Assessment of

chronic cough

Straight to the point of care

Last updated: Sep 01, 2022

 Table of Contents
Overview 3
Summary 3

Theory 4
Aetiology 4

Emergencies 6
Urgent considerations 6

Diagnosis 8
Approach 8
Differentials overview 31
Differentials 33

Guidelines 49

Evidence tables 52

References 54

Images 61

Disclaimer 82
Assessment of chronic cough Overview

Summary
Cough is one of the most common presenting symptom in primary practice.[1] Sub-acute cough is defined
as cough persisting for 3-8 weeks, and chronic cough as that persisting for more than 8 weeks in adults.[2]

OVERVIEW
[3] Chronic cough in children has been defined as the presence of cough every day for 4 weeks or more.[4]
Sub-acute cough is most often self-limiting, but chronic cough may provide significant challenges for effective
evaluation and management. The difficulty is in determining the cause of cough, because some 'aetiologies'
are syndromes without accurate diagnostic tests. The cause is determined instead by typical historical
features, elimination of alternative causes, and response to targeted therapies (therapeutic trials serve as
tests). Nonetheless, a careful history and examination, followed by carefully selected therapeutic trials and/or
diagnostic evaluations, may satisfactorily resolve cough in over 90% of cases.

However for children aged ≤14 years, common causes of chronic cough may be different to those in
adults; the child’s age, cough characteristics, clinical history and geographical setting should be taken into
account.[4] Detailed recommendations regarding diagnostic algorithms and therapeutic trials for children may
also differ from those for adults.[4]

Non-targeted cough suppressant therapy is rarely effective for chronic cough.

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 Assessment of chronic cough Theory

Aetiology
All chronic cough begins as sub-acute, and differential diagnosis includes all causes of sub-acute cough.
Post-infectious cough is the most common aetiology of sub-acute cough.[5] Most cases will be self-limiting.
THEORY

Once cough duration has exceeded 8 weeks, a systematic approach to elucidating cause and best treatment
is needed.

Common aetiologies
In most non-smoking adults with a normal chest x-ray who do not take ACE inhibitors, chronic cough is
caused by one or more of four conditions:[2] [3] [6] [7]

• Upper airway cough syndrome (formerly postnasal drip syndrome): 34%

• Asthma: 25%
• Gastro-oesophageal reflux disease: 20%
• Non-asthmatic eosinophilic bronchitis: 13%.
More than one cause of chronic cough is often present. Truly idiopathic cough is rare and is a diagnosis of
exclusion.[8] [9]

Cough as a principal or sole symptom of asthma, known as cough-variant asthma, is present in a sub-group
of patients.[10] It is usually worse at night.[10]

These commonest causes account for most patients presenting to specialty clinics with chronic cough and
should generally be considered first if there are no signs or symptoms pointing to alternative diagnoses.

Other common causes include the following.

• ACE inhibitors: dry cough, typically associated with a tickling or scratching sensation in the throat. The
reported incidence varies.[11] ACE inhibitor-induced cough is more frequent in women than men and
is associated with increasing age.[12] [13]
• Post-infectious cough: the most common aetiology of sub-acute cough.[5] A history typical for post-
infectious cough should prompt watchful waiting and symptomatic therapy as necessary.
• Bronchitis: chronic bronchitis may be considered when an adult has a history of chronic productive
cough lasting for more than 3 months of the year and for at least 2 consecutive years when other
diagnoses have been ruled out.[14] Chronic bronchitis is one of the manifestations of chronic
obstructive pulmonary disease. Predisposing factors may include nicotine and marijuana smoking,
second-hand exposure to nicotine smoke, and environmental exposure to toxins.[6] [15]
• Bordetella pertussis: when local epidemiology indicates a high rate of pertussis infection, testing
for Bordetella pertussis is recommended. If tests are supportive of pertussis, specific antimicrobial
therapy is indicated.

Less common aetiologies

Diagnoses to consider are those that impart cough through stimulation of airway mechanical and chemical
receptors that feed into the vagus nerve, including afferent nerves located in the chest wall, diaphragm,
oesophagus, abdominal wall, and external auditory meatus.[16] Other potential causes therefore are:

• Disorders that distort or irritate the airway (e.g., bronchiectasis, chronic suppurative lung disease,
endobronchial tumours, granulomatous disease, foreign bodies)

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Assessment of chronic cough Theory
• Disorders of lung parenchyma (e.g., interstitial lung disease resulting from hypersensitivity
pneumonitis, occupational/environmental exposure, or autoimmune diseases such as systemic lupus
erythematosus)
• Other diseases that involve systemic processes (rheumatoid arthritis, sarcoidosis), autoimmune

THEORY
diseases such as systemic lupus erythematosus, or diseases that stimulate afferent nerves mentioned
above
• Irritation of the external ear canal by an infection, wax, or hearing aids may produce cough, through a
reflex mediated by Arnold's nerve.
Oral-pharyngeal dysphagia that results in recurrent aspiration of foods and liquids may also cause cough.
Patients with cough who report difficulty swallowing should be further evaluated for such aetiology.[6]

Zenker’s diverticulum can cause chronic cough, accompanied by dysphagia, regurgitation, aspiration, and
weight loss.[17]

Bronchiolitis should also be considered, and may result from infection or may be drug/toxin-related. Diffuse
panbronchiolitis should be considered in patients who have recently lived in Japan, Korea, or China.[6]

In areas of endemic infection with fungi or parasites, diagnostic evaluation for these should be undertaken
when more common causes of cough have been ruled out.[6] Slow enlargement of intrathoracic blood
vessels, such as an aortic aneurysm, may cause chronic cough.[18]

Somatic cough syndrome (psychogenic cough) may be diagnosed after thorough evaluation has ruled out all
other causes.[19]

People who work with their voice (e.g., teachers, call centre operators, actors, singers, coaches) may
experience chronic cough and hoarseness.[15]

Coronavirus disease 2019 (COVID-19) may be associated with long-term symptoms, most commonly cough,
low grade fever, and fatigue, and/or organ dysfunction.[20] The definition and time frame of 'post-acute
COVID-19 syndrome' or 'long COVID' has not been universally determined. In the UK, 'ongoing symptomatic
COVID-19' has been defined as signs and symptoms of COVID-19 from 4 to 12 weeks. 'Post-COVID-19
syndrome' is defined as signs and symptoms that develop during or after COVID-19 and continue for more
than 12 weeks.[21] Incidence, natural history, and aetiology data continue to emerge. See the 'complications'
section in our topic 'Coronavirus disease 2019 (COVID-19)'.

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 Assessment of chronic cough Emergencies

Urgent considerations
(See Differentials for more details)
Chronic cough as a sole symptom typically lasts for months or years before presentation and does not
usually represent an urgent medical condition. A faster and more comprehensive evaluation (rather than
empirical treatment) should take place if other symptoms are present (such as dyspnoea, haemoptysis,
weight loss, fever, or chest pain) or if the patient is immunosuppressed.

Lung carcinoma
Cough is the most common symptom of lung cancer and is often accompanied by other symptoms such as
weight loss, haemoptysis, chest pain, dyspnoea, or hoarseness.[22] Patients may also present with non-
specific symptoms such as fatigue and anorexia. Lung cancer is more likely in current or prior smokers.
Diagnosis is confirmed by radiography and pathology, and treatment may involve surgery, chemotherapy, and
radiotherapy.[23]

Asthma
EMERGENCIES

Chronic cough accompanied by episodic dyspnoea, wheezing and chest tightness that worsens at night,
on exposure to allergens, cold, or fumes, may indicate asthma. Timely diagnosis of asthma is important to
reduce the risk of exacerbations and long-term airway remodelling.[24]

Diagnosis follows a structured clinical assessment, which may demonstrate the above symptoms and
previous documented symptom variability, clinical findings of bronchoconstriction, and demonstration of
airflow obstruction and reversibility, ideally confirmed by variable peak flow results.[10] [25] [26] If asthma
is poorly controlled at diagnosis, a short course of oral corticosteroids may be used prior to starting inhaled
corticosteroids.[25] In an acute exacerbation of asthma, bronchodilators and corticosteroids should be
administered to relieve airflow obstruction. If the patient has signs of a severe exacerbation (drowsiness,
confusion or a silent chest), arrange immediate transfer to the emergency department or intensive care.[10]
Careful monitoring is essential.[10] Treatment in these situations includes a short-acting beta agonist,
early corticosteroid, and oxygen.[10] An antimuscarinic agent is reserved for severe exacerbations, and
intravenous magnesium sulfate may be considered if patients are unresponsive to initial therapy.[10]

Pneumonia
May follow a prodrome of chronic cough and, in that instance, is typically manifested with a change in
the character of cough, appearance of sputum purulence, and fever. Less commonly, haemoptysis, chest
pain, or dyspnoea may be present. Diagnosis is based on clinical findings of lung consolidation, along with
radiographic findings of an infiltrate. Treatment consists of antibiotics.[27]

Tuberculosis
Chronic cough accompanied by night sweats and weight loss may indicate tuberculosis (TB), especially in
a patient living in or visiting an area with high prevalence of this disease.[28] People at increased risk for
TB infection include those with underlying conditions that affect their immune status such as HIV infection,
patients receiving immunosuppressant medications, transplant recipients, individuals with diabetes, and
patients receiving dialysis.[29]

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Assessment of chronic cough Emergencies
Epidemiological risk factors include recent immigrant or refugee status, being in prison, and having a
'contact' with active TB. These risk factors are associated with a particularly high risk of active TB if a test for
latent TB (e.g., tuberculin skin test, interferon-gamma release assay) is positive.

TB is typically accompanied by radiographic infiltrative, fibrotic, or cavitating changes and confirmed by

demonstration of Mycobacterium tuberculosis bacilli in sputum.

Confirmed TB should be treated promptly with antitubercular drugs to cure the patient and prevent
transmission to others.

Bordetella pertussis infection

Paroxysmal cough, inspiratory whooping, and post-tussive vomiting raise a possibility of B pertussis
infection. Diagnosis is suspected in household contacts of whooping cough and confirmed with
microbiological or serological testing.

First line treatment is with a macrolide antibiotic or, in the presence of contraindications or bacterial

EMERGENCIES
resistance, with trimethoprim/sulfamethoxazole.

