Thorax 1998;53:738-743 ( September )

Evaluation and outcome of patients with chronic non-productive cough using a comprehensive diagnostic protocol

L P A McGarvey,^a L G Heaney,^a J T Lawson,^b B T Johnston,^c C M Scally,^d M Ennis,^e D R T Shepherd,^a J MacMahon^a

^a Department of Respiratory Medicine, ^b Department of Radiology, ^c Belfast City Hospital, Belfast, BT9 7AB, UK Department of Medicine, Lagan Valley Hospital, ^d Department of ENT, Antrim Area Hospital, ^e Department of Clinical Biochemistry, The Queen's University of Belfast, Belfast

Correspondence to: Dr L P A McGarvey.

Received 8 December 1997; Returned to authors 9 February 1998; Revised version received 4 March 1998; Accepted for publication 6 March 1998

BACKGROUNDAsthma, post-nasal drip syndrome (PNDS), and gastro-oesophageal reflux (GOR) account for many cases of chronic non-productive cough (CNPC). Each may simultaneously contribute to cough even when clinically silent, and failure to recognise their contribution may lead to unsuccessful treatment.
MethodsPatients (all lifetime non-smokers with normal chest radiographs and spirometric measurements) referred with CNPC persisting for more than three weeks as their sole respiratory symptom underwent histamine challenge, home peak flow measurements, ear, nose and throat (ENT) examination, sinus CT scanning, and 24 hour oesophageal pH monitoring. Treatment was prescribed on the basis of diagnoses informed by investigation results.
RESULTSForty three patients (29 women) of mean age 47.5 years (range 18-77) and mean cough duration 67 months (range 2-240) were evaluated. On the basis of a successful response to treatment, a cause for the cough was identified in 35 patients (82%) as follows: cough variant asthma (CVA) (10 cases), PNDS (9 cases), GOR (8 cases), and dual aetiologies (8 cases). Histamine challenge correctly predicted CVA in 15 of 17 (88%) positive tests. ENT examination and sinus CT scans each had low positive predictive values for PNDS (10 of 16 (63%) and 12 of 18 (67%) positive cases, respectively), suggesting that upper airways disease frequently co-exists but does not always contribute to cough. When negative, histamine challenge and 24 hour oesophageal pH monitoring effectively ruled out CVA and GOR, respectively, as a cause for cough.
CONCLUSIONThis comprehensive approach aids the accurate direction of treatment and, while CVA, PNDS and GOR remain the most important causes of CNPC to consider, a group with no identifiable aetiology remains.

Keywords: chronic cough; diagnosis; treatment

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© 1998 by Thorax
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