Chronic Cough CC

​Chronic Cough

Alexander Jin, PGY-3
30SEP2025

Outline

• Introduction

  • Define terms and scope

  • Identify normal pathways and mechanisms of pathology

• Causes

  • Pulmonary vs extra-pulmonary

• Evaluation

  • Red flag signs

Outline

• Management

  • Medication and/or non-medication management

• Board Questions!

Multiple Choice

A chronic cough is defined as a daily cough lasting for how many weeks or longer?

• 2 weeks

• 4 weeks

• 6 weeks

• 8 weeks

Definitions

Chronic Cough

• Daily cough lasting for four weeks or longer

  • Per American College of Chest Physicians and European and Australian societies

• Why?

  • Most acute illnesses resolve within this interval

  • Further continuation impairs QoL and may be more sinister

• Not attributable to an identifiable cause after reasonable evaluation

Non-Specific Cough

• Ultimately attributable to an underlying physiologic cause

• Can be recognized through "specific cough pointers"

Specific Cough

Definitions

Multiple Choice

For chronic cough complaints in affluent countries, what percentage of parents seek 5 or more doctor's visits to address the complaint?

• 0%

• 25%

• 50%

• 75%

Multiple Choice

For chronic cough complaints in affluent countries, what percentage of parents seek 15 or more doctor's visits to address the complaint?

• 0%

• 7%

• 14%

• 21%

Multiple Choice

In 2022, how much money was estimated to be spent on OTC medicines for cough and cold relief globally?

• $5 billion

• $7 billion

• $9 billion

• $11 billion

Epidemiology

Prevalence

• Difficult to Estimate

• Higher in more affluent countries

• Estimates range between 10-22 percent based on systematic reviews

Epidemiology

Burden

• Substantial burden of QoL and parental concern

  • QoL impact approaches other chronic diseases (e.g. cardiac disease, diabetes)

  • Normalizes with resolution of coughing

Reorder

Identify the 3 physiologic phases of cough in correct order

• Inspiratory

• Compressive

• Expiratory

1

2

3

• 1
• 2
• 3

Multiple Choice

Which structure is in the brain is most involved with the afferent arm of the central pathway of coughing?

• Nucleus tractus solitarius

• Fastigial nucleus

• Globus pallidus

• Ventromedial hypothalamic nucleus

• Multiple sources of stimulus

• Matures throughout infancy

• Can be sensitized with repeated triggering

• Ineffectiveness can lead to increased cough

Cough Arc Schema

Causes of Chronic Cough

Pulmonary

All of them

Common

Uncommon

Causes of Chronic Cough

Extrapulmonary

• Cardiac

• GI

• Iatrogenic

• Other

Evaluation

Specific vs Non-Specific

Specific cough pointers - Productive cough, abnormal sounds on auscultation, history of choking (even distant), time of onset, suspicion for other underlying medical conditions, characteristic cough sound (e.g. staccato, paroxysmal, honking)

Symptoms and Associations

Question Format

Symptoms given; associate with potential underlying condition

Multiple Choice

Lymphadenopathy

• Retained foreign body/aspiration

• Chronic infection

• Asthma

• GERD

Multiple Choice

Hoarseness

• Retained foreign body/aspiration

• Chronic infection

• Asthma

• GERD

Multiple Choice

Abnormal PMI

• Cystic Fibrosis

• Congenital Heart Disease

• Primary Ciliary Dyskinesia

• Protracted Bacterial Bronchitis

Multiple Select

Hepatosplenomegaly

• Cystic Fibrosis

• Congenital Heart Disease

• Primary Ciliary Dyskinesia

• Protracted Bacterial Bronchitis

Multiple Choice

Rectal Prolapse

• Cystic Fibrosis

• Congenital Heart Disease

• Primary Ciliary Dyskinesia

• Protracted Bacterial Bronchitis

Non-Specific Cough

Trial of Therapy?

• Consider empiric asthma vs GERD treatment trial

• Anti-tussive agents NOT recommended

• Difficult to assess response to therapy

Non-Specific Cough

Other Management Considerations

• Set expectations with family/caregivers

• Avoidance of known triggers

• Avoidance of cough suppressants and caution with alternative therapies

• Consider SDOH factors leading to underreporting or poorly managing chronic cough

Management

Referral Guidelines

• Specific cough with pointers concerning for red flag symptoms

• Non-specific cough refractory to observation and therapy

• Other symptoms concerning for requiring further workup

Board Questions

Multiple Choice

A 12-year-old is evaluated for a nonproductive cough. They have no systemic symptoms other than fatigue, however, there is a history of recurrent respiratory illnesses over the past 2 years. During past episodes, physical examination demonstrated variable pulmonary crackles that resolved after oral antibiotic treatment. Chest radiographs demonstrated variable patchy densities suggestive of pneumonia that cleared within a week. There is no history of other recurrent infections.

Today, their oxygen saturation is 95% in room air. The patient appears pale with conjunctival pallor and mild nasal congestion. There is no cervical or supraclavicular adenopathy and their oropharynx is clear. Breath sounds are coarse with scattered crackles but no wheeze. Cardiovascular examination findings are normal. There is no digital clubbing. The remainder of the physical examination findings are normal. 