Interstitial pulmonary fibrosis

Cough accompanied by progressive dyspnoea may indicate the presence of interstitial pulmonary fibrosis.
Diagnosis is further suspected with signs of dry crackles and clubbing, and is confirmed clinically or
pathologically. Radiography shows a plethora of interstitial changes, and pulmonary function testing typically
demonstrates a restrictive pattern. Treatment depends on the specific clinical and pathological pattern of
disease.

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 Assessment of chronic cough Diagnosis

Approach
Patients may present with a sub-acute cough, most commonly post-infection; however, in most patients,
postinfectious cough is self-limited.[5] Observation and, if required, symptomatic therapy may be all
that is needed in these patients. Once the cough persists for longer than 8 weeks, further evaluation is
indicated.[30] [31] Several validated tools of cough assessment are available, although these are used mostly
for research purposes.[32]

Pursuing the cause and resolution of chronic cough requires ongoing commitment to the patient. The
approach to an individual patient with chronic cough may vary from full initial diagnostic evaluation for
common associated diseases, to empirical but targeted therapy for common conditions known to cause
chronic cough, with limited or no diagnostic efforts.[9] Choice of the specific approach may be individualised,
and depends on type and duration of symptoms, the patient's preference, and availability of resources.
Limiting diagnostic testing, treating assumed aetiologies, and applying sequential empirical trials of therapy
is most cost-effective, but leads to the longest time to resolution of cough and may be associated with
increased patient anxiety.[9] [33] [34] In practice, diagnostic and therapeutic processes are often applied
simultaneously. It is best to involve the patient in choosing the best approach and to explain the expected
duration and course of diagnostic and therapeutic trials.

History and examination

A detailed history is essential, and should include:

• Time and clinical setting of onset

• Exacerbating factors
• Associated symptoms
• Prior history suggestive of atopic disease
• A complete medical, smoking, drug, and exposure history
• Occupational and family history
• What measures have already been tried, and to what effect.
DIAGNOSIS

The history substantially influences the clinician's impression as to which (if any) of the four most common
aetiologies (upper airway cough syndrome [UACS], asthma, gastro-oesophageal reflux disease [GORD], or
non-asthmatic eosinophilic bronchitis [NAEB]) are most likely.

A careful examination is, unfortunately, unlikely to inform the clinician regarding the commonest causes of
chronic cough, but is essential for early detection of less common causes, such as bronchiectasis, interstitial
lung disease, neoplastic disorders, or chronic infectious pulmonary diseases.

Although no specific history or physical examination findings are reliably associated with specific aetiology of
chronic cough, they may direct further testing or therapeutic trials.

The symptoms and findings associated with the common causes (asthma, UACS, GORD, or NAEB) may
direct further diagnostic evaluation towards confirming that cause.

Asthma

May present with wheezing, chest tightness, or dyspnoea apart from paroxysms of cough, or exacerbation
of cough by seasonal exposures, specific irritants, or non-specific respiratory irritants such as cold air,
aromatic vapours, or dusty environments. In patients who do not ever wheeze, another cause should be

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Assessment of chronic cough Diagnosis
considered.[9] There may be variability of symptoms, nocturnal exacerbation of cough, or a strong family
history of asthma or atopic disease.[35] Cough-variant asthma, in which persistent cough is the principal or
sole symptom, tends to be worse at night.[10] [36]

UACS

A clinical syndrome and diagnosis is based on the clinical picture (which includes frequent throat clearing,
postnasal drip, nasal discharge, nasal obstruction, and sneezing) and response to therapy.[37] Potential
causes of UACS include allergic rhinitis, perennial non-allergic rhinitis, post-infectious rhinitis, bacterial
sinusitis, allergic fungal sinusitis, rhinitis due to anatomical abnormalities, nasal polyposis, rhinitis due to
physical or chemical irritants, occupational rhinitis, rhinitis medicamentosa, and rhinitis of pregnancy.[37]

GORD

May present with heartburn, dysphagia, acid regurgitation, and an associated cough with slouched posture.
Suggestive symptoms may include cough on phonation, cough on rising from bed, or association with certain
foods or with eating in general.[9] Reflux disease is clinically silent in up to 75% of cases.[38]

NAEB

Presents with a chronic, generally scantily productive or non-productive cough without prominent features of
asthma or reliable cough triggers, although patients may complain of wheezing at times.

ACE inhibitor cessation

The cough from an ACE inhibitor may begin within days or months of onset of ACE inhibitor therapy. If use
of ACE inhibitors is suspected as the cause, use should be stopped if at all possible. Diagnosis is then
confirmed by the resolution of cough, usually within 1 to 4 weeks (although it may be up to 3 months).[39]
Angiotensin receptor blocking agents do not appear significantly related to chronic cough symptoms.

Chest x-ray
A chest x-ray should be obtained early in the evaluation of chronic cough.[31] Although it is not diagnostic

DIAGNOSIS
of the most common causes, findings may quickly divert the evaluation to causes of greater gravity, such
as structural lung diseases. These include lung cancer, pulmonary fibrosis, tuberculosis, bronchiectasis,
pneumonia, aspiration, and sarcoidosis.

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 Assessment of chronic cough Diagnosis

Chest x-ray showing hyperinflation in a patient with COPD. The hyperinflation is caused by the
emphysema component of COPD, rather than the chronic bronchitis that underlies symptoms of cough
From the personal collection of Dr M. A. Sharifabadand, SUNY at Stony Brook School of
Medicine, Department of Pulmonary and Critical Care Medicine, Mineola, New York and Dr
J. P. Parsons, The Ohio State University Medical Center, Columbus; used with permission
DIAGNOSIS

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Assessment of chronic cough Diagnosis

DIAGNOSIS
Chest x-ray showing multiple miliary lung metastases (arrows). The primary tumour was a thyroid carcinoma
E. Dick, Student BMJ. 2001;9:10-12

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 Assessment of chronic cough Diagnosis

Chest x-ray showing left hilar carcinoma (arrow)

From: E. Dick, Student BMJ. 2000;8:358-360
DIAGNOSIS

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Assessment of chronic cough Diagnosis

DIAGNOSIS
Chest x-ray showing a cavitating right hilar carcinoma (arrow)
E. Dick, Student BMJ. 2001;9:10-12

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 Assessment of chronic cough Diagnosis

Chest x-ray in a patient with bronchogenic carcinoma showing a left-sided pleural effusion
From: R. Thakkar, Student BMJ. 2001;9:458
DIAGNOSIS

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Assessment of chronic cough Diagnosis

Chest x-ray showing interstitial fibrosis in a patient with amiodarone pulmonary toxicity
From the personal collection of Dr A. Pataka and Professor P. Argyropoulou,
Aristotle University, Thessaloniki, Greece; used with permission

DIAGNOSIS

Chest x-ray showing pulmonary tuberculosis with cavitation

From the personal collection of Dr M. Narita, Department of
Pulmonary and Critical Care Medicine, University of Washington

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 Assessment of chronic cough Diagnosis

Chest x-ray showing multiple discrete nodules throughout both

lungs (one of which is circled) in a patient with miliary tuberculosis
E. Dick, Student BMJ. 2001;9:10-12
DIAGNOSIS

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Assessment of chronic cough Diagnosis

DIAGNOSIS
Chest x-ray with lack of normal tapering producing a tram line in a patient with bronchiectasis
From the personal collection of Dr S.M. Bhorade, University of Chicago Medical Center; used with permission

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DIAGNOSIS Assessment of chronic cough Diagnosis

Chest x-ray with dilated and thickened airways in a patient with bronchiectasis
From the personal collection of Dr S.M. Bhorade, University of Chicago Medical Center; used with permission

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Assessment of chronic cough Diagnosis

Chest x-ray showing increased opacification of the right perihilar region and superior
segment of the right lower and upper lobes consistent with worsening aspiration pneumonia
From the personal collection of Dr R. Kanner, University of Utah School of Medicine

DIAGNOSIS

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 Assessment of chronic cough Diagnosis

Portable chest x-ray with bibasilar opacities, worse on the right

than the left, in a patient with hospital-acquired pneumonia
From the personal collection of Dr F. W. Arnold, Division of Infectious
Diseases, Department of Medicine, University of Louisville School of Medicine
DIAGNOSIS

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Assessment of chronic cough Diagnosis

Chest x-ray showing early ill-defined opacities of the right upper lobe above
the minor fissure consistent with early changes of aspiration pneumonia
From the personal collection of Dr R. Kanner, University of Utah School of Medicine

DIAGNOSIS

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 Assessment of chronic cough Diagnosis

A. Portable upright chest x-ray before aspiration; B. Chest x-ray 1 hour after aspiration,
showing bilateral diffuse alveolar infiltrates, worse at the bases on the right side
From the personal collection of Dr S. Murgu and Dr H. Colt, University of California at Irvine Medical Center
DIAGNOSIS

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Assessment of chronic cough Diagnosis

DIAGNOSIS
Chest x-ray showing bilateral hilar adenopathy in a patient with sarcoidosis
From the personal collection of Dr M.P. Muthiah, Division of Pulmonary
and Critical Care and Sleep Medicine, University of Tennessee

Choice of diagnostic testing or therapeutic trials

Following chest x-ray, the choice of either diagnostic testing or therapeutic trials depends on the clinician's
assessed probability of a specific aetiology and the patient's preferred approach.[31] Unless the history,
physical examination, and chest x-ray indicate otherwise, efforts should be concentrated on one or more of
the four most common causes (asthma, UACS, GORD, NAEB).

For example, if the history is most suggestive of asthma, then spirometry (to test for airway obstruction)
and bronchodilator variability testing would be appropriate first tests.[25] [26] Other investigations include
fractional exhaled nitric oxide and bronchoprovocation challenge testing (e.g., methacholine inhalation test).
Non-invasive tests to predict response to inhaled corticosteroids also include blood and sputum eosinophil
counts, and blood and sputum eosinophilic cationic protein (ECP).[36] In the presence of raised blood or
sputum eosinophil counts, negative reversibility tests should prompt consideration of a diagnosis of NAEB.

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 Assessment of chronic cough Diagnosis
If UACS is suspected, a therapeutic trial aimed at resolving rhinosinusitis and reducing excessive secretions
is indicated.

