Cough in Adults: A Merck Manual of Patient Symptoms podcast

Cough is an explosive expiratory maneuver that is reflexively or deliberately intended to clear the airways. It is the 5th most common symptom prompting physician visits.

Likely causes of cough (see Table 1: Symptoms of Pulmonary Disorders: Some Causes of Cough) differ depending on whether the symptom is acute (< 3 wk) or chronic.

In acute cough, the most common causes are

• URI (including acute bronchitis)
• Postnasal drip
• COPD exacerbation
• Pneumonia

In chronic cough, the most common causes are

• Chronic bronchitis
• Postnasal drip
• Airway hyperresponsiveness after resolution of a viral or bacterial respiratory infection (ie, postinfection cough)
• Gastroesophageal reflux

The causes in children (see Approach to the Care of Normal Infants and Children: Cough in Children) are similar to those in adults, but asthma and foreign body aspiration may be more common.

Very rarely, impacted cerumen or a foreign body in the external auditory canal triggers reflex cough through stimulation of the auricular branch of the vagus nerve. Psychogenic cough is even rarer and is a diagnosis of exclusion.

Table 1
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Some Causes of Cough Cause Suggestive Findings Diagnostic Approach Acute URI (including acute bronchitis) Rhinorrhea Red, swollen nasal mucosa Sore throat Malaise Clinical evaluation Pneumonia (viral, bacterial, aspiration, rarely fungal) Fever Productive cough Dyspnea Pleuritic chest pain Bronchial breath sounds or egophony Chest x-ray Cultures (eg, pleural fluid, blood, possibly bronchial washings) in seriously ill patients and patients with hospital-acquired pneumonia Postnasal drip (allergic, viral, or bacterial origin) Headache Sore throat Nausea Cobblestoning of posterior oropharynx Pale, boggy, swollen nasal mucosa Clinical evaluation Sometimes response to empiric antihistamine and decongestant therapy CT of the sinuses if diagnosis is unclear COPD exacerbation Known diagnosis of COPD Poor breath sounds Wheezing Dyspnea Pursed lip breathing Use of accessory muscles Tripod positioning of the arms against the legs or examination table Chest x-ray Foreign body* Sudden onset in a toddler who has no URI or constitutional symptoms Chest x-ray (inspiratory and expiratory views) Bronchoscopy Pulmonary embolism* Pleuritic chest pain Dyspnea Tachycardia CT angiography Ventilation-perfusion scanning Heart failure* Dyspnea Fine crackles Extrasystolic heart sound Dependent peripheral edema Chest x-ray Brain (B-type) natriuretic peptide level Chronic Chronic bronchitis (in smokers) Productive cough on most days of the month or for 3 mo of the year for 2 successive years in a patient with known COPD or smoking history Frequent clearing of the throat Dyspnea Chest x-ray Pulmonary function testing Postnasal drip (allergic most likely) Headache Sore throat Cobblestoning of posterior oropharynx Pale, boggy, swollen nasal mucosa Clinical evaluation Sometimes response to empiric antihistamine and decongestant therapy Allergy testing Gastroesophageal reflux Burning chest or abdominal pain that tends to worsen with consumption of certain foods, certain activities, or certain positions Sour taste, particularly on awakening Hoarseness Chronic nocturnal or early morning cough Clinical evaluation Response to empiric H2 blocker or proton pump inhibitor therapy Sometimes 24-h esophageal pH probe if diagnosis is unclear Asthma (cough variant) Cough in response to various provoking factors (eg, allergens, cold, exercise) Possibly wheezing and dyspnea Pulmonary function testing Methacholine challenge Response to empiric bronchodilator therapy Hyperresponsive airways after resolution of respiratory tract infection Dry, nonproductive cough that may persist for weeks or months after an acute respiratory tract infection Typically chest x-ray ACE inhibitors Dry, persistent cough that may occur within days or months after initiation of ACE inhibitor therapy Response to stopping ACE inhibitor Pertussis Repeated bouts of ≥ 5 rapidly consecutive, forceful coughs during a single expiration, followed by a hurried and deep inspiration (whoop) or