Cough is an explosive expiratory maneuver that is reflexively or deliberately intended to clear the airways. It is one of the most common symptoms prompting physician visits. (See also Cough in Children.)
Likely causes of cough (see table Some Causes of Cough) differ depending on whether the symptom is acute (present < 3 weeks) or chronic.
In acute cough, the most common causes are
In chronic cough, the most common causes are
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Postnasal drip
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Airway hyperresponsiveness after resolution of a viral or bacterial respiratory infection (ie, postinfection cough)
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COPD (chronic obstructive pulmonary disease)
The causes of cough in children are similar to those in adults, but asthma and foreign body aspiration may be more common in children.
Very rarely, impacted cerumen or a foreign body in the external auditory canal triggers reflex cough through stimulation of the auricular branch of the vagus nerve. Psychogenic cough is even rarer and is a diagnosis of exclusion.
Patients with chronic cough may develop a secondary reflex or psychogenic component to their cough. Also, protracted coughing may injure the bronchial mucosa, which may trigger more coughing.
Some Causes of Cough
Cause |
Suggestive Findings |
Diagnostic Approach |
Acute Cough |
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Foreign body* |
Sudden onset in a toddler who has no URI or constitutional symptoms |
Chest x-ray (inspiratory and expiratory views) Bronchoscopy |
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Dyspnea Fine crackles Extrasystolic heart sound Elevated jugular venous pressure Dependent peripheral edema Orthopnea Paroxysmal nocturnal dyspnea |
Chest x-ray Brain (B-type) natriuretic peptide level Transthoracic echocardiogram |
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Pneumonia (viral, bacterial, aspiration, rarely fungal) |
Fever Productive cough Dyspnea Pleuritic chest pain Localized bronchial breath sounds or egophony |
Chest x-ray Cultures (eg, sputum, pleural fluid, blood, possibly bronchial washings) in seriously ill patients and patients with hospital-acquired pneumonia |
|
Postnasal drip (allergic, viral, or bacterial origin) |
Headache Sore throat Nausea Cobblestoning of posterior oropharynx Pale, boggy, swollen nasal mucosa Frequent clearing of the throat |
Clinical evaluation Response to empiric antihistamine or decongestant therapy CT of the sinuses if diagnosis is unclear |
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Pleuritic chest pain Dyspnea Tachycardia |
CT angiography Less often, ventilation/perfusion scanning and possibly pulmonary arteriography |
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Upper respiratory infection (URI), including acute bronchitis |
Rhinorrhea Red, swollen nasal mucosa Sore throat Malaise |
Clinical evaluation |
Chronic Cough |
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Angiotensin converting enzyme (ACE) inhibitors |
Dry, persistent cough that may occur within days or months after initiation of ACE inhibitor therapy |
Response to stopping ACE inhibitor |
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Aspiration |
Cough after eating or drinking |
Chest x-ray Sometimes modified barium pharyngography Bronchoscopy |
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Asthma (cough variant) |
Cough in response to various provoking factors (eg, allergens, cold, exercise) Possibly wheezing and dyspnea |
Pulmonary function testing Methacholine challenge Response to empiric bronchodilator therapy |
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Chronic bronchitis (in smokers) |
Productive cough on most days of the month or for 3 months of the year for 2 successive years in a patient with known COPD or smoking history Frequent clearing of the throat Dyspnea |
Chest x-ray Pulmonary function testing |
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COPD (chronic obstructive pulmonary disease) |
Known diagnosis of COPD Decreased breath sounds Wheezing Dyspnea Pursed lip breathing Use of accessory respiratory muscles Tripod positioning of the arms against the legs or examination table
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clinical evaluation |
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Burning chest or abdominal pain that tends to worsen with consumption of certain foods, certain activities, or certain positions Sour taste, particularly on awakening Hoarseness Chronic nocturnal or early morning cough |
Response to empiric H2 blocker or proton pump inhibitor therapy Sometimes 24-hour esophageal pH probe if diagnosis is unclear |
