One-liner#

Evaluate chronic cough (>8 weeks) systematically, addressing the “big three” causes (upper airway cough syndrome, asthma, GERD) which account for >90% of cases in non-smokers with normal CXR, while identifying red flags requiring further workup.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Hemoptysis (more than blood-streaked sputum)
• Respiratory distress: SpO₂ <92%, severe dyspnea, accessory muscle use
• Stridor or signs of upper airway obstruction
• Massive weight loss with cough (malignancy concern)

Key history#

Cough characteristics:

• Duration: confirm >8 weeks (3–8 weeks = subacute, often post-infectious)
• Productive vs dry: productive suggests bronchiectasis, chronic bronchitis; dry suggests UACS, asthma, GERD, ACE-I
• Timing: nocturnal (asthma, GERD, HF), upon waking (bronchiectasis, chronic bronchitis), postprandial (GERD)
• Triggers: cold air, exercise, allergens (asthma); eating, lying down (GERD); talking, laughing (UACS)

The “Big Three” clues:

Associated symptoms:

• Dyspnea: COPD, ILD, HF, asthma
• Wheezing: asthma, COPD
• Heartburn/regurgitation: GERD
• Nasal symptoms: UACS (allergic or non-allergic rhinitis, chronic sinusitis)
• Weight loss: malignancy, TB, ILD
• Hemoptysis: bronchiectasis, malignancy, TB
• Purulent sputum daily: bronchiectasis, chronic bronchitis

Smoking history:

• Current/former smoker: chronic bronchitis, COPD, lung cancer
• Pack-years: quantify (>20 pack-years = significant lung cancer risk)
• Smoking cessation is THE most important intervention for smoker’s cough

Medication review:

• ACE inhibitors: cause cough in 5–20%; can occur months after starting; must stop to evaluate
• Other medications: rarely, ARBs, beta-blockers (in asthmatics)

Occupational/environmental:

• Occupational exposures: asbestos, silica, coal (ILD, malignancy)
• Environmental allergens: dust, mold, pets
• Irritants: smoke, fumes, pollution

Red flag symptoms:

• Hemoptysis
• Unintentional weight loss (>5% in 6 months)
• Night sweats, fever
• Dyspnea at rest or progressive
• Hoarseness (laryngeal involvement)
• Dysphagia

Focused exam#

• Vitals: SpO₂ (hypoxia suggests parenchymal disease), respiratory rate
• General: cachexia (malignancy), clubbing (bronchiectasis, ILD, lung cancer)
• HEENT: nasal mucosa (pale/boggy = allergic; erythematous = infectious), post-nasal drip, cobblestoning of posterior pharynx, sinus tenderness
• Neck: lymphadenopathy (malignancy, infection), thyromegaly (goiter compressing trachea)
• Lungs: wheezes (asthma, COPD), crackles (ILD, bronchiectasis, HF), rhonchi (secretions), decreased breath sounds
• Cardiac: S3, JVD, edema (HF)
• Extremities: clubbing, edema

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Initial workup for all patients with chronic cough:

1. CXR: Rule out mass, infiltrate, ILD, cardiomegaly
2. Stop ACE inhibitor: If on one, switch to ARB and reassess in 4 weeks
3. Smoking cessation: If smoker, this is the intervention; reassess after 4–8 weeks of abstinence

If CXR normal and not on ACE-I:

Empiric sequential therapy is appropriate before extensive testing (ACCP guidelines):

Step 1: Treat for UACS
  → Nasal steroid + 1st-gen antihistamine x 2–4 weeks
  
Step 2: If no response, add treatment for asthma
  → ICS (± SABA) x 6–8 weeks
  
Step 3: If no response, add treatment for GERD
  → PPI BID x 8 weeks + lifestyle modifications
  
Step 4: If no response to empiric therapy → further workup

Further workup if empiric therapy fails:

When NOT to order extensive workup:

• Before empiric therapy trial (unless red flags present)
• CXR for every chronic cough (do it once, not repeatedly unless new symptoms)
• CT chest as first-line (CXR first unless high suspicion for malignancy)

Initial management#

Systematic approach:

1. Address modifiable factors first:

   • Stop ACE inhibitor (switch to ARB)
   • Smoking cessation
   • Remove environmental irritants

2. Empiric therapy for the “Big Three”:

   • Can treat sequentially (one at a time) or in parallel (all three simultaneously)
   • Sequential approach: add next treatment if no response in 2–4 weeks
   • Parallel approach: faster but harder to identify which treatment worked