posttussive emesis Cultures of nasopharyngeal specimens Aspiration Wet-sounding cough after eating or drinking Chest x-ray Sometimes modified barium pharyngography Bronchoscopy Tumor* Atypical symptoms (eg, weight loss, fever, hemoptysis, night sweats) Lymphadenopathy Chest x-ray If positive, chest CT and bronchoscopic biopsy TB or fungal infections* Atypical symptoms (eg, weight loss, fever, hemoptysis, night sweats) Exposure history Immunocompromise Chest x-ray Skin testing; if positive, sputum cultures and stains for acid-fast bacilli and fungi Sometimes chest CT or bronchoalveolar lavage *Indicates rare causes. Some Causes of Cough Cause Suggestive Findings Diagnostic Approach Acute URI (including acute bronchitis) Rhinorrhea Red, swollen nasal mucosa Sore throat Malaise Clinical evaluation Pneumonia (viral, bacterial, aspiration, rarely fungal) Fever Productive cough Dyspnea Pleuritic chest pain Bronchial breath sounds or egophony Chest x-ray Cultures (eg, pleural fluid, blood, possibly bronchial washings) in seriously ill patients and patients with hospital-acquired pneumonia Postnasal drip (allergic, viral, or bacterial origin) Headache Sore throat Nausea Cobblestoning of posterior oropharynx Pale, boggy, swollen nasal mucosa Clinical evaluation Sometimes response to empiric antihistamine and decongestant therapy CT of the sinuses if diagnosis is unclear COPD exacerbation Known diagnosis of COPD Poor breath sounds Wheezing Dyspnea Pursed lip breathing Use of accessory muscles Tripod positioning of the arms against the legs or examination table Chest x-ray Foreign body* Sudden onset in a toddler who has no URI or constitutional symptoms Chest x-ray (inspiratory and expiratory views) Bronchoscopy Pulmonary embolism* Pleuritic chest pain Dyspnea Tachycardia CT angiography Ventilation-perfusion scanning Heart failure* Dyspnea Fine crackles Extrasystolic heart sound Dependent peripheral edema Chest x-ray Brain (B-type) natriuretic peptide level Chronic Chronic bronchitis (in smokers) Productive cough on most days of the month or for 3 mo of the year for 2 successive years in a patient with known COPD or smoking history Frequent clearing of the throat Dyspnea Chest x-ray Pulmonary function testing Postnasal drip (allergic most likely) Headache Sore throat Cobblestoning of posterior oropharynx Pale, boggy, swollen nasal mucosa Clinical evaluation Sometimes response to empiric antihistamine and decongestant therapy Allergy testing Gastroesophageal reflux Burning chest or abdominal pain that tends to worsen with consumption of certain foods, certain activities, or certain positions Sour taste, particularly on awakening Hoarseness Chronic nocturnal or early morning cough Clinical evaluation Response to empiric H2 blocker or proton pump inhibitor therapy Sometimes 24-h esophageal pH probe if diagnosis is unclear Asthma (cough variant) Cough in response to various provoking factors (eg, allergens, cold, exercise) Possibly wheezing and dyspnea Pulmonary function testing Methacholine challenge Response to empiric bronchodilator therapy Hyperresponsive airways after resolution of respiratory tract infection Dry, nonproductive cough that may persist for weeks or months after an acute respiratory tract infection Typically chest x-ray ACE inhibitors Dry, persistent cough that may occur within days or months after initiation of ACE inhibitor therapy Response to stopping ACE inhibitor Pertussis Repeated bouts of ≥ 5 rapidly consecutive, forceful coughs during a single expiration, followed by a hurried and deep inspiration (whoop) or posttussive emesis Cultures of nasopharyngeal specimens Aspiration Wet-sounding cough after eating or drinking Chest x-ray Sometimes modified barium pharyngography Bronchoscopy Tumor* Atypical symptoms (eg, weight loss, fever, hemoptysis, night sweats) Lymphadenopathy Chest x-ray If positive, chest CT and bronchoscopic biopsy TB or fungal infections* Atypical symptoms (eg, weight loss, fever, hemoptysis, night sweats) Exposure history Immunocompromise Chest x-ray Skin testing; if positive, sputum cultures and stains for acid-fast bacilli and fungi Sometimes chest CT or bronchoalveolar lavage *Indicates rare causes.

