Assessment of the Patient With Chronic Cough

doi:10.4065/72.10.957

Mayo Clinic Proceedings

Volume 72, Issue 10, October 1997, Pages 957-959

https://doi.org/10.4065/72.10.957 Get rights and content

Chronic cough, defined as cough that persists for 3 weeks or longer, is one of the most common symptoms evaluated by a primary-care physician. With the exclusion of cigarette smoking, postnasal drip, asthma, and gastroesophageal reflux are responsible for more than 80% of the causes of chronic cough. Elicitation of a thorough history and performance of a physical examination will usually provide clues about the cause of chronic cough. The use of diagnostic tests including methacholine challenge, gastroesophageal reflux studies, and sinus imaging is based on clinical suspicion. Treatment of chronic cough is aimed at the underlying cause.

Section snippets

Mechanism of Cough

Cough reflex has five components: cough receptors, afferent nerves, cough center (medulla), efferent nerves, and effector organs (respiratory muscles and muscles in the upper airway and tracheobronchial tree). Triggering of cough receptors by chemical or mechanical factors results in stimulation of the cough center. Impulse for the cough is then transmitted through the efferent pathways to the expiratory and laryngotracheobronchial musculature.

Cough receptors predominate along the

Acute Versus Chronic Cough

Acute and self-limited episodes of cough commonly stem from viral infections of the respiratory tract and usually do not pose a diagnostic problem. Chronic cough is generally defined as cough persisting for 3 weeks or longer.2, 3, 4 In this article, we discuss the diagnostic approach to patients with chronic cough in the absence of hemoptysis, a previously known chronic respiratory disease, or obvious clues detected on a chest roentgenogram. Because a chronic cough in an immunocompromised host

Causes of Chronic Cough

Cigarette smoking is the most common cause of chronic cough in the general population. Cigarette smokers, however, usually do not seek medical attention for their persistent cough, which likely represents chronic bronchitis. Aside from smoking, the most common causes of chronic cough are postnasal drip, asthma, and gastroesophageal reflux.²^,3 These three conditions together account for 80 to 90% of the cases of chronic cough evaluated at outpatient clinics (Table 1).³

Postnasal drip is probably

Diagnostic Evaluation

The patient's history and findings on physical examination provide a basis for the diagnostic evaluation of chronic cough. The physician should question the patient about production of phlegm, character of phlegm produced, exacerbating factors, time relationships, and associated symptoms. Examination of the patient with special attention to the lungs, ears, nose, and mouth may yield useful clues. A forced exhalation maneuver may produce a localized wheeze or diffuse wheezes suggestive of a

Questions About Evaluation of Chronic Cough

(See article, pages 957 to 959)

1.
Which one of the following is the most common cause of chronic cough in a nonsmoker who has normal findings on a chest roentgenogram?
- a.
  Chronic bronchitis
- b.
  Bronchiectasis
- c.
  Postinfectious cough
- d.
  Postnasal drip
- e.
  Occult lung cancer
2.
Which one of the following statements is correct regarding a methacholine challenge test?
- a.
  Should be performed when the baseline spirometry reveals moderate to severe airflow obstruction
- b.
  Is considered positive when the patient coughs

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There are more references available in the full text version of this article.