3. Duration of empiric trials:

   • UACS: 2–4 weeks
   • Asthma: 6–8 weeks (may take longer for full response)
   • GERD: 8 weeks minimum (reflux cough slow to respond)

4. Reassess and refer if no response:

   • If no improvement after addressing all three causes → pulmonology referral
   • Consider unexplained chronic cough (refractory cough, cough hypersensitivity syndrome)

Common scenarios:

Patient already on daily PPI:

• Daily PPI is often insufficient for reflux cough
• Increase to BID dosing (before breakfast AND before dinner) for full 8-week trial
• Ensure lifestyle modifications are in place

Patient already on nasal steroid:

• Add first-generation antihistamine (chlorpheniramine) for anticholinergic/drying effect
• Consider adding ipratropium nasal if rhinorrhea prominent
• Ensure proper nasal spray technique

Multiple causes (common!):

• Up to 25% of chronic cough has multiple contributing causes
• If partial response to one treatment, continue it and add treatment for next cause
• May need to treat all three simultaneously for full resolution

When to get spirometry:

• Before starting empiric asthma treatment if diagnosis uncertain
• If no response to empiric ICS trial (to confirm/exclude asthma)
• Smoker with chronic cough (to diagnose COPD)
• Do NOT delay empiric treatment waiting for spirometry if asthma clinically likely

Management by diagnosis#

Upper Airway Cough Syndrome (UACS)#

Education:

• Post-nasal drip from allergic or non-allergic rhinitis, chronic sinusitis
• Mucus dripping down throat triggers cough reflex
• May take 2–4 weeks of treatment to see improvement

Treatment:

Allergic rhinitis:

Non-allergic rhinitis:

Chronic sinusitis:

• Nasal saline irrigation (neti pot, squeeze bottle)
• Nasal steroids
• If bacterial sinusitis suspected: antibiotics per acute sinusitis guidelines
• Refractory cases: ENT referral for possible surgery

Follow-up: Reassess in 2–4 weeks. If no improvement, add empiric asthma treatment.

Cough-Variant Asthma#

Education:

• Asthma presenting primarily with cough rather than wheezing
• Cough is often nocturnal or triggered by exercise, cold air, allergens
• May have normal spirometry; diagnosis often made by response to treatment

Treatment:

Diagnosis confirmation:

• Response to ICS within 6–8 weeks supports diagnosis
• If uncertain: spirometry with bronchodilator response, or methacholine challenge

Follow-up: Reassess in 6–8 weeks. If good response, continue ICS and step down after 3 months of control. If no response, add GERD treatment.

GERD-Related Cough#

Education:

• Acid reflux can trigger cough even without classic heartburn (“silent reflux”)
• Mechanism: direct aspiration of acid OR vagal reflex from esophageal acid exposure
• Slow to respond—may take 2–3 months of treatment
• Lifestyle modifications are essential

Treatment:

Lifestyle modifications (all patients):

• Elevate head of bed 6–8 inches (blocks under bedposts, not just pillows)
• Avoid eating within 3 hours of bedtime
• Weight loss if overweight
• Avoid triggers: caffeine, alcohol, chocolate, fatty foods, acidic foods
• Smoking cessation

Pharmacotherapy:

Duration: Minimum 8 weeks of BID PPI; some patients need 3 months.

If no response to PPI:

• Confirm compliance and BID dosing
• Consider 24-hour pH monitoring to confirm diagnosis
• GI referral for refractory cases or consideration of anti-reflux surgery

Follow-up: Reassess in 8 weeks. If improved, can attempt to taper to daily PPI. If no improvement, consider further workup or pulmonology referral.

ACE Inhibitor Cough#

Education:

• Occurs in 5–20% of patients on ACE inhibitors
• Dry, tickling, persistent cough
• Can develop weeks to months after starting medication
• Resolves 1–4 weeks after stopping (occasionally up to 3 months)

Treatment:

• Stop ACE inhibitor
• Switch to ARB (cross-reactivity <1%)
• If ACE inhibitor strongly indicated (HF with reduced EF, post-MI, diabetic nephropathy), discuss risk/benefit; some patients tolerate cough

Follow-up: Reassess cough 4 weeks after stopping ACE-I. If cough persists, evaluate for other causes.

Chronic Bronchitis / COPD#

Education:

• Chronic bronchitis: productive cough most days for ≥3 months/year for ≥2 consecutive years
• Usually due to smoking; smoking cessation is THE most important intervention
• COPD is diagnosed by spirometry (FEV1/FVC <0.70 post-bronchodilator)

Treatment:

Smoking cessation (most important):

COPD maintenance therapy (if spirometry confirms):

• See COPD management guidelines
• LAMA (tiotropium) or LABA as initial maintenance
• ICS added if frequent exacerbations and eosinophils elevated

Follow-up: Reassess cough 4–8 weeks after smoking cessation. Spirometry to assess for COPD. Pulmonology referral if moderate-severe COPD.