A therapeutic trial of proton pump inhibitors (PPIs) is recommended for patients with typical GORD
symptoms (heartburn and regurgitation).[40] Diagnostic testing (oesophageal pH monitoring) may be
considered according to clinician or patient preference in those refractory to a therapeutic trial of PPIs, or
where there is a strong clinical suspicion of reflux-related cough.[40] [41]

Therapeutic trials
Therapeutic trials are selected based on clinical impression, at times supported by diagnostic testing. The
patient's response to the trial must be assessed and the cough resolved before a given aetiology may be
assigned with certainty. A partial response may indicate that more than one aetiology is in play. In this
event, further testing and/or additional therapeutic trials may be indicated, while the partially successful
therapy should be continued. Lack of a response requires reassessment both of suspected aetiology and of
treatment adherence and effectiveness. High placebo effect has been reported in empirical trials in chronic
cough.[42]

Empirical therapeutic trials may be undertaken sequentially (starting with the most likely aetiology first),
with subsequent selections made according to patient response. Alternatively, trials may be undertaken
simultaneously when multiple aetiologies are suspected from the outset, with subsequent sequential
withdrawal of therapies once the cough is controlled. The following are considered:

1. UACS: a trial of an antihistamine plus a decongestant should be undertaken. Failure of response to

appropriate therapeutic trials should prompt a sinus computed tomography (CT) scan and an ear,
nose, and throat (ENT) referral, particularly if other aetiologies have been considered and deemed
very unlikely.
2. Asthma or NAEB: non-invasive measurement of airway inflammation (such as fractional exhaled nitric
oxide (FeNO) sputum and blood eosinophilia, and sputum and blood eosinophilic cationic protein)
is suggested as a useful tool to predict response of cough to inhaled corticosteroid (ICS), based on
moderate supporting evidence.[36] If eosinophilic airway inflammation is found, it is likely to respond
DIAGNOSIS

to corticosteroids.[36] Since the availability of these non-invasive tests is limited, an empiric trial of
ICS is commonly used in clinical practice. Failure of response to 2-4 week trial of an ICS should
prompt an increase in the dose of the ICS with the addition of a therapeutic trial of a leukotriene
receptor antagonist.[36] Beta agonists may also be considered with ICS.[36] Treatment adherence,
anti-inflammatory effectiveness (measured by FeNO and peak-flow variability, as appropriate), and
conditions that contribute to ongoing poor asthma control such as GORD, sinus disease, or ongoing
allergen exposure, should be re-evaluated.[36]
3. GORD: failure of response to an appropriate therapeutic trial (e.g., 8-12 weeks with a proton-
pump inhibitor) should prompt confirmatory testing (if not already done), and careful assessment of
effectiveness of acid suppression and/or other factors contributing to ongoing non-acid reflux.[40] [41]

Laboratory tests
Laboratory assessment of sputum production is a key factor in narrowing the differential, as it can indicate
presence of an infectious cause. If the cough is productive, a sputum sample should be sent for Gram stain
and culture. Depending upon the history and examination, the following blood tests might be taken: FBC,
WBC count, CRP, total IgE blood test for allergic bronchopulmonary aspergillosis.

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Assessment of chronic cough Diagnosis

Further diagnostic evaluation

If none of the four most common causes seem likely after thorough assessment, other tests to consider
include:

• High-resolution CT imaging of the chest to look for bronchiectasis (which does not always promote
a productive cough), foreign body aspiration, pulmonary fibrosis, or or other structural lung disease
(which may not show well on chest x-ray). Chronic suppurative lung disease is diagnosed in patients
with clinical symptoms of bronchiectasis but no radiographic evidence of bronchiectasis.[44] CT
imaging may also indicate the presence of an aortic aneurysm or Zenker’s diverticulum. The
diagnostic yield of the CT scan of the chest in a patient with chronic cough and normal chest x-ray is
expected to be low.[3] [Evidence C] There is no high-quality evidence to support the use of chest CT in
the initial evaluation of patients presenting with chronic cough.[31]
• Bronchoscopy to search for endobronchial pathology.
• CT sinuses or nasendoscopy.
• 24-hour oesophageal pH and/or impedance monitoring to rule out silent GORD.
• Serum ferritin and iron, because iron deficiency has been associated with chronic cough.[45]

In addition, pulmonary and/or ENT consultation should be considered. In cases where the patient also has
features of stridor, laryngospasm, or paradoxical vocal fold motion, early involvement of a speech pathologist
is appropriate, because treatment directed at underlying causes may speed resolution of chronic cough as
well.[46]

DIAGNOSIS

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DIAGNOSIS Assessment of chronic cough Diagnosis

Chest CT with presence of signet ring on left in a patient with bronchiectasis

From the personal collection of Dr S.M. Bhorade, University of Chicago Medical Center

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Assessment of chronic cough Diagnosis

DIAGNOSIS
Chest CT with dilated and thickened airways and peripheral tree-in-bud pattern in a patient with bronchiectasis
From the personal collection of Dr S.M. Bhorade, University of Chicago Medical Center; used with permission

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 Assessment of chronic cough Diagnosis

Chest CT showing idiopathic pulmonary fibrosis

From the personal collection of Dr J.C. Munson, Center for Clinical
Epidemiology and Biostatistics, University of Pennsylvania School of Medicine
DIAGNOSIS

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Assessment of chronic cough Diagnosis

Chest CT of a patient with amiodarone pulmonary toxicity,

showing asymmetrical opacities with a peripheral distribution
From the personal collection of Dr A. Pataka and Professor

DIAGNOSIS
P. Argyropoulou, Aristotle University, Thessaloniki, Greece

CT of the chest with intravenous contrast material showing complete left lower lobe collapse
with a radiopaque object within the left lower main bronchus surrounded by a halo of air
BMJ Case Reports 2008 (doi:10.1136/bcr.06.2008.0013). Copyright 2008 BMJ Publishing Group Ltd

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 Assessment of chronic cough Diagnosis

Bronchoscopy image showing a loquat seed completely occluding the bronchus intermedius
From the personal collection of Dr S. Murgu and Dr H. Colt, University of California at Irvine Medical Center
DIAGNOSIS

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Assessment of chronic cough Diagnosis

Differentials overview

Common

Upper airway cough syndrome (UACS; postnasal drip)

Asthma

Gastro-oesophageal reflux disease (GORD)

Non-asthmatic eosinophilic bronchitis (NAEB)

Chronic bronchitis/COPD

Angiotensin-converting enzyme inhibitor (ACE inhibitor)

Pneumonia

Post-infectious cough

Bordetella pertussis infection

Uncommon

Lung cancer

Bronchiectasis and chronic suppurative lung disease

DIAGNOSIS
Interstitial pulmonary fibrosis

Sarcoidosis

Tuberculosis (TB)

Zenker’s diverticulum

Thoracic aortic aneurysm (TAA)

Foreign body

Hypersensitivity pneumonitis

Bronchiolitis

Recurrent aspiration

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 Assessment of chronic cough Diagnosis

Uncommon

Tropical filarial pulmonary eosinophilia

Somatic cough syndrome (psychogenic cough)

DIAGNOSIS

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Assessment of chronic cough Diagnosis

Differentials

Common

◊ Upper airway cough syndrome (UACS; postnasal drip)

History Exam 1st Test Other tests

frequent throat clearing, mucopurulent »therapeutic

postnasal drip, nasal secretions in the trial: response to
discharge, nasal nasopharynx empirical therapy with
obstruction or sneezing and oropharynx antihistamine and
typical, halitosis or cobblestone decongestant
appearance of posterior There is no definitive
oropharynx test that can prove or
disprove the presence
of UACS; a combination
of symptoms, physical
examination findings,
and response to
therapy is required
for diagnosis.[37]
When a specific
cause for UACS (e.g.,
allergic rhinitis or nasal
polyposis) is suspected
based on history and
physical examination,
therapy should first be
directed towards those

DIAGNOSIS
entities.

Asthma

History Exam 1st Test Other tests

wheezing, chest wheezing and »spirometry with »fractional exhaled

tightness, dyspnoea, prolonged expiratory bronchodilator: nitric oxide (FeNO):
symptom variability, phase on pulmonary FEV1/FVC ratio is the elevated (>40 parts per
strong family history of examination primary diagnostic test billion)
asthma/atopic disease, A bronchodilator In an untreated patient,
cough, paroxysms, reversibility test absence of elevated
exacerbation by irritants
or seasonal exposures; may be used, which FeNO would make
cough may sometimes can demonstrate asthma unlikely.[49]
be the principal or reversibility of airflow
sole symptom, usually »other non-invasive
obstruction to a short-
worse at night (cough- airway inflammation
variant asthma)[10] acting bronchodilator, biomarkers (blood
usually defined as and sputum

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 Assessment of chronic cough Diagnosis

Common

Asthma

History Exam 1st Test Other tests

improvement in FEV1 eosinophil counts
by >12% and >200 and eosinophilic
cationic protein):
mL from baseline.[10] elevated
[26] Spirometry
»therapeutic trial:
can be normal in improvement in
some patients.[26] symptoms following a
If normal, further 2-4 week course of an
inhaled corticosteroid
investigations such as
or a leukotriene
bronchoprovocation receptor antagonist
testing are
»bronchoprovocation
recommended. testing: provocative
concentration of
methacholine causing
a 20% fall in FEV1
(PC20) <4 mg/mL
Increased airway
responsiveness to
inhaled methacholine
is a sensitive but
not specific feature
Flow-volume loop of asthma.[10]
(spirogram) in [26] Negative
obstructive lung methacholine challenge
disease, such as while not receiving
DIAGNOSIS

asthma or COPD: inhaled corticosteroids

peak expiratory flow essentially excludes
may be normal, but asthma.[10] [50]
a concave shape is
seen following the »FBC: normal or
elevated eosinophils
point of maximal
and/or neutrophilia
flow due to the low
»serum IgE
flow rate in relation
antibodies: elevated
to lung volume antigen-specific IgE
Created by BMJ antibodies
Knowledge Centre For suspected work-
related asthma, perform
»peak expiratory testing before and
flow rate (PEFR): after exposure, i.e., at
may be reduced; may
the end of a regular
be variability (>10%)
of measurements working week and after
recorded at different vacation.[15]
times of the day

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Assessment of chronic cough Diagnosis

Common

Asthma

History Exam 1st Test Other tests

PEFR should be »skin-prick allergy
measured in patients testing: may be
positive for allergen
with normal spirometry.
May be done to support
Variability of airway
diagnosis and gauge
obstruction can be
treatment.
used to support
the diagnosis of
asthma.[26] [47] [48]
The diagnosis of
asthma is supported
if there is excessive
variability in twice
daily PEFR over 2
weeks. In adults, an
average daily diurnal
variability in PEFR of
>10% is considered
excessive. An increase
in PEFR by >20%
from baseline after 4
weeks of treatment also
indicates excessive
variability.[10]

