Cough - Nonproductive

Initial history of cough should include an assessment of the production of sputum. Additionally, associated history and physical findings, with particular attention to the quantity, quality, and circumstances surrounding coughing episodes and social details (such as history of smoking, farm work, or allergen exposure), are also important in identifying the etiology. A persistent, nonproductive cough caused by ACE inhibitor usage must not be overlooked, as it is both concerning and annoying to the patient and can be remediated by adjusting the medication regimen.

Differential Diagnosis

• Smoker's cough
• Postnasal drip (e.g., chronic sinusitis, allergic rhinitis)
  –Most common cause of chronic cough in nonsmokers

• GERD
  –Second most common cause of chronic cough in nonsmokers

• Asthma/reactive airway disease
  –Classic triad of chronic cough, dyspnea, and wheezing

• Cryptogenic organizing pneumonia
  –Most commonly occurs following viral infection or exposure

Workup and Diagnosis

• Complete history and physical examination
  –Note acute (<3 weeks) versus chronic or recurrent
• Initial tests may include CBC, pulse oximetery, ESR, peak flow measurements, PPD, and eosinophil count
• Chest X-ray and/or CT if patient has concerning symptoms (e.g., weight loss, hemoptysis, fever)
• Consider blood and sputum cultures
• Initial empiric treatment of postnasal drip (antihistamine, decongestant, nasal steroids), asthma (trial of bronchodilators or a methacholine challenge test), and/or GERD (proton pump inhibitor) may be advisable
• If imaging is normal and empiric treatment for GERD does not resolve symptoms, proceed with upper GI endoscopy or esophageal pH monitoring
• Consider CT of sinuses or nasolaryngoscopy to evaluate for sinusitis
• Consider bronchoscopy to identify subtle pulmonary causes
• Consider cardiac workup if pulmonary and GI evaluations are negative

Treatment

• Cessation of cigarette smoking and/or ACE inhibitors
• Postnasal drip: Treat underlying etiology (e.g., antibiotics for sinusitis, antihistamines and/or nasal steroids for allergies)
• GERD: Lifestyle modifications (e.g., weight loss, dietary changes to eliminate predisposing agents, avoid alcohol and tobacco, avoid food within 4 hours of bedtime, sleep with head of bed elevated), anti-ulcer/antacid medications (H2 blockers, proton pump inhibitors), anti-reflux surgery (fundoplication)
• Asthma: Avoid triggers; use inhaled β₂ agonists (e.g., albuterol) and anticholinergics (e.g., ipratropium), inhaled or oral steroids (delayed onset 2–6 hours), children may benefit from magnesium or cromolyn
• Acute bronchitis: Inhaled β₂ agonists (e.g., albuterol); since most cases are of viral origin, antibiotics are usually not indicated; increased fluid intake; antitussive
• Pneumonia: Appropriate oral or IV antibiotics

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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