Diagnosis
Diagnosis
Chronic cough is a disease, not just a symptom
Chronic cough is one of the most common reasons for consultation in general practice, but the condition has a wide diagnostic spectrum.1 In the past, chronic cough was often considered a symptom or consequence of another disease or condition, but this has changed:
In Sweden, the ICD -10 code R05.7 for “Unexplained or refractory chronic cough” was introduced in January 2023.2
Medical history and physical examination3
The European Respiratory Society (ERS) recommends starting with an assessment that takes the features of several common associated conditions of cough into account. This includes a detailed medical history, examination and investigation to exclude conditions for which directed therapy can be offered. This assessment should be directed to exclude malignancies, infection, foreign body inhalation or use of an ACE inhibitor.1 When suspecting refractory or unexplained chronic cough (RCC) in patients, other diagnoses can be ruled out based on various tests performed and treatment outcomes.3
Initial assessment
Cough duration
Family history
Cough impact and triggers
Risk factors
Associated symptoms
HARQ*
Cough Severity Score (0-10) or VAS
*HARQ, Hull Airway Reflux Questionnaire
Routine evaluations3
(Chest radiograph, pulmonary function test)
Chronic cough workup and investigation should exclude respiratory or other conditions for which directed treatment may be offered:3
Malignancy, infection, foreign body inhalation and medications that could cause cough
Consider smoking history and cessation in all patients3
Initial Management
Further investigation should aim to identify and manage treatable cough-associated conditions or traits3
Stop risk factors3
- ACE inhibitors
- Smoking
- Sleep apnea
Consider chronic cough in other respiratory diseases3
This includes those physically distorting the airway or causing bronchorrhea of cystic fibrosis and chronic bronchitis
Identify and begin appropriate initial managementa of treatable cough-associated conditions or traits3
- Asthmatic cough
- Eosinophilic bronchitis
- Reflux cough
- Upper airways cough syndrome
- Iatrogenic cough
It may not be possible to determine if an underlying condition is causing a patient’s chronic cough, despite thorough assessment4
ERS guidelines place high value on controlling ongoing chronic cough pathology with appropriate therapies3
a Initiate corticosteroids or leukotriene receptor antagonist. Initiate proton pump inhibitor if peptic symptoms or acid reflux are present.3
ACE, angiotensin-converting enzyme.
Perform follow-up assessment for cough
Assess patient cough score and associated symptoms
Improvement
Continue the treatment plan and attempt withdrawal after 3 months
No Improvement
Consider low-dose opioid, promotility agent, gabapentin, pregabalin, or cough control therapy
b Additional evaluations may be considered where indicated.
Low-dose morphine or codeine has a general depressant effect on the central nervous system and can be sedating.3 Long-term use of morphine medications can be addictive.4
Patients may feel that their disease is not being adequately addressed. This can leave them feeling frustrated as they are referred from doctor to doctor without getting rid of their chronic cough, which is associated with significant physical, social and psychological consequences.5,6,7
Consider refractory or unexplained chronic cough (RCC) if the cough persists despite thorough investigation and treatment.8
For more information on the treatment of refractory chronic coughs, click here.
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References:
- Investigation and treatment of cough | Ugeskriftet.dk. Accessed October 23, 2023. https://ugeskriftet.dk/videnskab/udredning-og-behandling-af-hoste
- Millqvist, E., C. Janson, and C. Bredin, New ICD-10 code for refractory and unexplained chronic cough. Lakartidningen 2023, 120
- 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;55(1):1901136.
- Legal information. Guidance on the Prescription of Addictive Medicines; 2019.
- Satia | et al. Clin Med (Lond). 2016;16(suppl 6):s92-s97.
- Kuzniar TJ et al. Mayo Clin Proc. 2007;82:56-60.
- Chamberlain SAF et al. Lung. 2015;193:401-408.
- Weinberger SE, Lipson DA. Chapter 3. In: Loscalzo J, ed. Harrison’s Pulmonary and Critical Care Medicine. Ist ed. New York, NY: McGraw-Hill Professional, 2010:14-19.