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Hyperresponsive airways after resolution of respiratory tract infection |
Dry, nonproductive cough that may persist for weeks or months after an acute respiratory tract infection |
Typically chest x-ray |
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Interstitial lung disease |
Shortness of breath of gradual onset Dry cough History of drug or occupational exposure |
Chest x-ray High-resolution CT |
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Repeated bouts of ≥ 5 rapidly consecutive, forceful coughs during a single expiration, followed by a hurried and deep inspiration (whoop) or posttussive emesis |
Cultures of nasopharyngeal specimens |
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Postnasal drip |
Headache Sore throat Cobblestoning of posterior oropharynx Pale, boggy, swollen nasal mucosa |
Clinical evaluation Response to empiric antihistamine or decongestant therapy Sometimes allergy testing |
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Tuberculosis (TB) or fungal infections* |
Atypical symptoms (eg, weight loss, fever, hemoptysis, night sweats) Exposure history Immunocompromise |
Chest x-ray Skin testing; if positive, sputum cultures and stains for acid-fast bacilli and fungi Sometimes chest CT or bronchoalveolar lavage |
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Atypical symptoms (eg, weight loss, fever, hemoptysis, night sweats) Change in chronic cough Lymphadenopathy |
Chest x-ray If positive, chest CT and bronchoscopic biopsy |
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* Indicates rare causes of cough. |
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Evaluation
History
History of present illness should cover the duration and characteristics of the cough (eg, whether dry or productive of sputum or blood, and whether it is accompanied by dyspnea, chest pain, or both). Asking about precipitating factors (eg, cold air, strong odors) and the timing of the cough (eg, primarily at night) can be revealing.
Review of systems should seek symptoms of possible cause, including runny nose and sore throat (URI, postnasal drip); fever, chills, and pleuritic chest pain (pneumonia); night sweats and weight loss (tumor, tuberculosis [TB]); heartburn (gastroesophageal reflux); and difficulty swallowing or choking episodes while eating or drinking (aspiration).
Past medical history should note recent respiratory infections (ie, within previous 1 to 2 months); history of allergies, asthma, COPD (chronic obstructive pulmonary disease), and gastroesophageal reflux disease; risk factors for (or known) TB or HIV infection; and smoking history. Drug history should specifically include use of angiotensin-converting enzyme (ACE) inhibitors. Patients with chronic cough should be asked about exposure to potential respiratory irritants or allergens and travel to or residence in regions with endemic fungal illness.
Physical examination
Vital signs should be reviewed for the presence of tachypnea and fever.
General examination should look for signs of respiratory distress and chronic illness (eg, wasting, lethargy).
Examination of the nose and throat should focus on appearance of the nasal mucosa (eg, color, congestion) and presence of discharge (external or in posterior pharynx). Ears should be examined for foreign bodies, masses, or signs of infection.
The cervical and supraclavicular areas should be inspected and palpated for lymphadenopathy.
A full lung examination is done, particularly including adequacy of air entry and exit; symmetry of breath sounds; and presence of crackles, wheezes, or both. Signs of consolidation (eg, egophony, dullness to percussion) should be sought.
Red flags
Interpretation of findings
Some findings point to particular diagnoses (1—see table Some Causes of Cough).
Other important findings are less specific. For example, the color (eg, yellow, green) and thickness of sputum do not help differentiate bacterial from other causes. Wheezing may occur with several causes. Hemoptysis in small amounts may occur with severe cough of many etiologies, although larger amounts of hemoptysis suggest bronchitis, bronchiectasis, TB, or primary lung cancer. Fever, night sweats, and weight loss may occur with many chronic infections as well as with cancer.
Testing
Pulse oximetry and chest x-ray should be done in patients with red flag findings of dyspnea or hemoptysis and patients in whom suspicion of pneumonia is high. A chest x-ray and testing for TB and HIV infection should be done in patients with weight loss or risk factors for those infections.
