Chest
Volume 95, Issue 4, April 1989, Pages 723-728
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Clinical Investigations
Chronic Persistent Cough: Experience in Diagnosis and Outcome Using an Anatomic Diagnostic Protocol

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Irwin and co-workers have designed an anatomic approach to the diagnosis and treatment of cough. In their hands, diagnosis was consistently determined and treatment successful almost without exception, if sustained. We reviewed the results of a similar approach in 139 consecutive and unselected patients referred to pulmonary specialists in two community hospitals. Thirty-nine patients demonstrated hyperreactive airways (HA) by carbachol inhalation and/or eucapnic hyperventilation of cold air. Twenty-seven of 78 without HA had postnasal drip, and 13 of 78 had a persistent cough following acute upper airway inflammation. Other less common diagnoses included chronic bronchitis, gastroesophageal reflux, occupational bronchitis, interstitial lung disease, and psychologic causes. We were able to find the cause of cough 88 percent of the time. Treatment adjusted for noncompliance was not always a success. While all patients with HA improved, 8 percent of patients without HA or specific diagnosis did not have an improvement in their cough upon retrospective inquiry. Based on this analysis, we find that the diagnosis and treatment of cough may not be as successful as originally reported using Irwin's approach.

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METHODS

The medical records of all patients with chronic cough referred to the Pulmonary Disease Units at Highland and St. Mary's Hospitals, Rochester, NY, over a five-year period ending December 1986 were reviewed. The two hospitals function both as community hospitals and referral centers for the surrounding region. Patients were selected for study if (1) persistent cough was the only presenting symptom, (2) was not associated with hemoptysis, (3) had been present for at least eight weeks, (4) there

RESULTS

One hundred and thirty nine patients met the criteria for study. There were 55 men and 84 women, 19 to 79 years of age, mean age 44.8 years. One hundred and seventeen underwent carbachol and/or EHCA challenge testing. One hundred of the 117 were challenged by carbachol, 14 by cold air, and three by both. Thirty nine of the 117 patients (33 percent) demonstrated HA; 78 (67 percent) had a negative challenge result including three patients who had a negative response to both carbachol and EHCA

DISCUSSION

We were able to establish a specific cause for chronic persistent cough in the majority of patients using a diagnostic protocol similar to that previously described by Irwin et al.2 Nevertheless, 16 (12 percent) patients had a cough that remained undiagnosed despite extensive diagnostic efforts. Thirteen were available for follow-up. All had negative inhalation challenge tests. In nine of the 13, the cough eventually disappeared spontaneously or substantially improved with nonspecific cough

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Manuscript received July 14; revision accepted September 30.

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