Conditions: Chronic Cough

What is a chronic cough?

What is the difference between a productive cough and a non-productive cough?

Essentially, a productive cough is when material, such as mucus, comes up with the cough. To be a productive cough, the amount of material would be enough to feel the material in the throat and enough that it could be spit out and have a bulk to it. A non-productive cough is the opposite—a cough that does not generate mucus or material in the throat. The sound of a productive cough is also distinct from that of a non-productive cough. Knowing the difference between a productive and a non-productive cough is useful in determining the cause of the cough.

What causes a chronic cough?

There are many potential causes of a chronic cough, with danger ranging from minimal to high. The following considerations are useful in evaluating and treating a chronic cough.

What are the “red flags” of a chronic cough?

“Red flags,” or suggestions of a dangerous process involving chronic cough include the following:

• Stridor (a high pitch noise with breathing due to air flowing through a narrow passage)

• Dyspnea (shortness of breath), cyanosis (blue or purple discoloration of the skin, especially in fingers or toes)

• Fever higher than 101.5 degrees F or 38.5 degrees C

• Hemoptysis (coughing up blood)

• New significant change in oxygen saturation

• Dysphagia (difficulty swallowing)

• Night sweats (drenching pajamas or sheets), unintentional weight loss

• Tachycardia (a rapid heart rate)

• Severe immunocompromise

Immediate medical attention is typically recommended when one or more of these is present.

Relevant History

Symptoms

• How long has the cough been present?

• Is the cough getting better or worse over time?

• Is the patient experiencing more than usual shortness of breath during physical exertion?

• Pain: Chest, head, throat

• Reflux symptoms (especially heartburn, frequent throat clearing, regurgitation, post-nasal drip sensation)

• Hypersensitivity: fragrances, cold

• Voice changes

• Cough while lying down or eating/drinking

• Is the cough productive or non-productive

Past Medical History:

• Previous infections

• Chronic diseases: bronchitis/ COPD, asthma, sinusitis

• Allergies

• Reflux (gastroesophageal reflux or laryngopharyngeal reflux)

• Heart disease

• History of surgery or use of a ventilatorwith use of a breathing tube (intubation)

• Pre-existing neurological conditions: aspiration possible?

Exposures:

• Smoking of tobacco/cannabis/vaping/other

• Occupational toxins

• Animal contact

• Infections among close contacts

• History of migration and travel

Drugs:

• Cough-triggering: A chronic cough may be induced by any of these medications at any time, even if one has tolerated a particular medication for months or years prior to developing a cough.

  • ACE inhibitors: [benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), lisinopril (Prinivil, Zestril), moexipril (Univasc), perindopril (Aceon), quinapril (Accupril), ramipril (Altace), and trandolapril (Mavik)]

  • ARB’s: [Azilsartan (Edarbi), Candesartan (Atacand), Irbesartan (Avapro), Losartan (Cozaar), Olmesartan (Benicar), Telmisartan (Micardis), Valsartan (Diovan)]

• Bronchoconstrictive:

  • β blocker medications [e.g., metoprolol (Lopresor), atenolol (Tenormin), carvedilol, labetalol (Trandate), propranolol (Inderal), sotalol, or bisoprolol (Cardicor or Emcor)]

• Prothrombotic:

  • oral contraceptives

• Pulmonary toxicity:

  • amiodarone

  • some cancer drugs (e.g., gemcitabine, paclitaxel, dasatinib, 5-fluorouracil, bleomycin)

• Also, though less commonly causative, antiarrhythmic agents, nonsteroidal anti-inflammatory drugs, anti-infective agents, methotrexate, tricyclic antidepressants, and cholinesterase inhibitors

Patient specific factors:

• Risk group for tuberculosis?

• Vocally demanding profession, vocal strain?

Testing:

Chest x-ray - 2 views

Pulmonary Function Testing

Fiberoptic laryngoscopy

Possibly allergy testing, provocation testing

If imaging and testing is normal:

Consider upper airway cough syndrome

Consider laryngopharyngeal reflux

Consider cough variant asthma or eosinophilic bronchitis

What suggests an upper airway versus a lower airway cause of the cough?

A lower airway cause in suggested when:

• The cough is productive of mucus

• The sensation or irritation initiating the cough is felt in the chest