Chronic Cough

Differential Overview

❑ Upper respiratory infection

❑ Allergy

❑ Asthma

❑ Chronic bronchitis

❑ Chronic sinusitis

❑ Gastroesophageal reflux

❑ ACE inhibitor

❑ Pollutants

❑ Psychogenic

❑ Foreign body

❑ Congestive heart failure

❑ Lung cancer

❑ Tuberculosis

❑ Mediastinal mass

❑ Bronchiectasis

❑ Pulmonary fibrosis

❑ Cystic fibrosis

❑ Aspergillosis

Diagnostic Approach

Chronic cough persists 3 weeks or longer. During vigorous coughing intrathoracic pressure of 300 mm Hg and expiratory velocity of 500 miles per hour develop, which over time are responsible for the secondary effects of exhaustion, insomnia, chest wall pain, dizziness, syncope, and urinary incontinence. Postnasal drip, asthma, and gastroesophageal reflux are responsible for 99.4% of cases in patients with the characteristics: nonsmoker, no use of ACE inhibitor, and normal or stable chest x-ray.

Green color in the sputum may be caused by either polymorphonuclear leukocytes or eosinophils. Hoarseness suggests tumor with involvement of the vocal cords or recurrent laryngeal nerve, or it may suggest chronic esophageal reflux.

Clinical Findings

Upper respiratory infection  Prolonged cough (and bronchial hyperreactivity) following a URI is common. One-fourth of patients still have cough 1 month after the onset of symptoms, usually those with a history of asthma, allergy, or atopy (e.g., allergic rhinitis or hay fever).

Allergy  The patient will relate a sensation of chronic drainage of postnasal mucous, prompting chronic coughing, or throat-clearing. Nasal congestion is often present.

Asthma  Recurrent cough may be the predominant symptom, sometimes without apparent wheeze. The patient’s breathing feels tight. There is a history of asthma (wheeze), allergy, or atopy.

Chronic bronchitis  A prominent morning cough, productive of clear-white mucoid sputum with occasional blood streaks, develops in a cigarette smoker.

Chronic sinusitis  Facial fullness or pain, associated with a purulent postnasal drainage (which may be seen in the pharynx), produces an “irritated” cough and a sensation that the throat needs to be cleared.

Gastroesophageal reflux  Reflux is recognized by nocturnal cough, concurrent with heartburn, an acid or sour taste in the throat, and hoarseness. The cough may produce a foamy mucous partly due to reflex hypersalivation.

ACE inhibitor  A dry, irritative cough occurs in 10% to 20% of patients taking any ACE inhibitor, which will resolve soon after discontinuation of the drug.

Pollutants  Heavy smog, sulphur dioxide, and nitrous oxide are typical causes. Dust and particulate matter may potentiate the problem.

Psychogenic  Cough occurs at times of emotional stress and ceases during the night. Cough suppressants are not effective.

Foreign body  Beginning after a choking episode, a localized wheeze develops.

Congestive heart failure  Typically the cough is nocturnal, with orthopnea and paroxysmal nocturnal dyspnea. A third heart sound and dependent rales are often present.

Lung cancer  Cough is an early manifestation of an endobronchial lesion, suggested by a change in the pattern of a smoker’s cough. Hemoptysis may be an early finding in 10% to 15% of cases, and should raise concern when occurring in the absence of an airway infection in a smoker. Other clues are clubbing, localized wheezing, or decreased lung sounds, and an unexplained minor weight loss.

Tuberculosis  Night sweats, hemoptysis, fever, and recent immigrant status are clues. Apical lung findings are occasionally present.

Mediastinal mass  Extrinsic compression produces a dry, “brassy” cough, which may be positional. Hoarseness caused by recurrent laryngeal compression is an additional clue.

Bronchiectasis  Copious amounts of mucopurulent sputum along with repeated bouts of hemoptysis and pneumonia are characteristic. Focal rhonchi and wheezes are often found on exam. The sputum will separate upon sitting into a foamy top layer, a serous middle layer, and pus and debris in the bottom layer.

Pulmonary fibrosis  The cough is nonproductive and associated with dyspnea on exertion. Fine, dry, “Velcro” rales are fixed in location. Clubbing is often found.

Cystic fibrosis  Infrequently it is first recognized in adulthood, manifest as a chronic cough since childhood, progressive dyspnea, hemoptysis, malabsorption with low weight and diarrhea, and a swallowing disorder with choking when ingesting food or drink.

Aspergillosis  Atopic asthmatics cough up tough, spindle-shaped plugs, 1 to 2 cm in length.

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Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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