Conditions: Chronic Cough

What is a chronic cough?

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

A productive cough is when material, such as mucus, comes up with the cough. To be considered productive, the amount of material would be enough to feel it in the throat and enough that it could be spit or coughed out with some bulk to it*. A non-productive (dry) cough is the opposite—a cough that does not bring up mucus or material in the throat. The sound of a productive cough is also different from that of a non-productive cough. Knowing the difference between a productive and a non-productive cough is useful for finding the cause of the cough.

What causes a chronic cough?

There are many possible causes of a chronic cough, with danger ranging from minimal to high. The following information helps your care team evaluate and treat a chronic cough.

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

"Red flags," or warning signs of a dangerous cause of chronic cough, include the following:

• Stridor (a high-pitch noise when breathing caused by air moving through a narrow passage)

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

• Fever higher than 101.5 degrees F (38.5 degrees C)

• Hemoptysis (coughing up blood)

• A new, significant change in oxygen saturation (the amount of oxygen in the blood, measured with a fingertip device called a pulse oximeter)

• Dysphagia (difficulty swallowing)

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

• Tachycardia (a rapid heart rate)

• Severe immunocompromise (weakening of the immune system)

Seek immediate medical care when one or more of these is present.

Relevant History

Your care team may ask about the following.

Symptoms

• How long has the cough been present?

• Is the cough getting better or worse over time?

• Is there more shortness of breath than usual with physical activity?

• Pain in the chest, head, or throat

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

• Sensitivity to fragrances or cold air

• 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 breathing machine (ventilator) or breathing tube (intubation)

• Pre-existing neurological conditions that could make aspiration of food or liquid going into the airway more likely

Exposures

• Smoking of tobacco/cannabis/vaping/other

• Occupational exposures or toxins

• Animal contact

• Infections among close contacts

• History of migration or travel

Cough-triggering drugs

A chronic cough may be caused by any of these medications at any time, even if the medication has been taken safely for months or years before developing a cough.

• Blood pressure lowering:

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

  • ARBs: azilsartan (Edarbi), candesartan (Atacand), irbesartan (Avapro), losartan (Cozaar), olmesartan (Benicar), telmisartan (Micardis), valsartan (Diovan)

• Bronchoconstrictive:

  • β-blocker medications (e.g., metoprolol (Lopressor), 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 a cause, antiarrhythmic agents, nonsteroidal anti-inflammatory drugs (NSAIDs), anti-infective agents, methotrexate, tricyclic antidepressants, and cholinesterase inhibitors

Patient-specific factors

• Any risk factors for tuberculosis?

• Vocally demanding profession or vocal strain?

Tests that may be done

• Chest x-ray (2 views)

• Pulmonary Function Testing (breathing tests)

• Fiberoptic laryngoscopy (looking at the voice box with a thin, flexible camera)

• Possibly allergy testing or provocation testing (tests that check for triggers of the cough)

If imaging and testing are normal:

• Consider upper airway cough syndrome

• Consider laryngopharyngeal reflux

• Consider cough variant asthma or eosinophilic bronchitis (a type of airway inflammation)

What suggests an upper airway versus a lower airway cause of the cough?A lower airway cause in is suggested when:

• The cough is productive of mucus

• The sensation or irritation that starts the cough is felt in the chest