For many patients without red flag findings, clinicians can base the diagnosis on history and physical examination findings and begin treatment without testing. For patients without a clear cause but no red flag findings, many clinicians empirically begin treatment for postnasal drip (eg, antihistamine and decongestant combinations, nasal corticosteroid sprays, or nasal muscarinic antagonist sprays) or gastroesophageal reflux disease (eg, proton pump inhibitors, H2 blockers). An adequate response to these interventions usually precludes the need for further evaluation.
A chest x-ray should be done in patients with chronic cough in whom presumptive treatment is ineffective. If the x-ray findings are unremarkable, many clinicians sequentially test for asthma (pulmonary function tests with methacholine challenge if standard spirometry is normal), sinus disease (sinus CT), and gastroesophageal reflux disease (esophageal pH monitoring).
Sputum culture is helpful for patients with a possible indolent infection, such as pertussis, TB, or nontuberculous mycobacterial infection.
Chest CT and possibly bronchoscopy should be done in patients in whom lung cancer or another bronchial tumor is suspected (eg, patients with a long smoking history, nonspecific constitutional signs) and in patients in whom empiric therapy has failed and who have inconclusive findings on preliminary testing.
Evaluation reference
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1. Morice AH, Millqvist E, Bieksiene K, et al: ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J 55(1): 1901136, 2020. doi: 10.1183/13993003.01136-2019
Treatment
Treatment is management of the cause.
There is little evidence to support the use of cough suppressants or mucolytic agents. Coughing is an important mechanism for clearing secretions from the airways and can assist in recovery from respiratory infections. Therefore, although patients often expect or request cough suppressants, such treatment should be given with caution and reserved for patients with a URI and for patients receiving therapy for the underlying disorder for whom cough is still troubling. Cough suppressants may help some patients with chronic cough who have a reflex or psychogenic component to their cough or who develop bronchial mucosal injury.
Antitussives depress the medullary cough center (dextromethorphan and codeine) or anesthetize stretch receptors of vagal afferent fibers in bronchi and alveoli (benzonatate). Dextromethorphan, a congener of the opioid levorphanol, is effective as a tablet or syrup at a dose of 15 to 30 mg orally 1 to 4 times a day for adults or 0.25 mg/kg orally 4 times a day for children. Codeine has antitussive, analgesic, and sedative effects, but dependence is a potential problem, and nausea, vomiting, constipation, and tolerance are common adverse effects. Usual doses are 10 to 20 mg orally every 4 to 6 hours as needed for adults and 0.25 to 0.5 mg/kg orally 4 times a day for children. Other opioids (hydrocodone, hydromorphone, methadone, morphine) have antitussive properties but are avoided because of high potential for dependence and abuse. Benzonatate, a congener of tetracaine that is available in liquid-filled capsules, is effective at a dose of 100 to 200 mg orally 3 times a day.
Expectorants are thought to decrease viscosity and facilitate expectoration (coughing up) of secretions but are of limited, if any, benefit in most circumstances. Guaifenesin (200 to 400 mg orally every 4 hours in syrup or tablet form) is most commonly used because it has no serious adverse effects, but multiple expectorants exist, including bromhexine, ipecac, and saturated solution of potassium iodide (SSKI). Aerosolized expectorants such as N-acetylcysteine, DNase, and hypertonic saline are generally reserved for hospital-based treatment of cough in patients with bronchiectasis or cystic fibrosis. Ensuring adequate hydration may facilitate expectoration, as may inhalation of steam, although neither technique has been rigorously tested.
Topical treatments, such as acacia, licorice, glycerin, honey, and wild cherry cough drops or syrups (demulcents), are locally and perhaps emotionally soothing, but their use is not supported by scientific evidence.
Protussives, which stimulate cough, are indicated for such disorders as cystic fibrosis and bronchiectasis, in which a productive cough is thought to be important for airway clearance and preservation of pulmonary function. DNase or hypertonic saline is given in conjunction with chest physical therapy and postural drainage to promote cough and expectoration. This approach is beneficial in cystic fibrosis but not in most other causes of chronic cough.
Bronchodilators, such as albuterol and ipratropium or inhaled corticosteroids, can be effective for cough after URI and in cough-variant asthma.
