A cough occurs when cells along the air passages get irritated and trigger a chain of events. The diagnosis should begin with a medical history, physical examination, and chest radiograph. Most patients with chronic cough are otherwise healthy, and in these patients the four most common causes of cough are upper airway cough syndrome, asthma, gastroesophageal reflux disease (GERD), and nonasthmatic eosinophilic bronchitis. The diagnostic and therapeutic approach to cough in adults has evolved significantly in the last decade and has recently been summarized in consensus guidelines (17,18). Uncommon causes of cough include nonacid reflux disease, a swallowing disorder, congestive heart failure, and habit cough. Cough is one of the most common complaints presented at physician visits and accounts for an estimated 29.5 million annual outpatient visits. Despite the broad repercussions of acute cough on patient quality of life, school and work productivity, and public health resources, research on this condition is minimal, as are the available treatment options. In patients who do not respond or cannot take inhaled medication, treatment with oral corticosteroids for five to 10 days is an option. Some doctors have questioned whether bronchitis is a clear diagnostic entity; maybe it is just a cold on the chest. Ears, nose, and throat examination findings are normal; no cervical or axillary lymphadenopathy is present. Don't miss a single issue. Copyright © 2021 by The College of Family Physicians of Canada, Sign In to Email Alerts with your Email Address. The American College of Chest Physicians’ evidence-based clinical practice guidelines1 recommend that patients with acute cough be divided into children (younger than 15 years of age) and adults (15 years of age or older). Sign up for the free AFP email table of contents. Diagnosis and management of cough: ACCP evidence-based clinical practice guidelines. Although he has smoked for 20 years, he felt fine until 9 days ago; he has not noticed any weight loss, chest pain, or hemoptysis. Because acute cough has a different range of causes in adults than it does in children, adults should be assessed and treated differently. Figure 1 shows the distribution of cough causes in typical general practice.4, Distribution of causes of acute cough among adults in typical general practice. Chronic cough is often caused by more than one condition. There might be signs of reduced air entry, consolidation, or restricted air entry. If the patient appears to have nonasthmatic eosinophilic bronchitis, treatment with inhaled corticosteroids is recommended. Previous: Updated CDC Guidelines for the Treatment of STDs, Next: CDC Releases Data on HIV-Related Risk Behaviors in U.S. HIgh School Students, Home There are no clearly effective treatments for the cough of acute bronchitis. This content is owned by the AAFP. His temperature is 37.0°C, his pulse is 82 beats/min, and his respiratory rate is 17 breaths/min. / Vol. Enter multiple addresses on separate lines or separate them with commas. Mr Smith looks slightly tired but otherwise well. 26 Up to that time, and unless there are signs of super-infection or other complications such as painful pleural inflammation, cough seems to be best managed with simple breathing control exercises 28 (see box 2) and medication where indicated (such as proton pump inhibitors if reflux is suspected). Aim: The authors set out to develop a new prediction rule for poor outcome (re-consultation with new or worsened symptoms, or hospital admission) in adults presenting to primary care with acute cough. / afp Thank you for your interest in spreading the word on The College of Family Physicians of Canada. To diagnose nonasthmatic eosinophilic bronchitis, an induced-sputum test should be performed to determine if the patient has an increased number of eosinophils. At this point, referral to a cough specialist is appropriate. Newer-generation nonsedating antihistamines are not effective for reducing cough. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. He or she will remember recent air travel or surgical procedures (eg, pulmonary embolism), or being exposed to an unusual respiratory irritant (eg, chemicals, gases, excessive tobacco smoke). You make a mental note to consider a chest x-ray scan if his cough persists, he loses weight, or he remains unwell. Although cough suppressants and antihistamines have not specifically been well studied in patients with acute bronchitis, the former can be effective in chronic bronchitis and the latter provide some relief for patients with colds. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Chest X-ray. The condition is like a “cold on the chest” and it will get better by itself; there is no need for antibiotic treatment. In healthy children it may be normal in the absence of any disease to cough ten times a day. Coughs (Acute and Chronic) : A cough is a symptom of an underlying disease or condition. Instead, it focuses on patients whose initial work-up has failed to find an ob… The American College of Chest Physicians’ evidence-based clinical practice guidelines1 recommend that patients with acute cough be divided into children (younger than 15 years of age) and adults (15 years of age or older). Approach to patients 15 years and older with cough lasting more than eight weeks. This is especially important, because Upper Respiratory Conditions don’t tend to kill, like lower ones might. The American College of Chest Physicians1 recommends that absence of the following findings reduces the likelihood of pneumonia sufficiently to eliminate the need for a chest x-ray scan: respiratory rate greater than 24 breaths/min; chest examination showing focal consolidation, egophony, or fremitus. Am Fam Physician. Adapted with permission from Irwin RS, Baumann MH, Bolser DC, Boulet LP, Braman SS, Brightling CE, et al. ... diagnosis or treatment. The patient will seem unusually ill (eg, pneumonia, influenza) or short of breath (eg, congestive heart failure, SARS, acute asthma). Coloured sputum cannot be used to predict whether an infection is viral or bacterial. In the differential diagnosis of acute cough, however, it is essential not to miss a potentially life‐threatening condition such as pulmonary embolism or acute cardiac failure. Copyright © 2020 American Academy of Family Physicians. Pain and discharge may be … Note that these classifications are not mutually exclusive. The first step in the treatment of acute cough is to determine if the cause of the cough is one of these serious conditions or an acute upper respiratory infection (i.e., common cold), lower respiratory tract infection, or an exacerbation of a pr… afpserv@aafp.org for copyright questions and/or permission requests. Mr Smith says he does not, as far as he knows, have asthma or any heart troubles. On a typical day, a family physician will see at least one patient presenting with cough. The illness spreads from your nose and throat to your windpipe and airways. Distinguish between acute (≤8 weeks duration) and chronic cough (>8 weeks); history and physical exam are usually adequate for diagnostic workup of patients with acute cough. Patients with chronic cough should first be treated with a first-generation antihistamine/decongestant. What can I do to manage my cough? Reports have shown that up to 80% of non-smokers and 90% of smokers with acute bronchitis receive antibiotics.13,14 There have been a number of reviews of the effects of antibiotics on the course of acute bronchitis. If none of these therapies has been successful for treating the cough, then an additional work-up is necessary, possibly including 24-hour esophageal pH monitoring, upper gastrointestinal tract endoscopy, a barium swallow, or a high-resolution CT scan. Your careful history has excluded any likely serious causes for Mr Smith’s acute cough; in particular, your careful clinical examination has ruled out asthma and CAP. Cough should resolve within four weeks of therapy. Contact Acute bronchitis is an infection of the tracheo-bronchial tree, which might transiently produce sputum and symptoms of airway obstruction. Figure 1 presents a diagnostic approach to chronic cough. If symptoms still persist, it is an indication for sinus imaging. However, most GPs are worried that they might miss a case of acute community-acquired pneumonia (CAP), which still has relatively high mortality, especially among the elderly.6 The criterion standard for diagnosing CAP is the presence of consolidation on the chest radiograph, but GPs cannot be ordering chest x-ray scans for every patient with acute cough. He complains of a cough that has been bothering him for 9 days. The cough is worse at night but it is also present during the day. Any patient who responds only partially or not at all to the above therapies should be empirically treated for GERD. ; for the American College of Chest Physicians. A positive challenge usually warrants trial treatment for asthma and clinical monitoring. If the patient is taking an angiotensin-converting enzyme (ACE) inhibitor, treatment should be stopped to determine if the medication is the cause. Two clarifications are necessary. He coughs once into a tissue while in your office; a small amount of yellowish sputum appears on the tissue. Cet article a fait l’objet d’une révision par des pairs. The illness came on slowly, over a day or so. 2007 Feb 15;75(4):567-575. Ongoing allergen or irritant exposure, lingering effects of an infection, pneumonia, and acute exacerbation of chronic bronchitis should also be considered. Copyright © 2007 by the American Academy of Family Physicians. A cough in children may be either a normal physiological reflex or due to an underlying cause. He has not felt short of breath. By Mayo Clinic Staff While an occasional cough is normal, a cough that persists may be a sign of a medical problem. If the cough is due to the common cold, a first-generation antihistamine plus a decongestant should be prescribed. The patient will usually remember wheezing. Acute cough is one of the most common complaints prompting patient visits to healthcare professionals. You have not heard of any outbreaks of influenza or other respiratory disease in your area. question for acute, subacute, and chronic cough. They do, however, certainly suggest a chest x-ray scan should be done. They are helpful indicators to guide your differential diagnosis. Similarly, apart from a previous history of asthma and a currently runny nose, few symptoms or signs have much of a negative likelihood ratio. As no one symptom or sign has a large effect of the likelihood of pneumonia being present in a person with an acute cough, investigators have combined various symptoms and signs to make clinical decision