Patients with chronic cough may develop a secondary reflex or psychogenic component to their cough. Also, protracted coughing may injure the bronchial mucosa, which may trigger more coughing.

Evaluation

History: History of present illness should cover the duration and characteristics of the cough (eg, whether dry or productive of sputum or blood) and whether it is accompanied by dyspnea, chest pain, or both. Asking about precipitating factors (eg, cold air, strong odors) and the timing of the cough (eg, primarily at night) can be revealing.

Review of systems should seek symptoms of possible cause, including runny nose and sore throat (URI, postnasal drip); fever, chills, and pleuritic chest pain (pneumonia); night sweats and weight loss (tumor, TB); heartburn (gastroesophageal reflux); and difficulty swallowing or choking episodes while eating or drinking (aspiration).

Past medical history should note recent respiratory infections (ie, within previous 1 to 2 mo); history of allergies, asthma, COPD, and gastroesophageal reflux disease; risk factors for (or known) TB or HIV infection; and smoking history. Drug history should specifically include use of ACE inhibitors. Patients with chronic cough should be asked about exposure to potential respiratory irritants or allergens and travel to or residence in regions with endemic fungal illness.

Physical examination: Vital signs should be reviewed for the presence of tachypnea and fever.

General examination should look for signs of respiratory distress and chronic illness (eg, wasting, lethargy).

Examination of the nose and throat should focus on appearance of the nasal mucosa (eg, color, congestion) and presence of discharge (external or in posterior pharynx). Ears should be examined for triggers of reflex cough.

The cervical and supraclavicular areas should be inspected and palpated for lymphadenopathy.

A full lung examination is done, particularly including adequacy of air entry and exit; symmetry of breath sounds; and presence of crackles, wheezes, or both. Signs of consolidation (eg, egophony, dullness to percussion) should be sought.

Red flags: The following findings are of particular concern:

• Dyspnea
• Hemoptysis
• Weight loss
• Risk factors for TB or HIV infection

Interpretation of findings: Some findings point to particular diagnoses (see Table 1: Symptoms of Pulmonary Disorders: Some Causes of Cough).

Other important findings are less specific. For example, the color (eg, yellow, green) and thickness of sputum do not help differentiate bacterial from other causes. Wheezing may occur with several causes. Hemoptysis in small amounts may occur with severe cough of many etiologies, although larger amounts of hemoptysis suggest bronchitis, bronchiectasis, TB, or primary lung cancer. Fever, night sweats, and weight loss may occur with many chronic infections as well as with cancer.

Testing: Patients with red flag findings of dyspnea or hemoptysis and patients in whom suspicion of pneumonia is high should have pulse oximetry and chest x-ray. Those with weight loss or risk factors should have chest x-ray and testing for TB and HIV infection.

For many patients without red flag findings, clinicians can base the diagnosis on history and physical examination findings and begin treatment without testing. For patients without a clear cause but no red flag findings, many clinicians empirically begin treatment for postnasal drip (eg, antihistamine and decongestant combinations, nasal corticosteroid sprays) or gastroesophageal reflux disease (eg, proton pump inhibitors, H₂ blockers). An adequate response to these interventions usually precludes the need for further evaluation.

Patients with chronic cough in whom presumptive treatment is ineffective should have a chest x-ray. If the x-ray findings are unremarkable, many clinicians sequentially test for asthma (pulmonary function tests with methacholine challenge), sinus disease (sinus CT), and gastroesophageal reflux disease (esophageal pH monitoring). Sputum culture is helpful for patients with a possible indolent infection, such as pertussis, TB, or nontuberculous mycobacterial infection. Sputum cytology is noninvasive and should be done if cancer is suspected and the patient is producing sputum or having hemoptysis. Chest CT and possibly bronchoscopy should be done in patients in whom lung cancer or another bronchial tumor is suspected (eg, patients with a long smoking history, nonspecific constitutional signs) and in patients in whom empiric therapy has failed and who have inconclusive findings on preliminary testing.