DIAGNOSIS
◊ Gastro-oesophageal reflux disease (GORD)

History Exam 1st Test Other tests

heartburn, dysphagia, no differentiating »therapeutic trial »24-hour

acid regurgitation, features on of proton-pump oesophageal pH
association of cough examination, may be inhibitors (PPIs) monitoring: pH
with slouched posture, overweight or obese for 8 weeks: relief of <4 for 4% or more
phonation, rising from symptoms of monitoring time
bed, or eating suggest Alleviation of symptoms and coinciding with
reflux disease; may be may require 8 weeks cough is consistent
silent[38] [41] with pathological acid
of PPI therapy, so the exposure
trial should not be Most sensitive and
considered 'negative' specific for reflux
before 8 weeks; disease-related cough.
in rare cases, this Testing first may be
improvement may take considered as an
up to 3 months.[40] [41] alternative to a PPI

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 Assessment of chronic cough Diagnosis

Common

◊ Gastro-oesophageal reflux disease (GORD)

History Exam 1st Test Other tests

As reflux disease trial. Controversy exists
is clinically silent in this regard.[41]
in 75% of cases, Testing should be
empirical therapy with performed if a PPI
a PPI should precede trial does not resolve
formal testing.[38] [41] symptoms but GORD
Patients should also be is still considered likely.
advised to lose weight A detailed assessment
if overweight or obese, of symptom correlation
to elevate the head with reflux events is
of the bed, and avoid most supportive of the
meals within 3 hours of diagnosis.[41]
bedtime.[41]
»barium
oesophagram: reflux
Not sensitive.

◊ Non-asthmatic eosinophilic bronchitis (NAEB)

History Exam 1st Test Other tests

chronic non- no differentiating »sputum or »FeNO: elevated

productive cough; no features on examination broncho-alveolar Sensitive in patients
differentiating features lavage (BAL) not treated with inhaled
on history differential count:
DIAGNOSIS

eosinophilia corticosteroids.[52]
Eosinophilia in
»therapeutic
sputum or BAL response to inhaled
without obstruction steroids: present
on spirometry, without Cough due to NAEB
peak flow variability improves after a course
or hyperreactivity on of inhaled steroids for
bronchoprovocation 4-6 weeks.
testing, suggests
NAEB.[51]

◊ Chronic bronchitis/COPD

History Exam 1st Test Other tests

history of smoking mild cases: »pulmonary »chest x-ray:

may be present; most respiratory function tests: hyperinflation, but may
cough may produce examinations are decreased FEV1,

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Assessment of chronic cough Diagnosis

Common

◊ Chronic bronchitis/COPD

History Exam 1st Test Other tests

sputum; dyspnoea, normal, may show FEV1/FVC <70%, not be present in some
especially exertional, quiet breath sounds, residual volume cases
may accompany the prolonged expiratory >120%, total lung Not useful in diagnosis,
cough phase, rhonchi, or capacity >120%, but may be useful
wheezes; advanced diffusion capacity for
cases: cyanosis, barrel CO <80% to exclude other
chest, use of accessory The 2022 Global conditions or
muscles of inspiration, Initiative for Chronic for diagnosing
increased S2 over comorbidities.[53]
left sternal border, or Obstructive Lung
peripheral oedema Disease (GOLD)
guideline recommends
a repeat spirometry
test if the FEV1/FVC
ratio is between 0.6 and
0.8.[53]

Spirometric, lung
volume, and diffusion
capacity may be
present in different
combinations
depending on the
clinical presentation.

DIAGNOSIS

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 Assessment of chronic cough Diagnosis

Common

◊ Chronic bronchitis/COPD

History Exam 1st Test Other tests

Flow-volume loop
(spirogram) in
obstructive lung
disease, such as
asthma or COPD:
peak expiratory flow
may be normal, but
a concave shape is
seen following the
point of maximal
flow due to the low
flow rate in relation
to lung volume
Created by BMJ
Knowledge Centre
DIAGNOSIS

◊ Angiotensin-converting enzyme inhibitor (ACE inhibitor)

History Exam 1st Test Other tests

dry cough, typically no specific examination »stop ACE inhibitor

associated with tickling findings use: resolution of
or scratching sensation cough
in the throat; cough Stopping ACE inhibitor
may begin within days resolves cough in 1-12
or months of initiating
ACE inhibitor therapy weeks, typically 1-4
weeks.[39]

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Assessment of chronic cough Diagnosis

Common

Pneumonia

History Exam 1st Test Other tests

fever, malaise, cough, dullness to percussion, »chest x-ray: »WCC (blood): usually
usually productive of decreased breath infiltrate suggestive of elevated but non-
sputum, chest pain[27] sounds, and presence pneumonia specific
of rales »serum C-reactive
protein (CRP): may be
elevated
CRP >10 mg/L has
a sensitivity of 90%
and a specificity of
48% for diagnosing
community-acquired
pneumonia.[56]

»sputum Gram stain

and culture: presence
of micro-organisms
and leukocytes in a
good sputum sample
(<25 squamous
epithelial cells per field)
supports the diagnosis
of respiratory tract
infection

◊ Post-infectious cough

DIAGNOSIS
History Exam 1st Test Other tests

cough of duration diagnosis is clinical and »chest x-ray: normal, »WCC (blood): usually
between 3 and 8 weeks one of exclusion rules out pneumonia elevated but non-
following symptoms specific
of acute respiratory »sputum Gram stain
infection; nasal/ and culture: presence
sinus congestion, of micro-organisms
non-purulent nasal and leukocytes in a
discharge, sore good sputum sample
throat[57] (<25 squamous
epithelial cells per field)
supports the diagnosis
of respiratory tract
infection

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 Assessment of chronic cough Diagnosis

Common

Bordetella pertussis infection

History Exam 1st Test Other tests

paroxysms of cough, petechiae and »nasopharyngeal »polymerase chain

post-tussive vomiting, conjunctival culture (if symptoms reaction, and/
or inspiratory whooping haemorrhages may <2 weeks): positive or serology (if
sound; more likely if result from cough In presence of symptoms present
local epidemiology paroxysms; lung symptoms, pertussis >4 weeks): positive
suggests increased examination is typically
prevalence normal should be diagnosed
using appropriate tests
when available, unless
another diagnosis is
proven.[57] Patient
should be isolated
for 5 days and case
reported to public
health authorities.
Enriched media is
required for culturing.

Uncommon

Lung cancer

History Exam 1st Test Other tests

DIAGNOSIS

history of tobacco central lung cancers »chest x-ray: »CT chest: presence
smoking, change in may cause unilateral presence of the lesion of the lesion and loco-
character of chronic localised wheezing; Up to 26% of the regional disease
cough, haemoptysis, superior vena cava parenchyma may »sputum cytology:
hoarseness, chest syndrome; cachexia
not be adequately may document
pain, weight loss, and symptoms related presence of malignant
superior vena cava to distant metastases visualised on a chest x-
cells
syndrome (localised (e.g., bone pain) are ray.[54]
oedema of face and late symptoms »bronchoscopy:
upper extremities, facial presence of tumour
plethora, distended Allows visualisation of
neck and chest veins), extent of tumour and
symptoms related to
collection of material for
distant metastases and
advanced stages of biopsy.
cancer

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Assessment of chronic cough Diagnosis

Uncommon

◊ Bronchiectasis and chronic suppurative lung disease

History Exam 1st Test Other tests

cough productive crackles and wheezing, »chest x- »pulmonary

of large amounts of predominantly over ray: increased function tests:
mucopurulent sputum, lower lobes; clubbing in bronchovascular irreversible obstructive
diurnal variation (e.g., a minority of patients markings defect, with FEV1/FVC
worse in the morning), Sensitive but not <70%
positional worsening; specific finding. Should Peak expiratory flow
dyspnoea, wheezing, may be normal, but a
haemoptysis; be the first examination
paroxysmal cough non- if high-resolution CT not concave shape is seen
productive of sputum available. following the point of
may sometimes be maximal flow due to the
present »high-resolution low flow rate in relation
CT chest: bronchial
to lung volume.
dilatation, size of the
bronchi exceeding
the size of the
accompanying artery,
lack of tapering of the
bronchi at the lung
peripheries[55]
Should be the first
examination if available.

Flow-volume loop
(spirogram) in
obstructive lung
disease, such as

DIAGNOSIS
asthma or COPD:
peak expiratory flow
may be normal, but
a concave shape is
seen following the
point of maximal
flow due to the low
flow rate in relation
to lung volume
Created by BMJ
Knowledge Centre

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 Assessment of chronic cough Diagnosis

Uncommon

Interstitial pulmonary fibrosis

History Exam 1st Test Other tests

dyspnoea of sub-acute dry, velcro crackles, »chest x-ray: »pulmonary

onset dominates the typically over lung increased interstitial function tests:
clinical picture; cough bases; clubbing may be markings restrictive pattern with
typically dry present First test if high- total lung capacity
resolution CT not <80%, functional
residual capacity <80%,
available. and vital capacity
<80%, with diffusion
»high-resolution capacity for CO <80%
CT chest: interstitial
Flow-volume loop
pneumonitis: patchy,
predominantly basilar (spirogram) in
and sub-pleural restrictive lung disease
reticular changes with (e.g., interstitial
honeycombing and
pulmonary fibrosis).
traction bronchiectasis
in later stages of the
disease
Confirmatory, sensitive
and specific. Findings
depend on specific
interstitial pathology.
Interstitial pneumonitis
is the most common
form. Flow-volume loop
(spirogram) in
restrictive lung
DIAGNOSIS

disease (e.g.,
interstitial pulmonary
fibrosis): peak
expiratory flow may
be normal or low.
The shape of the
curve is generally
normal, but the loop
is narrowed and the
forced vital capacity
is low because of the
reduced lung volume.
Created by BMJ
Knowledge Centre

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Assessment of chronic cough Diagnosis

Uncommon

Interstitial pulmonary fibrosis

History Exam 1st Test Other tests

»biopsy: pattern
of usual interstitial
pneumonia

◊ Sarcoidosis

History Exam 1st Test Other tests

most patients most often normal; »chest x-ray: various »chest CT with
asymptomatic; skin lesions (erythema findings, bilateral high-resolution
symptomatic patients: nodosum and hilar and mediastinal cuts: bilateral hilar
shortness of breath, maculopapular skin lymphadenopathy, and mediastinal
dyspnoea on exertion, lesions), enlargement reticular infiltrates; lymphadenopathy,
and chest pain are of lacrimal glands, fibrosis with decreased interstitial infiltrates
present in minority of lymphadenopathy lung volumes in late »pulmonary
patients; low-grade in cervical, sarcoidosis function tests: often
fever; other symptoms supraclavicular, or Severity of radiographic normal, but may show
reflect involvement of axillary areas; redness lung involvement may non-specific reduction
various organs of eye, tearing, and
not correlate with in diffusion capacity,
photophobia may obstruction, restriction,
represent uveitis severity of physiological
or mixed picture
deficit. Not sensitive or specific
for this disorder,
but results may
influence therapeutic
choices once coupled

DIAGNOSIS
with clinical and
radiographic data.

