Key issues in the history include triggers for onset of cough, determinants of increased or decreased cough, and sputum production. Symptoms of nasopharyngeal disease should be assessed, including postnasal drip, sneezing, and rhinorrhea. GERD may be suggested by heartburn, hoarseness, and frequent eructation. Cough-variant asthma is suggested by noting the relationship of cough onset to asthmatic triggers. Usage of ACE inhibitors, but not angiotensin receptor blockers, can cause cough long after treatment is initiated.
On physical examination, signs of cardiopulmonary diseases should be assessed, including adventitious lung sounds and digital clubbing. Examination of the nasal passages, posterior pharyngeal wall, auditory canals, and tympanic membranes should be performed.
Laboratory evaluation should include chest radiography. Spirometry with bronchodilator testing can assess for reversible airflow obstruction. With normal spirometry, methacholine challenge testing can be used to assess for asthma. Purulent sputum should be sent for routine bacterial and possibly mycobacterial cultures. Sputum cytology can reveal malignant cells in lung cancer and eosinophils in eosinophilic bronchitis. Esophageal pH probes or radiotransmitter capsules can be used to assess for GERD. Chest CT should be considered in pts with normal chest radiographs who fail to improve with treatment. Evaluation of hemoptysis is discussed below.
Treatment: Chronic Cough In pts with chronic cough and a normal chest x-ray, empiric treatment is directed at the most likely cause based on the history and physical examination. If treatment directed at one empiric cause fails, empiric treatment of an alternative etiology can be considered. Postnasal drip treatment may include antihistamines, nasal corticosteroids, anticholinergics, and/or antibiotics. GERD can be treated with antacids, type 2 histamine blockers, or proton pump inhibitors. Cough-variant asthma is treated with inhaled glucocorticoids and as-needed inhaled β agonists. Pts on ACE inhibitors should be given a 1-month trial of discontinuing this medication. Chronic eosinophilic bronchitis often improves with inhaled glucocorticoid treatment. Symptomatic treatment of cough can include narcotics such as codeine; however, somnolence, constipation, and addiction can result. Dextromethorphan and benzonatate have fewer side effects but reduced efficacy. |
Section 3. Common Patient Presentations