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Cough: A Practical and Multifaceted Approach to Diagnosis and Management
2020, Medical Clinics of North America
Citation Excerpt :
Health care providers should consider atypical presentations of pneumonia in those who are older or immunosuppressed.1 Patients with a confirmed diagnosis of pneumonia should be prepared for the potential for a postinfectious cough and to address any instigating factors that may contribute to the cough, such as LPRD/GER, and sinusitis.2,8 Anticipating the likelihood of a postinfectious cough can help direct management and also provide reassurance to patients.
Oral corticosteroid use among children in TennCare
2002, Ambulatory Pediatrics
Background.—Lack of information about medication effects and use in children is a long-standing and troublesome policy issue. Documenting patterns of use for medications with potential for suboptimal use and adverse effects, such as oral corticosteroids, would be useful.
Objective.—To describe the use of oral corticosteroids among children enrolled in TennCare, Tennessee's managed care program for Medicaid enrollees and uninsured individuals.
Design.—A retrospective cohort study.
Drug Exposure.—Children enrolled in TennCare who had prescriptions filled in their name for oral corticosteroids during 1998 were identified. Descriptive information included age, race, sex, and county of residence. We identified possible indications for corticosteroid use for new users by searching encounter files for encounters temporally related to the index prescription. Subsequent use of corticosteroids was measured in the 365 days after the index prescription.
Results.—Of 400 724 children continuously enrolled in TennCare during the study period, 29 362 (7327 per 100 000) children had a prescription filled for an oral corticosteroid. Steroid prescription filling was more common among young children and male children and less common among black children. Children in rural counties had oral corticosteroid prescriptions filled at a higher rate than children residing in urban counties. Nearly 75% of corticosteroid users filled only 1 prescription during the study period; 1319 children filled 4 or more prescriptions. Asthma was the most common indication for oral corticosteroid use (16%), whereas 1 in 5 users (22%) had an unknown indication for oral corticosteroid use.
Conclusions.—A large number of children enrolled in TennCare had a prescription for oral corticosteroids filled in 1998. Further population-based studies describing the development of adverse effects in users of corticosteroids would be important.
Pertussis infection in adults presenting with persistent cough in general practice
2001, Medecine et Maladies Infectieuses
La toux est un motif fréquent de consultations d'adultes en médecine générale. Les causes des toux chroniques sont bien répertoriées. La coqueluche est rarement évoquée parmi les étiologies. Elle l'est encore moins pour les toux persistantes précoces qui posent des problèmes diagnostics et thérapeutiques en soins primaires. L'évocation du diagnostic de coqueluche à l'occasion d'une consultation pour toux relève souvent de l'anecdote. Pourtant les études retrouvent une infection à Bordetella pertussis chez 12 à 32 % des patients adultes qui consultent pour une toux persistante, souvent sans particularité clinique. Parallèlement, nous observons une résurgence de coqueluche parmi les nourrissons contaminés par des adultes, en particulier en Île-de-France, où la couverture vaccinale anti-coquelucheuse est élevée et où l'efficacité du vaccin utilisé est bien documentée. Une étude a permis de recruter 217 patients adultes, de la région, présentant une toux récente ou inhabituelle, sans amélioration depuis sept jours et moins de 31 jours consécutifs afin d'estimer la prévalence de la coqueluche et d'en décrire les formes cliniques.
Coughing is a common symptom in patients consulting a general pratictioner. Causes of chronic coughs are well defined. Whooping cough is rarely mentioned among etiology. It is suspected even less frequently for early persistent coughs that present diagnostic and therapeutic problems in primary care. A diagnosis of whooping cough is often anecdotal. However, studies find Bordetella pertussis infection among 12 to 32% of adults consulting for a persistent cough without any clinical particularity. At the same time, a resurgence of whooping cough is being observed among infants contaminated by adults, especially in the Ile de France region. In this area, the vaccination coverage is high and the vaccine efficacy is well documented. A study involving 217 adult patients recruited from this region with recent or unusual cough of less than 31 successive days that had not improved in the last seven days was conducted to determine the prevalence of whooping cough and to describe its clinical symptoms.
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2010, Revista Brasileira de Medicina
Recommendations for clinical practice: Chronic cough of adults - Conclusions and perspectives
2006, Revue de Pneumologie Clinique

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Address reprint requests to Dr. J. H. Ryu, Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905.

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Concise Review for Primary-Care PhysiciansAssessment of the Patient With Chronic Cough

Section snippets

Mechanism of Cough

Acute Versus Chronic Cough

Causes of Chronic Cough

Diagnostic Evaluation

Questions About Evaluation of Chronic Cough

Med Clin North Am

Chest

Chest

Chest

Chest

Concise Review for Primary-Care Physicians
Assessment of the Patient With Chronic Cough