»bronchoscopy
with biopsy: non-
caseating granuloma
is supportive, but
other granulomatous
disorders should be
reasonably excluded
with special stains and
clinical assessment
When pulmonary
involvement is present,
has a high sensitivity.

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 Assessment of chronic cough Diagnosis

Uncommon

Tuberculosis (TB)

History Exam 1st Test Other tests

residence in/visit to fever, cachexia, »chest x-ray: primary »tuberculin skin

high-prevalence area; tachycardia; asymmetry TB: mid-lung infiltrate; test: positive
immunosuppressed in chest movement and secondary TB: Reactivity to intra-
status (e.g., dullness to percussion predominantly upper dermal injection of
HIV infection, due to pleural effusion, lobe infiltrates with
immunosuppressant bronchial breathing, distinct tendency for tuberculin is primarily
medication, transplant crackles, rales due fibrosis and volume used to detect latent
recipients, diabetes, to an infiltrate or loss TB, but may be used as
dialysis treatment); rhonchi in presence of Calcified parenchymal an adjunct in diagnosis
epidemiological risk significant bronchial and hilar lymph node
factors, particularly purulence; palpable of active TB.
close contact with extra-thoracic granulomata may
support the diagnosis; »interferon-gamma
active TB; history of lymphadenopathy is
release assays:
anorexia, malaise, uncommon pleural effusion may
positive
weight loss, fever, or accompany both
night sweats; chronic Detection of
cough productive of primary and secondary lymphocytes reacting
sputum, occasionally TB. to tuberculin in vitro is
associated with
»sputum Gram stain primarily used to detect
haemoptysis
and culture: presence latent TB, but may be
of acid-fast bacilli used as an adjunct in
(Ziehl-Neelsen stain) diagnosis of active TB.
in sputum or broncho-
alveolar lavage (BAL) »lateral flow urine
Culture of lipoarabinomannan
Mycobacterium (LF-LAM) assay:
tuberculosis typically positive
DIAGNOSIS

One Cochrane
takes several weeks
review found the
(up to 8); decisions on
lateral flow urine
treatment are usually
lipoarabinomannan
made before culture
(LF-LAM) assay to
results are known.
have a sensitivity of
»nucleic acid 42% in diagnosing
amplification tests TB in HIV-positive
(NAAT): positive for M
tuberculosis individuals with TB
NAAT should be symptoms, and 35% in
performed on at HIV-positive individuals
least one respiratory not assessed for TB
specimen when a symptoms.[62] WHO
diagnosis of TB is being recommends that
considered. NAAT may LF-LAM can be
speed the diagnosis used to assist in the
in smear-negative diagnosis of active
cases and may be TB in HIV-positive

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Assessment of chronic cough Diagnosis

Uncommon

Tuberculosis (TB)

History Exam 1st Test Other tests

helpful to differentiate adults, adolescents,
non-tuberculous and children.[63]
mycobacteria when
Culture would still
sputum is AFB smear
be required for drug
positive but NAAT
susceptibility testing
negative.[58]

Genotyping might be
considered useful in
outbreaks of TB to
identify transmission
of TB, especially when
contact had not been
appreciated in the
course of epidemiologic
investigations. Several
rapid NAATs are
available and some
are also able to detect
genes encoding
resistance to TB
drugs.[59] [60] [61]

◊ Zenker’s diverticulum

DIAGNOSIS
History Exam 1st Test Other tests

dysphagia present halitosis, voice changes »barium »endoscopy:

in 98% of patients; oesophagram: visualisation of
regurgitation of bland positive contrast within diverticulum
undigested food; the structure connected
frequent aspiration; to the posterior wall
noisy deglutition of oesophagus is
(gurgling); halitosis; consistent with a
voice changes diverticulum

Thoracic aortic aneurysm (TAA)

History Exam 1st Test Other tests

most patients have no generally no obvious »chest radiograph: »spiral CT of

symptoms attributable physical findings in widened mediastinum, chest with three-
to TAA at the time chest area unless prominence of the dimensional

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 Assessment of chronic cough Diagnosis

Uncommon

Thoracic aortic aneurysm (TAA)

History Exam 1st Test Other tests

of diagnosis; most tracheal deviation aortic knob, or tracheal reconstructions:
common initial is present; patients deviation visualisation of
symptom is vague pain, with an abdominal aneurysm, seen as an
which can occur in the component may have increase in size of a
chest, back, flank, or a pulsatile abdominal section of the aorta
abdomen; hoarseness mass similar to pure »MRI and magnetic
due to stretching or abdominal aortic resonance
compression of left aneurysms; signs angiography:
recurrent laryngeal of arterial perfusion visualisation of
nerve; tracheal differentials in both aneurysm, seen as an
deviation, persistent upper and lower increase in size of a
cough, or other extremities; evidence section of the aorta
respiratory symptoms of visceral ischaemia;
such as shortness of focal neurological
breath or chest pain; deficits; murmur of
dysphagia (uncommon) aortic regurgitation;
due to compression bruits
of the oesophagus by
the aneurysm; sudden
and catastrophic
haemoptysis or
haematemesis;
neurological deficits
including paraplegia

Foreign body

History Exam 1st Test Other tests

DIAGNOSIS

abrupt onset, more may be asymptomatic »laryngoscopy/ »chest CT:

common in young or show signs of bronchoscopy: visualisation of foreign
children airways obstruction, visualisation of foreign body
including cough, body
wheeze, decreased »chest x-ray:
breath sounds, visualisation of foreign
dyspnoea, or fever body (if object is radio-
opaque)

◊ Hypersensitivity pneumonitis

History Exam 1st Test Other tests

occupational/ clubbing, increased »chest x-ray: fibrotic »chest CT: features of

environmental exposure respiratory rate, changes; loss of lung fibrosis
to allergens (e.g., inspiratory crackles volume particularly »IgG testing: high
farmers, bird breeders), over lower lung fields affecting the upper titres with antigen-
progressive dyspnoea, lobes specific antibodies
fatigue, and weight loss

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Assessment of chronic cough Diagnosis

Uncommon

◊ Bronchiolitis

History Exam 1st Test Other tests

age <1 year, cough, high respiratory rate, »chest x-ray: »virology: may be
wheeze, and accessory muscle consolidation and positive for respiratory
dyspnoea, history of use, retractions, atelectasis in severe syncytial virus
prematurity, underlying wheezes, crackles, disease Rarely useful in making
cardiopulmonary purulent secretions on management decisions.
disease or bronchoscopy
immunodeficiency »high-resolution CT
scan: signs of small
airways disease

Recurrent aspiration

History Exam 1st Test Other tests

dysphagia, association signs of neurological »chest x-ray:

of cough with eating/ disease such as stroke, persistent lower lobe
drinking, fear of choking multiple sclerosis, infiltrates
with eating/drinking; Parkinson's disease »swallow evaluation:
may have history of aspiration
neurological disease
Patient should be
including stroke,
multiple sclerosis, referred to speech-
Parkinson's disease language pathologist
for this evaluation.

◊ Tropical filarial pulmonary eosinophilia

DIAGNOSIS
History Exam 1st Test Other tests

travel to endemic area frequently normal; »blood count »filarial antibody

(sub-Saharan Africa, wheezing, rhonchi, with differential: levels: elevated
Indian subcontinent, crackles may be eosinophilia »serum IgE: elevated
southeast Asia, present on lung exam; »chest x-ray:
Oceania); dry, some patients develop increased interstitial
paroxysmal cough, hepatosplenomegaly markings
frequently nocturnal

◊ Somatic cough syndrome (psychogenic cough)

History Exam 1st Test Other tests

extensive evaluation cough improves »none: extensive

has ruled out other following behaviour evaluation has already
causes modification or ruled out other causes
psychiatric therapy

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DIAGNOSIS Assessment of chronic cough Diagnosis

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Assessment of chronic cough Guidelines

Guidelines

United Kingdom

Bronchiolitis in children: diagnosis and management (ht tps://

www.nice.org.uk/guidance/ng9)

Published by: National Institute for Health and Care Excellence

Last published: 2021

Asthma: diagnosis, monitoring and chronic asthma management (ht tps://

www.nice.org.uk/guidance/ng80)

Published by: National Institute for Health and Care Excellence

Last published: 2020

GUIDELINES
British guideline on the management of asthma (ht tps://www.brit-
thoracic.org.uk/quality-improvement/guidelines/asthma)

Published by: British Thoracic Society; Scottish Intercollegiate Guidelines Network

Last published: 2019

Europe

European Respiratory Society guidelines for the diagnosis of asthma in

adults (ht tps://www.ersnet.org/guidelines)

Published by: European Respiratory Society

Last published: 2022

European Respiratory Society clinical practice guidelines for the diagnosis of

asthma in children aged 5–16 years (ht tps://www.ersnet.org/guidelines)

Published by: European Respiratory Society

Last published: 2021

European Respiratory Society guidelines on the diagnosis and treatment of

chronic cough in adults and children (ht tps://www.ersnet.org/guidelines)

Published by: European Respiratory Society

Last published: 2020

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 Assessment of chronic cough Guidelines

International

Global strategy for the diagnosis, management, and prevention of chronic

obstructive pulmonary disease: 2022 report (ht tps://goldcopd.org/2022-gold-
reports-2)

Published by: Global Initiative for Chronic Obstructive Lung Disease

Last published: 2022

Global strategy for asthma management and prevention (ht tps://

ginasthma.org/gina-reports)

Published by: Global Initiative for Asthma

Last published: 2022
GUIDELINES

North America

ACR Appropriateness Criteria: chronic cough (ht tps://www.acr.org/Clinical-

Resources/ACR-Appropriateness-Criteria)

