks duration, also consider the CKS guidelines on Cough (May 2021)

Who to refer

Referral for patients with abnormal investigations

Where chest X-ray or examination is suggestive of a chronic cardio-respiratory condition, further appropriate investigation such as NTproBNP, high-resolution CT and/or echocardiogram should be considered. Consider onward referral to appropriate speciality in secondary care depending on results. 

Referral for patients for spirometry, if this is not available in primary care

It is recommended that all patients with chronic cough should have spirometry. If this cannot be done in primary care then a referral should be considered.

See Spirometry page for details.on how to refer.

Referral to respiratory clinic

If all the potential causes outlined above have been excluded and/or treated then a diagnosis of chronic refractory cough can confidently be made. This can usually be managed in primary care (see final section on the page for details).

A patient information leaflet is available and should be shared with the patient (Appendix D)

In patients with ongoing symptoms despite primary care management, referral to respiratory secondary care may be considered (please complete Appendix E: Cough referral checklist to submit alongside the eRS referral).

Red Flags

Please see the Lung - USC (2WW) page for advice on management of patients with suspected lung cancer.

See CKS guidelines on Symptoms suggestive of lung and pleural cancers

Before referral

Please see summary document ‘Cough management flow chart’ for advice on investigation management prior to secondary care referral (Appendix A).

If considering referral for chronic refractory cough which has not responded to management in primary care (see guidelines in final  section below), please complete cough referral checklist documentation (Appendix E).

Referral

Respiratory Referral

For chronic refractory cough not responding to managment in primary care,  consider referral to a secondary care respiratory services via eRS.

Please complete the chronic cough referral checklist and include with your referral (Appendix E)

ENT Referral

For patients with dysphonia associated with chronic cough, the UBHW voice service may be considered -  refer to ENT via eRS to access.

Research

Consider referral to Dr Sam Davies (Sam.Davies4@nhs.net), local GP running national cough research studies.

Chronic Refractory Cough

If examination and investigations are normal then most patients can be managed in primary care.

Patient information is available on the NBT website and should be shared with all patients with chronic refractory cough.

The most common causes of chronic cough in the absence of other pathology are;

1. Asthmatic cough syndromes
2. Reflux cough
3. Upper airways cough syndrome

Despite thorough clinical assessment it is not always possible to identify a treatable cause and therefore sequential therapeutic trials should be considered depending on history, examination and investigations.

Asthma cough syndromes

Asthma is a clinical diagnosis. There is no single diagnostic test to diagnose or exclude asthma. Variants include;

1. Classic asthma with airflow variability/reversibility
2. Cough variant asthma
3. Eosinophilic bronchitis

In cough variant asthma and eosinophilic bronchitis, cough may be the only symptom and there may be no airflow variability. These patients may respond to inhaled corticosteroids and markers of eosinophilic inflammation such as blood eosinophils can help to direct therapy.

Cough variant asthma in particular can respond well to leukotriene receptor antagonists such as montelukast in combination with an inhaled corticosteroid.

1. Assess for eosinophilic inflammation by checking blood eosinophils (FBC)
2. Spirometry and bronchodilator reversibility is an essential investigation to identify patients with classic asthma
3. Consider therapeutic trial
• Oral prednisolone 40mg OD for 2 weeks
• OR Low Dose Inhaled corticosteroids (ICS) for 6-8 weeks. Refer to the BNSSG Asthma Guidelines for formulary choice of low dose ICS dry powder or equivalent. 
• AND/OR Leukotriene receptor antagonists (Montelukast 10mg ON) for 4 weeks

Reflux cough

The diagnosis of airway reflux relies on clinical history supported by validated questionnaires such as the Hull Airways Reflux Questionnaire (see Appendix C). A score of >13 indicates a strong likelihood of cough hypersensitivity syndrome; most commonly caused by reflux. Suggestive symptoms include heartburn, distorted sense of taste and nasal symptoms.

Of note, bisphosphonates and calcium channel antagonists may worsen reflux causing increased cough.

1. Complete the Hull Airway reflux questionnaire (Appendix C)
2. If dyspepsia symptoms, then trial proton pump inhibitors eg Omeprazole 20mg bd, with or without trial of Peptac fluid or OTC equivalent for 4 weeks.
3. Stop any medications that might be contributing to symptoms
4. In the absence of symptoms or evidence of acid reflux, anti-acid drugs are unlikely to improve cough outcomes
5. Prokinetics are no longer recommended due to insufficient evidence
6. Consider non-pharmacological measures including weight reduction, avoiding alcohol, spicy foods and caffeine, smoking cessation, propping the head of the bed up.

Upper airways cough syndrome

Rhinosinusitis (inflammation of the nasal and sinus passages) can be either allergic or non-allergic, seasonal (hay fever) or perennial. Upper airway symptoms act as a trigger for cough hypersensitivity. Alternatively, they may merely reflect more generalised airway inflammation due to asthma or airway reflux. There is an absence of evidence for localised treatment.

Suggestive symptoms include sneezing, nasal discharge and nasal obstruction.

1. Consider therapeutic trial - see Rhinosinustitis page.

• Nasal topical corticosteroid BD e.g. beclomethasone 100mcg bd
• AND/OR oral antihistamine for at least 6 weeks e.g. cetirizine 10mg OD
• AND/OR nasal douching g. Neil Med, Sterimar (available a over the counter (OTC) purchase only)

2. Consider ENT referral if red flags or diagnostic uncertainty (see Rhinosinustitis page ).

Chronic refractory cough

Most patients presenting with chronic cough have features of cough reflex hypersensitivity and cough in response to low levels of thermal, chemical or mechanical stimulation as a result of heightened sensitivity of the vagal neuronal pathways mediating cough.

Patient information is available on the NBT website and should be shared with all patients

Resources

Homemade Nasal douch recipe and patient leaflet on how to perform nasal douching: Nasal Irrigation - UH Bristol pt leaflet

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