rules for CAP7–9; unfortunately, even if a patient without asthma has fever, tachycardia, and crackles—a combination of symptoms and signs very suggestive of pneumonia—the rules still do not have enough power to definitively “rule in” pneumonia. It seems reasonable that a combined cough suppressant and antihistamine might provide short-term symptomatic relief in a patient with acute bronchitis. diagnosis and management of acute cough and bronchitis. Diagnosing pneumonia by history and physical examination, Guideline for the management and treatment of acute bronchitis, The treatment of acute bronchitis by general practitioners in the UK. Mr Smith accepts your diagnostic explanation, but explains that the cough at night is preventing good sleep, and he does not wish to miss work because of the illness. If treatment for upper airway cough syndrome and asthma have both failed, nonasthmatic eosinophilic bronchitis should be considered next. It is most probably caused by postnasal drip, upper airway irritation, mucus accumulation, or a manifestation of branchial hyperresponsiveness that may be associated with asthma. Chronic cough is most frequently related to the chronic inhalation of cigarette smoke by either active or passive smoking [6]. Honey ; Menthol (vapors) Hydration, lozenges, and humidifiers; NSAIDs: for myalgia, headaches, fever; Antibiotics: usually not recommended ; Hypersensitivity pneumonitis: antigen avoidance with/without glucocorticoid therapy ; Life-threatening acute cough You are becoming almost certain that he has acute bronchitis. Because cough is a common presenting complaint, pediatricians must become familiar with the initial evaluation and management of children with cough to establish a diagnosis and determine appropriate therapy. Differential diagnosis. Findings consistent with congestive heart failure should be followed by a cardiovascular examination and possibly an empiric attempt at diuresis. SUMMARY -- “ACUTE COUGH” (less than 2-3 weeks) Causes of Acute Cough Upper Respiratory Tract Conditions Lower Respiratory Tract ConditionsCommon ColdCovid - 19Allergies (Hay Fever)Influenza (& other viruses)SinusitisPneumoniaTracheitis ("Croup" in children under 3)AsthmaHypertension medication ("ACE-Inhibitors")COPD exacerbation(if sudden onset while eating: … Adapted with permission from Irwin RS, Baumann MH, Bolser DC, Boulet LP, Braman SS, Brightling CE, et al. It is also important to determine if the patient is a current smoker. Clinical course and diagnosis. If the cough is not caused by bacterial sinusitis or Bordetella pertussis, treatment with inhaled ipratropium (Atrovent) should be initiated to attenuate the cough. Table 1 shows positive and negative likelihood ratios for pneumonia of various respiratory symptoms and physical signs.10 Note that, apart from egophony, neither symptoms nor signs have high positive likelihood ratios for pneumonia; in a low-prevalence primary care situation, the positive likelihood ratio has to be very high to significantly increase the chances of pneumonia being present. If the patient has severe COPD, cough may persist after smoking cessation. This article does not address the initial approach to patients with chronic cough that is due to obvious causes, such as smoking, pneumonia, bronchitis, post-inflammatory cough or therapy with angiotensin converting enzyme (ACE) inhibitors, or relatively uncommon but easily diagnosable causes such as tuberculosis or lung cancer. You are certain that his recent-onset productive cough is due to acute bronchitis. COPD—chronic obstructive pulmonary disease. You hear 1 or 2 faint crackles on inspiration; these disappear when he coughs. Once he had an ingrown toenail, once he had an acute back strain (helping a passenger unload at the airport), and once he had tonsillitis. This type of cough, also described as acute bronchitis, is the fifth most common new presentation to FPs in Australia2 and the United States.3 Figures from the United Kingdom suggest there are about 50 cases per 1000 people each year,4 and acute cough leads to 10 ambulatory visits per 1000 visits each year in the United States.5 Evidence from such general practice reports and the US and UK morbidity surveys shows that the overwhelming majority of acute coughs are infectious in origin. Acute bronchitis often starts because of another illness, such as a cold or the flu. It has been shown that bronchoprovocation is useful in the evaluation for cough caused by asthma. Because recent Health Canada regulations have prohibited smoking in the taxi, he has actually reduced his daily cigarette consumption from 20 to about 10. The first step in the workup of patients who present with subacute cough is to determine whether they have a postinfectious cough. Coughs that have lasted at least 3 weeks but not more than 8 are classified as "subacute." If the cough does not appear to be postinfectious, it should be managed as if it were a chronic cough. Non-life-threatening acute cough (URI, acute bronchitis): Nonpharmacological treatment . Therefore, a detailed history, physical examination, and if necessary, CXR should be performed. Response to therapy, prokinetic therapy should be empirically treated for sinusitis others who smoke usually... Story suggests an acute URTI, it is just a cold or the flu longer than weeks. 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