Published by: American College of Radiology

Last published: 2021

Focused updates to the Asthma management guidelines (ht tps://

www.nhlbi.nih.gov/health-topics/asthma-management-guidelines-2020-
updates)

Published by: National Institutes of Health

Last published: 2020

Managing Chronic Cough Due to Asthma and NAEB in Adults and

Adolescents CHEST Guideline and Expert Panel Report (ht tps://
journal.chestnet.org/guidelines)

Published by: American College of Chest Physicians

Last published: 2020

Classification of cough as a symptom in adults and management algorithms

(ht tps://journal.chestnet.org/guidelines)

Published by: American College of Chest Physicians

Last published: 2017

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BMJ Best Practice topics are regularly updated and the most recent version
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Assessment of chronic cough Guidelines

North America

Chronic cough due to gastroesophageal reflux in adults (ht tps://

journal.chestnet.org/guidelines)

Published by: American College of Chest Physicians

Last published: 2016

Somatic cough syndrome (previously referred to as psychogenic cough)

and tic cough (previously referred to as habit cough) in adults and children
(ht tps://journal.chestnet.org/guidelines)

Published by: American College of Chest Physicians

Last published: 2015

GUIDELINES
Guidelines for the diagnosis and management of asthma (ht tps://
www.nhlbi.nih.gov/health-topics/all-publications-and-resources?
field_audience_target_id%5B220%5D=220)

Published by: National Institutes of Health

Last published: 2007

ACG clinical guideline for the diagnosis and management of

gastroesophageal reflux disease (ht tps://gi.org/guidelines)

Published by: American College of Gastroenterology

Last published: 2022

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 Assessment of chronic cough Evidence tables

Evidence tables
What is the diagnostic yield of chest computed tomography (CT) scan in people
EVIDENCE TABLES

with chronic cough, normal chest x-ray and physical examination?[3]

This table is a summary of the analysis reported in a guideline (underpinned by a systematic review)
that focuses on the above important clinical question.

View the full source guideline (https://erj.ersjournals.com/content/55/1/1901136.figures-only)

Evidence C * Confidence in the evidence is very low or low where GRADE has been performed
and the intervention may be less effective or likely to be more harmful than the
comparison for key outcomes. However, this is uncertain and new evidence could
change this in the future.

Population: People with chronic cough and normal chest x-ray and physical examination
Intervention: Chest CT scan
Comparison: No chest CT scan

† ‡
Outcome Effectiveness (BMJ rating) Confidence in evidence (GRADE)

Diagnostic yield See note ᵃ Very Low

Recommendations as stated in the source guideline

We suggest that clinicians do not routinely perform a chest CT scan in patients with chronic cough who have
a normal chest radiograph and physical examination.

Note
ᵃ The content of this table is based on four observational studies. One prospective study found that the
diagnostic yield of chest CT scan was 3/46 (6.5%) participants, while three retrospective studies produced
the following results: 20/34 (58%) participants, 9/21 (43%) participants, and 21/59 (36%) participants.

The guideline task force noted that the variation in the above results, regarding the diagnostic yield of CT
scan, were unlikely to explain the cause of coughs or influence treatment.

The guideline task force also noted that there is concern about the potential cancer risk from CT radiation
exposure, particularly in children and women, which should be weighed against any diagnostic yields.

52 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 01, 2022.
BMJ Best Practice topics are regularly updated and the most recent version
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Assessment of chronic cough Evidence tables
* Evidence levels
The Evidence level is an internal rating applied by BMJ Best Practice. See the EBM Toolkit (https://
bestpractice.bmj.com/info/evidence-tables/) for details.

EVIDENCE TABLES
Confidence in evidence

A - High or moderate to high

B - Moderate or low to moderate
C - Very low or low

† Effectiveness (BMJ rating)

Based on statistical significance, which demonstrates that the results are unlikely to be due to chance, but
which does not necessarily translate to a clinical significance.

‡ Grade certainty ratings

High The authors are very confident that the true

effect is similar to the estimated effect.
Moderate The authors are moderately confident that
the true effect is likely to be close to the
estimated effect.
Low The authors have limited confidence in the
effect estimate and the true effect may be
substantially different.
Very Low The authors have very little confidence in
the effect estimate and the true effect is
likely to be substantially different.
BMJ Best Practice EBM Toolkit: What is GRADE? (https://bestpractice.bmj.com/info/toolkit/learn-ebm/what-
is-grade/)

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53
of the topics can be found on bestpractice.bmj.com . Use of this content is
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 Assessment of chronic cough References

Key articles
• Morice AH, Millqvist E, Bieksiene K, et al. ERS guidelines on the diagnosis and treatment of
REFERENCES

chronic cough in adults and children. Eur Respir J. 2020 Jan;55(1):1901136. Full text (https://
erj.ersjournals.com/content/55/1/1901136.long) Abstract

• Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management of cough executive summary:
ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 suppl):1S-23S. Full text
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3345522) Abstract

• American College of Radiology. ACR Appropriateness Criteria: chronic cough. Nov 2021 [internet
publication]. Full text (https://acsearch.acr.org/docs/3158177/Narrative) Abstract

• Kahrilas PJ, Altman KW, Chang AB, et al. Chronic cough due to gastroesophageal reflux in adults:
CHEST guideline and expert panel report. Chest. 2016 Dec;150(6):1341-60. Full text (https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC6026249) Abstract

• National Asthma Education and Prevention Program. Expert panel report 3: guidelines for the
diagnosis and management of asthma: full report 2007. August 2007 [internet publication].

References
1. Hermer L, Kang K, Rui P, et al. National ambulatory medical care survey - community health centers:
2014 state and national summary tables. 2019 [internet publication]. Full text (https://www.cdc.gov/
nchs/data/ahcd/namcs_summary/2014_namcs_chc_web_tables-508.pdf)

2. Irwin RS, French CL, Chang AB, et al. Classification of cough as a symptom in adults and
management algorithms: CHEST guideline and expert panel report. Chest. 2018 Jan;153(1):196-209.
Full text (http://journal.chestnet.org/article/S0012-3692(17)32918-5/fulltext) Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/29080708?tool=bestpractice.bmj.com)

3. 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. 2020 Jan;55(1):1901136. Full text
(https://erj.ersjournals.com/content/55/1/1901136.long) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/31515408?tool=bestpractice.bmj.com)

4. Chang AB, Oppenheimer JJ, Irwin RS, et al. Managing Chronic Cough as a Symptom in
Children and Management Algorithms: CHEST Guideline and Expert Panel Report. Chest. 2020
Jul;158(1):303-329. Full text (https://www.doi.org/10.1016/j.chest.2020.01.042) Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/32179109?tool=bestpractice.bmj.com)

5. Kwon NH, Oh MJ, Min TH, et al. Causes and clinical features of subacute cough. Chest. 2006
May;129(5):1142-7. Full text (http://journal.chestnet.org/article/S0012-3692(15)50691-0/fulltext)
Abstract (http://www.ncbi.nlm.nih.gov/pubmed/16685003?tool=bestpractice.bmj.com)

54 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 01, 2022.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2022. All rights reserved.
Assessment of chronic cough References
6. Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management of cough executive summary:
ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 suppl):1S-23S. Full text
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3345522) Abstract (http://www.ncbi.nlm.nih.gov/

REFERENCES
pubmed/16428686?tool=bestpractice.bmj.com)

7. Gonlugur U, Gonlugur TE. Eosinophilic bronchitis without asthma. Int Arch Allergy Immunol.
2008;147(1):1-5. Full text (http://www.karger.com/Article/FullText/128580) Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/18446047?tool=bestpractice.bmj.com)

8. Ramanuja S, Kelkar P. Habit cough. Ann Allergy Asthma Immunol. 2009 Feb;102(2):91-5. Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/19230457?tool=bestpractice.bmj.com)

9. Ojoo JC, Everett CF, Mulrennan SA, et al. Management of patients with chronic cough using
a clinical protocol: a prospective observational study. Cough. 2013 Jan 24;9(1):2. Full text
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3565860) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/23347748?tool=bestpractice.bmj.com)

10. Global Initiative for Asthma. Global strategy for asthma management and prevention. 2022 [internet
publication]. Full text (https://ginasthma.org/gina-reports)

11. Bangalore S, Kumar S, Messerli FH. Angiotensin-converting enzyme inhibitor associated cough:
deceptive information from the Physicians' Desk Reference. Am J Med. 2010 Nov;123(11):1016-30.
Full text (https://www.doi.org/10.1016/j.amjmed.2010.06.014) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/21035591?tool=bestpractice.bmj.com)

12. Alharbi FF, Kholod AAV, Souverein PC, et al. The impact of age and sex on the reporting of cough
and angioedema with renin-angiotensin system inhibitors: a case/noncase study in VigiBase. Fundam
Clin Pharmacol. 2017 Dec;31(6):676-684. Full text (https://www.doi.org/10.1111/fcp.12313) Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/28767167?tool=bestpractice.bmj.com)

13. Brugts JJ, Arima H, Remme W, et al. The incidence and clinical predictors of ACE-inhibitor
induced dry cough by perindopril in 27,492 patients with vascular disease. Int J Cardiol. 2014 Oct
20;176(3):718-23. Full text (https://www.doi.org/10.1016/j.ijcard.2014.07.108) Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/25189490?tool=bestpractice.bmj.com)

14. Braman SS. Chronic cough due to chronic bronchitis: ACCP evidence-based clinical practice
guidelines. Chest. 2006 Jan;129(1 suppl):104S-15S. Full text (https://www.doi.org/10.1378/
chest.129.1_suppl.104S) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/16428699?
tool=bestpractice.bmj.com)

15. Tarlo SM, Altman KW, Oppenheimer J, et al. Occupational and environmental contributions to
chronic cough in adults: chest expert panel report. Chest. 2016 Oct;150(4):894-907. Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/27521735?tool=bestpractice.bmj.com)

16. Canning BJ, Chang AB, Bolser DC, et al. Anatomy and neurophysiology of cough: CHEST Guideline
and Expert Panel report. Chest. 2014 Dec;146(6):1633-48. Full text (https://www.doi.org/10.1378/
chest.14-1481) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/25188530?tool=bestpractice.bmj.com)

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 01, 2022.
BMJ Best Practice topics are regularly updated and the most recent version
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of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2022. All rights reserved.
 Assessment of chronic cough References
17. Siddiq MA, Sood S, Strachan D. Pharyngeal pouch (Zenker's diverticulum). Postgrad Med J. 2001
Aug;77(910):506-11. Full text (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1742115) Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/11470929?tool=bestpractice.bmj.com)
REFERENCES

18. Miller CP, Firoozan S, Woo EK, et al. Chronic cough: a herald symptom of thoracic aortic aneurysm
in a patient with a bicuspid aortic valve. BMJ Case Rep. 2014 Sep 1;2014. Full text (https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC4158188) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/25178892?tool=bestpractice.bmj.com)

19. Vertigan AE, Murad MH, Pringsheim T, et al. Somatic cough syndrome (previously referred
to as psychogenic cough) and tic cough (previously referred to as habit cough) in adults and
children: CHEST guideline and expert panel report. Chest. 2015 Jul;148(1):24-31. Full text
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4493876) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/25856777?tool=bestpractice.bmj.com)

20. Greenhalgh T, Knight M, A'Court C, et al. Management of post-acute covid-19 in primary care.
BMJ. 2020 Aug 11;370:m3026. Full text (https://www.doi.org/10.1136/bmj.m3026) Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/32784198?tool=bestpractice.bmj.com)

21. National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing the long-term
effects of COVID-19. Dec 2020 [internet publication]. Full text (https://www.nice.org.uk/guidance/
ng188)

22. National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. Dec
2021 [internet publication]. Full text (https://www.nice.org.uk/guidance/ng12)

23. National Institute for Health and Care Excellence. Lung cancer: diagnosis and management. Aug 2022
[internet publication].

