Chronic cough: what are the signs?

A chronic cough is something which is often a cause for concern, but what are the main and underlying symptoms? Leading respiratory and sleep physician Dr Sandip Banerjee explains symptoms, diagnosis and treatment options.

What are the main signs and symptoms of chronic cough?

The cough is a vital protective reflex to prevent aspiration and enhance airway clearance. Chronic cough is defined as a cough which lasts for more than eight weeks. It is reported by up to 10 to 20 per cent of adults.

A cough is a symptom of an underlying pre-medical condition. The most common symptoms associated with cough are as follows:

• reflux symptoms
• symptoms of a postnasal drip
• allergic rhinitis or in some instances
• symptoms of sinusitis

In addition, some patients produce phlegm, which is generally due to an underlying lung parenchymal disease. Some patients may also suffer from systemic symptoms such as fever or generalised body aches, often associated with an underlying chronic infection, which may be responsible for the cough.

What are the main causes of chronic cough?

The most frequent causes of chronic cough are based on the various organs that might be affected which would exhibit symptoms of cough.

The most common reflux disease is associated with an increased incidence of cough. This occurs either because of gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux disease (LPRD).

Additionally, asthma symptoms including either cough variant asthma or classical bronchial asthma can be associated with persistent cough rhinitis. Postnasal drip is also associated with cough.

When should patients with a cough seek immediate medical attention?

Non-pulmonary reasons for cough may include drug-related reasons, which are predominantly secondary to ace inhibitors smoking-related cough.

The pulmonary reasons for cough may include respiratory conditions such as:

• asthma
• COPD
• bronchiectasis
• pulmonary fibrosis
• lung cancer (in rare instances)

On the other hand, there are non-pulmonary reasons for cough which commonly include heart diseases, liver and kidney diseases, while for a very small proportion of patients, autoimmune conditions such as rheumatoid arthritis or lupus can provoke problems.

How is a chronic cough diagnosed exactly?

Immediate medical attention should be sought when the cough is associated with sudden onset breathlessness or other systemic symptoms such as fever or the production of significant amounts of phlegm in the cough.

For individuals with a persistent cough who have underlying liver disease, chronic kidney disease or those who are immunosuppressed because of other drugs, immediate medical attention should be sought to avoid further complications to their underlying disease.

The guidelines published for the management of chronic cough include a pathway of investigations. A detailed history and physical examination is the first step of any assessment of patients with chronic cough, followed by a simple chess radiograph and spirometry.

This would help us identify if there is the presence of underlying bronchial asthma responsible for the cough. If it is not bronchial asthma, we would investigate further by doing a CT scan of the sinuses and of the chest to help identify if the sinuses are responsible for your cough.

However, if both these investigations are negative, we can arrange for an endoscopy to understand if this was a reflux-related cough. Further investigations in the form of chest or heart CT scans can be performed to understand if these were the reasons for your current cough. In up to 15% of patients all the investigations come back to be normal in this small proportion of patients we would make a diagnosis of chronic hypersensitivity cough which is idiopathic, meaning that there is no known reason for the cough these patients are managed symptomatically

What are the different treatment options for chronic cough?

In my practise, I follow the principle of treating the underlying territory which is responsible for the cough. For instance, if this is bronchial asthma or cough variant asthma, I will initiate the patient on a steroid-containing inhaled inhaler. This helps to reduce the intensity and frequency of the cough. If the patient presents with symptoms of post-nasal drip coma, allergic rhinitis or symptoms of cyanosis, I provide them with nasal sprays containing steroids or provide them with antihistamines.

If the cough is secondary to reflux-related disease, I would consider starting the patient on a proton pump inhibitor or gastric motility agents and if this is a drug-related cough, secondary to an ace inhibitor, I would discontinue this drug.

For smoking-related cough, I would consider advising or encouraging the patient to give up smoking. If the cause of the cough is secondary to an underlying lung disease such as COPD, I will provide appropriate management for the underlying COPD.

Frequently, a cough with phlegm could occur secondary to a condition called bronchiectasis. This condition responds best to chest physiotherapy and postural drainage. I would recommend that treatment via a referral to a chess physiotherapist.

Regarding chronic hypersensitivity cough, currently classified as idiopathic cough, I would provide small doses of opioids to help suppress the cough and to bring about symptom control.

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