Lab data are shown:

WBC - 10.5

Hgb: 10.5

Hct: 31%

CMP - wnl

Serum immunoglobulin levels - wnl

This patient is referred for a pulmonology evaluation. Bronchoscopy with bronchoalveolar lavage demonstrates alveolar macrophages with a positive stain for iron. 

Of the following, the MOST likely cause of this patient’s findings is

• 
  immunologic reaction to avian proteins

• pulmonary parenchymal trauma

• repeated subclinical pulmonary hemorrhage

• silent aspiration of gastric contents

Explanation

• Idiopathic pulmonary hemosiderosis presents with repeated transient pulmonary illnesses and radiographic changes, in the context of anemia. It is treated with anti-inflammatory agents.

• Collagen vascular diseases with capillaritis may cause diffuse alveolar hemorrhage.

• Immunoglobulin G–mediated milk intolerance may cause pulmonary hemosiderosis in infants and young children and is managed with milk protein avoidance.

Multiple Choice

A 7-year-old boy is seen for evaluation of hoarseness that has been present for several months. He has an intermittent, nonproductive cough and has recently had difficulty keeping up with his peers when playing, becoming winded more quickly than his mother and teachers think he should. He has not had fever, recent respiratory or other illness, snoring, noisy breathing, or trauma to his neck.

On physical examination, he is comfortable at rest. His vital signs are a blood pressure of 105/55 mm Hg, a heart rate of 80 beats/min, a respiratory rate of 15 breaths/min, and an oxygen saturation of 98% in room air via pulse oximetry.

His body mass index is at the 40th percentile for age. There is a hemangioma over his left cheek and upper lip that extends to the oral surface; it has been present since birth and has not changed. He is able to breathe comfortably through his nose. 

Chest examination reveals good aeration with no adventitious sounds, a 1:1 inspiratory-to-expiratory ratio, and a slight suprasternal tug on inspiration. The remainder of his physical examination findings are unremarkable.

Of the following, the BEST next step in this boy’s care is

• counseling regarding voice hygiene

• 
  flexible fiberoptic laryngoscopy

• magnetic resonance imaging of his neck

• 
  referral for speech therapy

Explanation

• The most common causes of hoarseness are benign and self-limited (eg, viral infection, voice abuse). Hoarseness accompanied by evidence of airway compromise should prompt expedited direct visualization of the airway (laryngoscopy) under controlled conditions.

• Neonates with a hoarse cry should undergo prompt evaluation for congenital anomalies of the airway.

• Children who require intervention for hoarseness should undergo visualization of the larynx via direct or fiberoptic laryngoscopy before imaging or referral for speech therapy.

Multiple Choice

A 6-year-old girl is brought to the office for breathing problems. She has had repeated episodes of wheezing which occurred only with viral respiratory infections. Over the past 2 months she has been coughing at night 2 to 3 times weekly, frequently becomes short of breath while running, and must stop and rest while playing with friends. She required a course of oral corticosteroids for wheezing with a viral respiratory illness during the most recent winter season. Her mother and a paternal aunt had asthma as children. The girl’s vital signs are normal. There is no increased work of breathing or use of accessory muscles. Breath sounds are clear and equal to auscultation with good aeration. The remainder of her physical examination findings are normal.

Of the following, the BEST treatment for this girl is a/an

• combined inhaled steroid and formoterol inhaler used daily and as needed

• medium-dose inhaled corticosteroid as needed

• oral leukotriene modifier daily

• short-acting bronchodilator inhaler as needed

Explanation

The girl in the vignette has mild to moderate persistent asthma, with symptoms occurring more than twice per week but less than daily. The preferred management for persistent asthma in children 5 years of age and older is daily and as-needed use of a combined inhaler with corticosteroid and formoterol.

Multiple Choice

A 3-year-old boy is seen in the office to establish care after emigrating from Southeast Asia 2  months ago. He has had a cough for 12 months and has been eating less for the past 6 months. He has a habit of soil pica. The family has 4 dogs and 5 cats. The boy’s physical examination findings are remarkable for scattered wheezing in both lung fields and a liver edge palpable 2 cm below the right costal margin. His weight is less than the third percentile. His parents report that his weight is usually at the 25th percentile.

Laboratory data are shown:

WBC - 15

Neutrophil - 45%

Lymphocyte - 30%

Monocyte - 5%

Eosinophil - 20%

Hgb - 10

Plt - 200

AST/ALT - 65/55

• 
  serum for Ascaris IgG

• 
  serum for Toxocara IgG

• stool for bacterial culture

• 
  stool for ova and parasites

Explanation

The boy in the vignette has toxocariasis, a tissue roundworm infection. His signs and symptoms (wheezing, hepatomegaly, anorexia, and weight loss), exposure to dogs and cats, habit of soil pica, and eosinophilia are consistent with infection with the visceral larva migrans form of Toxocara. In Southeast Asia, the seroprevalence of toxocariasis is approximately 34%. In the United States, the seroprevalence is 5%. 

Questions?