24. Kavanagh J, Jackson DJ, Kent BD. Over- and under-diagnosis in asthma. Breathe (Sheff). 2019
Mar;15(1):e20-7. Full text (https://www.doi.org/10.1183/20734735.0362-2018) Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/31031841?tool=bestpractice.bmj.com)

25. British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the
management of asthma: a national clinical guideline. July 2019 [internet publication]. Full text (https://
www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma)

26. Louis R, Satia I, Ojanguren I, et al. European Respiratory Society guidelines for the
diagnosis of asthma in adults. Eur Respir J. 2022 Feb 15:2101585. Full text (https://
www.doi.org/10.1183/13993003.01585-2021) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/35169025?tool=bestpractice.bmj.com)

27. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired
pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious
Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. Full text (https://
www.idsociety.org/practice-guideline/community-acquired-pneumonia-cap-in-adults) Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.bmj.com)

56 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 01, 2022.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2022. All rights reserved.
Assessment of chronic cough References
28. World Health Organization. Global tuberculosis report. October 2019 [internet publication]. Full text
(https://apps.who.int/iris/bitstream/handle/10665/329368/9789241565714-eng.pdf?ua=1)

REFERENCES
29. Campbell JR, Winters N, Menzies D. Absolute risk of tuberculosis among untreated populations with
a positive tuberculin skin test or interferon-gamma release assay result: systematic review and meta-
analysis. BMJ. 2020 Mar 10;368:m549. Full text (https://www.doi.org/10.1136/bmj.m549) Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/32156698?tool=bestpractice.bmj.com)

30. Gibson P, Wang G, McGarvey L, et al. Treatment of unexplained chronic cough: CHEST guideline
and expert panel report. Chest. 2016 Jan;149(1):27-44. Full text (https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC5831652) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/26426314?
tool=bestpractice.bmj.com)

31. American College of Radiology. ACR Appropriateness Criteria: chronic cough. Nov 2021 [internet
publication]. Full text (https://acsearch.acr.org/docs/3158177/Narrative) Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/34794590?tool=bestpractice.bmj.com)

32. Leconte S, Ferrant D, Dory V, et al. Validated methods of cough assessment: a systematic review of
the literature. Respiration. 2011;81(2):161-74. Full text (http://www.karger.com/Article/FullText/321231)
Abstract (http://www.ncbi.nlm.nih.gov/pubmed/21079381?tool=bestpractice.bmj.com)

33. Lin L, Poh KL, Lim TK. Empirical treatment of chronic cough: a cost-effectiveness analysis. Proc AMIA
Symp. 2001:383-7. Full text (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2243434) Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/11825215?tool=bestpractice.bmj.com)

34. Kuzniar TJ, Morgenthaler TI, Afessa B, et al. Chronic cough from the patient's perspective. Mayo
Clin Proc. 2007 Jan;82(1):56-60. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/17285786?
tool=bestpractice.bmj.com)

35. McGarvey LP, Heaney LG, Lawson JT, et al. Evaluation and outcome of patients with chronic non-
productive cough using a comprehensive diagnostic protocol. Thorax. 1998 Sep;53(9):738-43. Full
text (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1745317) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/10319055?tool=bestpractice.bmj.com)

36. Côté A, Russell RJ, Boulet LP, et al. Managing Chronic Cough Due to Asthma and NAEB in Adults
and Adolescents: CHEST Guideline and Expert Panel Report. Chest. 2020 Jul;158(1):68-96.
Full text (https://linkinghub.elsevier.com/retrieve/pii/S0012-3692(20)30045-3) Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/31972181?tool=bestpractice.bmj.com)

37. Pratter MR. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously
referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Chest.
2006 Jan;129(1 suppl):63S-71. Full text (http://journal.chestnet.org/article/S0012-3692(15)52833-X/
fulltext) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/16428694?tool=bestpractice.bmj.com)

38. Irwin RS, French CL, Curley FJ, et al. Chronic cough due to gastroesophageal reflux. Clinical,
diagnostic, and pathogenetic aspects. Chest. 1993 Nov;104(5):1511-7. Full text (http://
journal.chestnet.org/article/S0012-3692(15)42301-3/fulltext) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/8222816?tool=bestpractice.bmj.com)

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BMJ Best Practice topics are regularly updated and the most recent version
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of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2022. All rights reserved.
 Assessment of chronic cough References
39. Dicpinigaitis PV. Angiotensin-converting enzyme inhibitor-induced cough: ACCP evidence-
based clinical practice guidelines. Chest. 2006 Jan;129(1 suppl):169S-73. Full text (http://
journal.chestnet.org/article/S0012-3692(15)52845-6/fulltext) Abstract (http://www.ncbi.nlm.nih.gov/
REFERENCES

pubmed/16428706?tool=bestpractice.bmj.com)

40. Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG Clinical Guideline for the Diagnosis and
Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2022 Jan 1;117(1):27-56.
Abstract (http://www.ncbi.nlm.nih.gov/pubmed/34807007?tool=bestpractice.bmj.com)

41. Kahrilas PJ, Altman KW, Chang AB, et al. Chronic cough due to gastroesophageal reflux in
adults: CHEST guideline and expert panel report. Chest. 2016 Dec;150(6):1341-60. Full text
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026249) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/27614002?tool=bestpractice.bmj.com)

42. Faruqi S, Molyneux ID, Fathi H, et al. Chronic cough and esomeprazole: a double-blind placebo-
controlled parallel study. Respirology. 2011 Oct;16(7):1150-6. Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/21707852?tool=bestpractice.bmj.com)

43. British Thoracic Society and Scottish Intercollegiate Guidelines Network. British guideline on the
management of asthma. July 2019 [internet publication]. Full text (https://www.brit-thoracic.org.uk/
quality-improvement/guidelines/asthma)

44. Chang AB, Bell SC, Byrnes CA, et al. Chronic suppurative lung disease and bronchiectasis
in children and adults in Australia and New Zealand: a position statement from the Thoracic
Society of Australia and New Zealand and the Australian Lung Foundation. Med J Aust. 2010 Sep
20;193(6):356-65. Full text (https://www.mja.com.au/journal/2010/193/6/chronic-suppurative-lung-
disease-and-bronchiectasis-children-and-adults-australia) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/20854242?tool=bestpractice.bmj.com)

45. Bucca C, Culla B, Brussino L, et al. Effect of iron supplementation in women with chronic cough and
iron deficiency. Int J Clin Pract. 2012 Nov;66(11):1095-100. Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/23067033?tool=bestpractice.bmj.com)

46. Murry T, Sapienza C. The role of voice therapy in the management of paradoxical vocal fold motion,
chronic cough, and laryngospasm. Otolaryngol Clin North Am. 2010 Feb;43(1):73-83. Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/20172258?tool=bestpractice.bmj.com)

47. National Asthma Education and Prevention Program. Expert panel report 3: guidelines for the
diagnosis and management of asthma: full report 2007. August 2007 [internet publication].

48. Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered
and coordinated National Asthma Education and Prevention Program Coordinating Committee
(NAEPPCC)., Cloutier MM, Baptist AP, et al. 2020 Focused updates to the asthma management
guidelines: a report from the National Asthma Education and Prevention Program Coordinating
Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020 Dec;146(6):1217-70.
Full text (https://www.doi.org/10.1016/j.jaci.2020.10.003) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/33280709?tool=bestpractice.bmj.com)

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Assessment of chronic cough References
49. Chatkin JM, Ansarin K, Silkoff PE, et al. Exhaled nitric oxide as a noninvasive assessment of chronic
cough. Am J Respir Crit Care Med. 1999 Jun;159(6):1810-3. Full text (http://www.atsjournals.org/doi/
full/10.1164/ajrccm.159.6.9809047)

REFERENCES
50. Cockcroft DW. Direct challenge tests: airway hyperresponsiveness in asthma: its measurement and
clinical significance. Chest. 2010 Aug;138(2 suppl):18S-24. Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/20668014?tool=bestpractice.bmj.com)

51. Brightling CE. Chronic cough due to nonasthmatic eosinophilic bronchitis: ACCP evidence-
based clinical practice guidelines. Chest. 2006 Jan;129(1 suppl):116S-21. Full text (http://
journal.chestnet.org/article/S0012-3692(15)52839-0/fulltext) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/16428700?tool=bestpractice.bmj.com)

52. Berlyne GS, Parameswaran K, Kamada D, et al. A comparison of exhaled nitric oxide and induced
sputum as markers of airway inflammation. J Allergy Clin Immunol. 2000 Oct;106(4):638-44. Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/11031333?tool=bestpractice.bmj.com)

53. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management,
and prevention of chronic obstructive pulmonary disease. 2022 [internet publication]. Full text (https://
goldcopd.org/2022-gold-reports-2)

54. Chotas HG, Ravin CE. Chest radiography: estimated lung volume and projected area obscured
by heart, mediastinum and diaphragm. Radiology. 1994 Nov;193(2):403-4. Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/7972752?tool=bestpractice.bmj.com)