Treatment

Treatment is management of the cause.

There is little evidence to support the use of cough suppressants or mucolytic agents. Coughing is an important mechanism for clearing secretions from the airways and can assist in recovery from respiratory infections. Therefore, although patients often expect or request cough suppressants, such treatment should be given with caution and reserved for patients with a URI and for patients receiving therapy for the underlying disorder for whom cough is still troubling. Cough suppressants may help some patients with chronic cough who have a reflex or psychogenic component to their cough or who develop bronchial mucosal injury.

Antitussives depress the medullary cough center (dextromethorphanSome Trade Names
BENYLIN DM
DELSYM
DEXALONE
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and codeineSome Trade Names
No US trade name
Click for Drug Monograph
) or anesthetize stretch receptors of vagal afferent fibers in bronchi and alveoli (benzonatateSome Trade Names
TESSALON
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). DextromethorphanSome Trade Names
BENYLIN DM
DELSYM
DEXALONE
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, a congener of the opioid levorphanol, is effective as a tablet or syrup at a dose of 15 to 30 mg po 1 to 4 times/day for adults or 0.25 mg/kg po qid for children. CodeineSome Trade Names
No US trade name
Click for Drug Monograph
has antitussive, analgesic, and sedative effects, but dependence is a potential problem, and nausea, vomiting, constipation, and tolerance are common adverse effects. Usual doses are 10 to 20 mg po q 4 to 6 h as needed for adults and 0.25 to 0.5 mg/kg po qid for children. Other opioids (hydrocodone, hydromorphoneSome Trade Names
DILAUDID
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, methadoneSome Trade Names
DOLOPHINE
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, morphineSome Trade Names
DURAMORPH
MS CONTIN
MSIR
ROXANOL
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) have antitussive properties but are avoided because of high potential for dependence and abuse. BenzonatateSome Trade Names
TESSALON
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, a congener of tetracaine that is available in liquid-filled capsules, is effective at a dose of 100 to 200 mg po tid.

Expectorants are thought to decrease viscosity and facilitate expectoration (coughing up) of secretions but are of limited benefit. GuaifenesinSome Trade Names
ROBITUSSIN
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(200 to 400 mg po q 4 h in syrup or tablet form) is most commonly used because it has no serious adverse effects, but multiple expectorants exist, including bromhexine, ipecac, and saturated solution of K iodide (SSKI). Aerosolized expectorants such as N-acetylcysteineSome Trade Names
MUCOMYST
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and DNase are generally reserved for hospital-based treatment of cough in patients with bronchiectasis or cystic fibrosis. Ensuring adequate hydration may facilitate expectoration, as may inhalation of steam, although neither technique has been rigorously tested.

Topical treatments, such as acacia, licorice, glycerin, honey, and wild cherry cough drops or syrups (demulcents), are locally and perhaps emotionally soothing, but their use is not supported by scientific evidence.

Protussives, which stimulate cough, are indicated for such disorders as cystic fibrosis and bronchiectasis, in which a productive cough is thought to be important for airway clearance and preservation of pulmonary function. DNase or hypertonic saline is given in conjunction with chest physical therapy and postural drainage to promote cough and expectoration. This approach is beneficial in cystic fibrosis but not in most other causes of chronic cough.

Bronchodilators, such as albuterolSome Trade Names
PROVENTIL
VENTOLIN
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and ipratropiumSome Trade Names
ATROVENT
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or inhaled corticosteroids, can be effective for cough after URI and in cough-variant asthma.

Key Points

• Danger signs include respiratory distress, chronic fever, weight loss, and hemoptysis.
• Clinical diagnosis is usually adequate.
• Occult gastroesophageal reflux disease should be remembered as a possible cause.
• Antitussives and expectorants should be used selectively.

Last full review/revision July 2012 by Noah Lechtzin, MD, MHS

Content last modified November 2012