Bronchiectasis#

Education:

• Permanent dilation of bronchi with impaired mucus clearance
• Causes: prior severe infection, cystic fibrosis, immunodeficiency, autoimmune disease
• Daily productive cough with recurrent respiratory infections
• Requires HRCT for diagnosis

Treatment:

• Airway clearance: chest physiotherapy, flutter valve, postural drainage
• Mucolytics: hypertonic saline nebulizer, guaifenesin
• Treat exacerbations: antibiotics based on sputum culture (Pseudomonas common)
• Pulmonology referral: for management, workup for underlying cause, consideration of chronic suppressive antibiotics

Follow-up: Pulmonology co-management. Monitor for exacerbations. Vaccinations (influenza, pneumococcal) important.

Unexplained Chronic Cough / Cough Hypersensitivity Syndrome#

Education:

• Chronic cough persisting despite treatment of UACS, asthma, and GERD
• May represent heightened cough reflex sensitivity
• Often triggered by talking, laughing, strong odors, temperature changes
• Predominantly affects middle-aged women

Treatment:

• Speech therapy: cough suppression techniques; often first-line
• Neuromodulators: gabapentin, pregabalin, amitriptyline (off-label)
• Pulmonology referral: for confirmation of diagnosis and management

Follow-up: Pulmonology referral recommended. Trial of neuromodulator for 4–8 weeks before assessing efficacy.

Follow-up#

Default intervals:

• Empiric UACS treatment: reassess in 2–4 weeks
• Empiric asthma treatment: reassess in 6–8 weeks
• Empiric GERD treatment: reassess in 8 weeks
• ACE-I cough: reassess 4 weeks after stopping

Referral thresholds:

• No response to empiric therapy for all three common causes → pulmonology
• Abnormal CXR or CT → pulmonology or oncology as appropriate
• Suspected ILD → pulmonology
• Suspected bronchiectasis → pulmonology
• Hemoptysis with normal imaging → pulmonology for bronchoscopy consideration

Return precautions:

• Coughing up blood (more than streaks)
• Worsening shortness of breath
• Unintentional weight loss
• Fever, night sweats
• Cough significantly worsening despite treatment

Patient instructions#

• Chronic cough (lasting more than 8 weeks) usually has a treatable cause. The most common causes are post-nasal drip, asthma, and acid reflux.
• Finding the right treatment may take time. Each treatment trial needs several weeks to work, so please be patient.
• If you smoke, quitting is the single most important thing you can do for your cough and overall health.
• If you take a blood pressure medication called an ACE inhibitor (lisinopril, enalapril, etc.), it may be causing your cough. We may need to switch you to a different medication.
• Take all medications as prescribed, even if you don’t notice immediate improvement.
• For acid reflux: avoid eating within 3 hours of bedtime, elevate the head of your bed, and avoid trigger foods.
• Call the office if you cough up blood, have worsening shortness of breath, or notice unintentional weight loss.

Smartphrase snippets#

.COUGHCHRONICWORKUP Chronic cough >8 weeks. CXR [normal/shows X]. Not on ACE inhibitor [or: ACE inhibitor stopped, switched to ARB]. Starting empiric treatment for [UACS with nasal steroid + antihistamine / asthma with ICS / GERD with PPI BID]. Will reassess in [2–4 / 6–8 / 8] weeks. Discussed that finding the cause may require sequential treatment trials. Return precautions reviewed.

.COUGHCHRONICUACS Chronic cough likely due to upper airway cough syndrome (post-nasal drip). Started fluticasone nasal spray + [cetirizine/loratadine]. Advised nasal saline irrigation. Will reassess in 2–4 weeks. If no improvement, will add empiric asthma treatment.

.COUGHCHRONICREFRACTORY Chronic cough refractory to empiric treatment for UACS, asthma, and GERD. CXR normal. Referring to pulmonology for further evaluation including consideration of methacholine challenge, HRCT, and/or evaluation for cough hypersensitivity syndrome.

Related pages#

• Cough (Acute) — evaluation of cough <3 weeks
• Dyspnea (Chronic) — chronic shortness of breath differential
• Wheeze — wheezing-focused evaluation
• Asthma (problem) — chronic asthma management
• COPD (problem) — chronic COPD management
• GERD (problem) — chronic GERD management (coming soon)
• Heart Failure (problem) — HF management when cough is due to pulmonary congestion