Cough Assessment and Management
Cough should be triaged by acuity, symptom duration, and presence of red-flag features that suggest serious disease. Chronic cough requires a systematic, protocol-based evaluation for common treatable conditions before labeling cough as unexplained. [1][2]
Initial Triage and Risk Stratification
Acute cough is typically defined as lasting ≤3 weeks and is usually self-limiting and due to viral infection. [2] Chronic cough is typically defined as lasting >8 weeks. [2] Immediate escalation is indicated when serious pathology is suspected. [2] A chest radiograph and further evaluation should not be deferred when there is any concern for serious disease. [2]
Focused History and Physical Examination
History should target obvious etiologies for chronic cough, including airway disease, upper-airway disease, reflux symptoms, medication exposure, smoking exposure, and other comorbidities. [2] Risk assessment should include identification of chronic cough “treatable traits” that guide phenotype-directed treatment selection. [2] A systematic approach to chronic cough assessment in primary care and secondary care should be used. [2]
Acute Cough Management (≤3 Weeks)
Antibiotics should not be offered for acute cough associated with an upper respiratory tract infection when the person is not systemically very unwell and is not at higher risk of complications. [1] Routine bronchodilator or corticosteroid treatment should not be offered for acute cough associated with an upper respiratory tract infection or acute bronchitis unless an underlying airways disease is present. [1] Mucolytics should not be offered to treat acute cough associated with an upper respiratory tract infection or acute bronchitis. [1] For people identified as systemically very unwell, an immediate antibiotic prescription should be offered. [1] For people identified as being at higher risk of complications, immediate or back-up antibiotic prescribing should be considered. [1]
Chronic Cough Management (>8 Weeks)
Unexplained chronic cough should be diagnosed only after cough persists >8 weeks with no etiology identified after evaluation and supervised therapeutic trial(s) consistent with published best-practice guidance. [3] Adults with unexplained chronic cough should undergo guideline/protocol-based assessment, including objective testing for bronchial hyperresponsiveness and eosinophilic bronchitis, or a therapeutic corticosteroid trial. [3] Multimodality speech pathology therapy is recommended for adults with unexplained chronic cough. [3] A trial of gabapentin is recommended for adults with unexplained chronic cough with reassessment at 6 months. [3] Inhaled corticosteroids should not be used in patients with unexplained chronic cough with negative testing for bronchial hyperresponsiveness and eosinophilia. [3] Proton pump inhibitors should not be used when the workup for acid reflux disease is negative. [3]
Medication Selection Algorithm for Chronic Cough
Phenotype-directed treatment should be based on identified treatable traits that include asthma/COPD-related mechanisms, eosinophilic airway inflammation, reflux-associated phenotypes supported by appropriate evidence, and upper airway disorders. [2] When inflammatory or bronchial hyperresponsiveness traits are not supported by testing, inhaled corticosteroids should be avoided for unexplained chronic cough. [3] When reflux testing does not support acid reflux disease, proton pump inhibitors should be avoided. [3] When unexplained chronic cough is confirmed, multimodality speech pathology therapy and gabapentin constitute recommended treatment options. [3]
Treatment Initiation Thresholds and Referral Triggers
Chronic cough should be managed using a systematic assessment pathway in primary care and referral to secondary care when indicated by red-flag features or lack of response to appropriate evaluation and management steps. [2] Unexplained chronic cough should be diagnosed only after a full evaluation and supervised therapeutic trials and only when cough persists beyond 8 weeks with no identified etiology. [3] Acute cough antibiotic treatment decisions should be based on severity and complication risk categories rather than cough duration alone. [1]
Common Pitfalls to Avoid
Blinded treatment of suspected causes without indication leads to ineffective care in many patients. [2] A substantial proportion of patients with chronic cough (reported 30%–40%) do not improve after treating comorbidities or when no obvious comorbidity is present. [2] Prescribing proton pump inhibitors in the absence of heartburn symptoms is commonly performed yet ineffective according to randomized trial evidence summarized in the BTS statement. [2] Antibiotics should not be used as routine symptomatic treatment for acute bronchitis or uncomplicated upper respiratory tract infection cough due to minimal impact on symptom duration and potential adverse effects. [1]
Treatment Goals
Acute cough management should focus on symptom support and limiting unnecessary antibiotic exposure. [1] Chronic cough management should focus on identifying treatable traits, applying phenotype-directed therapy, and using evidence-based therapies for unexplained chronic cough when diagnostic evaluation does not identify an etiology. [2][3]