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Chronic non-productive cough

 

Chronic cough is defined by the BTS as a cough lasting longer than 8 weeks.

These guidelines are for those who have an isolated dry cough, a normal clinical examination, CXR and spirometry: there is a low frequency of serious pathology in these patients1.

These guidelines are based on those of the BTS2 , which suggests a “test of treatment” strategy.

Chronic cough lowers the cough threshold. This means even successful treatment trials can have a delayed effect.3

 

When to consider referral:

  • Those who have completed primary care management and whose cough is of significant impact to their daily lives and would like a referral to secondary care (but the majority of patients should be managed in the community and referred to secondary care only if associated with significant pathology).

  • Those whom have red flag signs (see below)

 

Primary care management prior to referral:

  • Stop any ACE inhibitors and Sitagliptin5. (Response can take up to 4 weeks, but occasionally can persist for several months)

  • Stop smoking
     
  • Perform a CXR and spirometry (within the past 6 months)

Most chronic cough is the result of the following pathologies. After a careful history and examination, a trial of treatment is appropriate: (each trial should last a minimum of 2 months and consider a two week ‘washout’ between trials:

  • Asthma/oesinophilic airways disease: give inhaled steroids and PRN beta agonist via spacer device.
    • E.g Clenil Modulite 100mcg 2 puffs b.d plus salbutamol PRN
  • GORD: give a PPI + alginates.
    •  E.g omeprazole 20mg bd and gaviscon QDS
  • Upper Airway Cough Syndrome  (post-nasal drip  rhinitis, nasal congestion, prominent sneezing, anosmia/reduced sense of smell or frequent throat-clearing)  Give a nasal steroid spray (advise not to sniff nasal spray), nasal rinsing (see attached leaflet) +/- non-sedating antihistamine
    • e.g Fluticasone furoate (Avamys) 27.5mcg 2 sprays into each nostril o.d  and Cetirizine 10mg od.
  • Post-infectious cough: Can last up to a year
  • If after the recommended review period, symptoms have not been resolved, then reconsider and treat as appropriate.
     
  • It is appropriate to consider secondary care review when all above therapeutic trials are complete.

 

Information required with referral:

  • Details of investigations done
     
  • Details of prior therapeutic trials, including length of use of medications. Referrals will be cancelled if therapeutic trials are not complete and of an appropriate period of time, unless other concerns are detailed.

 

Clinic options:

  • All referrals will be seen and assessed by the respiratory team

 

Red flags (for whom this guideline is not intended)

  • Those who have a copious sputum production
     
  • Those who have systemic symptoms: Fever sweats weight loss
     
  • Those with haemoptysis
     
  • Significant dyspnoea
     
  • Hoarseness
     
  • Those with an abnormal X-ray or CT scan.

 

Post-covid cough:

Consider this in those with persistent cough (often dry) after Covid-19 infection. This should be investigated as with other causes of chronic cough, but if symptoms of:

 

 

References:

1. Pavord ID, Chung KF; Management of chronic cough. Lancet. 2008 Apr 19;371(9621):1375-84.

2. Morice AH, McGarvery L, Pavord I; Recommendations for the management of cough in adults, on behalf of the British Thoracic Society Cough Guideline Group Thorax 2006;61(Suppl I):i1–i24. doi: 10.1136/thx.2006.065144

3. Gibson Peter G, Vertigan Anne E.  Management of chronic refractory cough BMJ 2015; 351 :h5590

4. Fokkens, W.J., Lund, V.J., Mullol, J. et al. (2012) European Position Paper on Rhinosinusitis and Nasal Polyps 2012.Rhinology supplement 23(3)

5. https://cks.nice.org.uk/topics/cough/management/management/

 

 

Date reviewed                     25/11/2021

Next review due                  25/11/2022

Sifter name                          Dr Madeleine Attridge