55. British Thoracic Society. BTS guideline for bronchiectasis in adults. December 2018 [internet
publication]. Full text (https://brit-thoracic.org.uk/quality-improvement/guidelines/bronchiectasis-in-
adults)

56. Ebell MH, Bentivegna M, Cai X, et al. Accuracy of biomarkers for the diagnosis of adult community-
acquired pneumonia: a meta-analysis. Acad Emerg Med. 2020 Mar;27(3):195-206. Full text (https://
www.doi.org/10.1111/acem.13889) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/32100377?
tool=bestpractice.bmj.com)

57. Braman SS. Postinfectious cough: ACCP evidence-based clinical practice guidelines. Chest. 2006
Jan;129(1 suppl):138S-46. Full text (http://journal.chestnet.org/article/S0012-3692(15)52842-0/fulltext)
Abstract (http://www.ncbi.nlm.nih.gov/pubmed/16428703?tool=bestpractice.bmj.com)

58. Centers for Disease Control and Prevention. Updated guidelines for the use of nucleic acid
amplification tests in the diagnosis of tuberculosis. Jan 2009 [internet publication]. Full text (https://
www.cdc.gov/mmwr/preview/mmwrhtml/mm5801a3.htm)

59. World Health Organization. WHO consolidated guidelines on tuberculosis Module 3: Diagnosis
- Rapid diagnostics for tuberculosis detection. Jun 2020 [internet publication]. Full text (https://
www.who.int/publications/i/item/who-consolidated-guidelines-on-tuberculosis-module-3-diagnosis---
rapid-diagnostics-for-tuberculosis-detection)

60. Zifodya JS, Kreniske JS, Schiller I, et al. Xpert Ultra versus Xpert MTB/RIF for pulmonary
tuberculosis and rifampicin resistance in adults with presumptive pulmonary tuberculosis. Cochrane

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 01, 2022.
BMJ Best Practice topics are regularly updated and the most recent version
59
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2022. All rights reserved.
 Assessment of chronic cough References
Database Syst Rev. 2021 Feb 22;2:CD009593. Full text (https://www.cochranelibrary.com/
cdsr/doi/10.1002/14651858.CD009593.pub5/full) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/33616229?tool=bestpractice.bmj.com)
REFERENCES

61. Shapiro AE, Ross JM, Yao M, et al. Xpert MTB/RIF and Xpert Ultra assays for screening for
pulmonary tuberculosis and rifampicin resistance in adults, irrespective of signs or symptoms.
Cochrane Database Syst Rev. 2021 Mar 23;3:CD013694. Full text (https://www.cochranelibrary.com/
cdsr/doi/10.1002/14651858.CD013694.pub2/full) Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/33755189?tool=bestpractice.bmj.com)

62. Bjerrum S, Schiller I, Dendukuri N, et al. Lateral flow urine lipoarabinomannan assay for
detecting active tuberculosis in people living with HIV. Cochrane Database Syst Rev. 2019 Oct
21;10:CD011420. Full text (https://www.doi.org/10.1002/14651858.CD011420.pub3) Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/31633805?tool=bestpractice.bmj.com)

63. World Health Organization. WHO consolidated guidelines on tuberculosis Module 3: diagnosis-rapid
diagnostics for tuberculosis detection. Jun 2020 [internet publication]

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Assessment of chronic cough Images

Images

IMAGES
Figure 1: Chest x-ray showing hyperinflation in a patient with COPD. The hyperinflation is caused by the
emphysema component of COPD, rather than the chronic bronchitis that underlies symptoms of cough
From the personal collection of Dr M. A. Sharifabadand, SUNY at Stony Brook School of Medicine,
Department of Pulmonary and Critical Care Medicine, Mineola, New York and Dr J. P. Parsons, The Ohio
State University Medical Center, Columbus; used with permission

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IMAGES Assessment of chronic cough Images

Figure 2: Chest x-ray showing multiple miliary lung metastases (arrows). The primary tumour was a thyroid
carcinoma
E. Dick, Student BMJ. 2001;9:10-12

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Assessment of chronic cough Images

IMAGES
Figure 3: Chest x-ray showing left hilar carcinoma (arrow)
From: E. Dick, Student BMJ. 2000;8:358-360

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IMAGES Assessment of chronic cough Images

Figure 4: Chest x-ray showing a cavitating right hilar carcinoma (arrow)

E. Dick, Student BMJ. 2001;9:10-12

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Assessment of chronic cough Images

IMAGES
Figure 5: Chest x-ray in a patient with bronchogenic carcinoma showing a left-sided pleural effusion
From: R. Thakkar, Student BMJ. 2001;9:458

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IMAGES Assessment of chronic cough Images

Figure 6: Chest x-ray showing interstitial fibrosis in a patient with amiodarone pulmonary toxicity
From the personal collection of Dr A. Pataka and Professor P. Argyropoulou, Aristotle University,
Thessaloniki, Greece; used with permission

Figure 7: Chest x-ray showing pulmonary tuberculosis with cavitation

From the personal collection of Dr M. Narita, Department of Pulmonary and Critical Care Medicine, University
of Washington

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Assessment of chronic cough Images

IMAGES
Figure 8: Chest x-ray showing multiple discrete nodules throughout both lungs (one of which is circled) in a
patient with miliary tuberculosis
E. Dick, Student BMJ. 2001;9:10-12

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IMAGES Assessment of chronic cough Images

Figure 9: Chest x-ray with lack of normal tapering producing a tram line in a patient with bronchiectasis
From the personal collection of Dr S.M. Bhorade, University of Chicago Medical Center; used with permission

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Assessment of chronic cough Images

IMAGES
Figure 10: Chest x-ray with dilated and thickened airways in a patient with bronchiectasis
From the personal collection of Dr S.M. Bhorade, University of Chicago Medical Center; used with permission

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IMAGES Assessment of chronic cough Images

Figure 11: Chest x-ray showing increased opacification of the right perihilar region and superior segment of
the right lower and upper lobes consistent with worsening aspiration pneumonia
From the personal collection of Dr R. Kanner, University of Utah School of Medicine

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Assessment of chronic cough Images

IMAGES
Figure 12: Portable chest x-ray with bibasilar opacities, worse on the right than the left, in a patient with
hospital-acquired pneumonia
From the personal collection of Dr F. W. Arnold, Division of Infectious Diseases, Department of Medicine,
University of Louisville School of Medicine

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IMAGES Assessment of chronic cough Images

Figure 13: Chest x-ray showing early ill-defined opacities of the right upper lobe above the minor fissure
consistent with early changes of aspiration pneumonia
From the personal collection of Dr R. Kanner, University of Utah School of Medicine

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Assessment of chronic cough Images

IMAGES
Figure 14: A. Portable upright chest x-ray before aspiration; B. Chest x-ray 1 hour after aspiration, showing
bilateral diffuse alveolar infiltrates, worse at the bases on the right side
From the personal collection of Dr S. Murgu and Dr H. Colt, University of California at Irvine Medical Center

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IMAGES Assessment of chronic cough Images

Figure 15: Chest x-ray showing bilateral hilar adenopathy in a patient with sarcoidosis
From the personal collection of Dr M.P. Muthiah, Division of Pulmonary and Critical Care and Sleep
Medicine, University of Tennessee

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Assessment of chronic cough Images

IMAGES
Figure 16: Chest CT with presence of signet ring on left in a patient with bronchiectasis
From the personal collection of Dr S.M. Bhorade, University of Chicago Medical Center

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IMAGES Assessment of chronic cough Images

Figure 17: Chest CT with dilated and thickened airways and peripheral tree-in-bud pattern in a patient with
bronchiectasis
From the personal collection of Dr S.M. Bhorade, University of Chicago Medical Center; used with permission

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Assessment of chronic cough Images

IMAGES
Figure 18: Chest CT showing idiopathic pulmonary fibrosis
From the personal collection of Dr J.C. Munson, Center for Clinical Epidemiology and Biostatistics, University
of Pennsylvania School of Medicine

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IMAGES Assessment of chronic cough Images

Figure 19: Chest CT of a patient with amiodarone pulmonary toxicity, showing asymmetrical opacities with a
peripheral distribution
From the personal collection of Dr A. Pataka and Professor P. Argyropoulou, Aristotle University,
Thessaloniki, Greece

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Assessment of chronic cough Images
Figure 20: CT of the chest with intravenous contrast material showing complete left lower lobe collapse with a
radiopaque object within the left lower main bronchus surrounded by a halo of air
BMJ Case Reports 2008 (doi:10.1136/bcr.06.2008.0013). Copyright 2008 BMJ Publishing Group Ltd

IMAGES
Figure 21: Bronchoscopy image showing a loquat seed completely occluding the bronchus intermedius
From the personal collection of Dr S. Murgu and Dr H. Colt, University of California at Irvine Medical Center

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IMAGES Assessment of chronic cough Images

Figure 22: Flow-volume loop (spirogram) in obstructive lung disease, such as asthma or COPD: peak
expiratory flow may be normal, but a concave shape is seen following the point of maximal flow due to the
low flow rate in relation to lung volume
Created by BMJ Knowledge Centre

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Assessment of chronic cough Images

IMAGES
Figure 23: Flow-volume loop (spirogram) in restrictive lung disease (e.g., interstitial pulmonary fibrosis): peak
expiratory flow may be normal or low. The shape of the curve is generally normal, but the loop is narrowed
and the forced vital capacity is low because of the reduced lung volume.
Created by BMJ Knowledge Centre

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Contributors:

// Authors:

Tomasz J. Kuzniar, MD, PhD

Clinical Assistant Professor of Medicine
University of Chicago, Division of Pulmonary and Critical Care Medicine, North Shore University Health
System, Evanston, IL
DISCLOSURES: TJK is the author of an article cited in this topic.

// Acknowledgements:
Dr Tomasz J. Kuzniar would like to gratefully acknowledge Dr Timothy I. Morgenthaler, a previous
contributor to this topic.
DISCLOSURES: TIM declares that he has no competing interests.

// Peer Reviewers:

Nawal Lut fiyya, MD

Director of Research
Assistant Professor, Family and Community Medicine, University of Illinois at Chicago, IL
DISCLOSURES: NL declares that she has no competing interests.

Graeme Currie, MD
Consultant Chest Physician
Aberdeen Royal Infirmary, Aberdeen, Scotland
DISCLOSURES: GC declares that he has no competing interests.