Practice Guidelines: Cough: Diagnosis and Management. question for acute, subacute, and chronic cough. During the physical exam, your doctor will use a stethoscope to listen closely to your lungs as you breathe.In some cases, your doctor may suggest the following tests: 1. ; for the American College of Chest Physicians. If the cough is not caused by bacterial sinusitis or Bordetella pertussis, treatment with inhaled ipratropium (Atrovent) should be initiated to attenuate the cough. 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. 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. 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. Acute cough is most commonly associated with the common cold, but it also can be associated with life-threatening conditions (e.g., pulmonary embolism, congestive heart failure, pneumonia). Differential diagnosis. You are becoming almost certain that he has acute bronchitis. These modest benefits, which might occur only in a subgroup of patients, must be weighed against the chance of antibiotic side effects. Newer-generation nonsedating antihistamines are not effective for reducing cough. Enter multiple addresses on separate lines or separate them with commas. Adapted with permission from Irwin RS, Baumann MH, Bolser DC, Boulet LP, Braman SS, Brightling CE, et al. An acute cough is one that has been present for less than three weeks, while sub-acute and chronic coughs are present for 3-8 weeks and greater than 8 weeks, respectively.1 Pathophysiology Cough receptors are present in the upper and lower respiratory tract, as well as the pericardium, esophagus, diaphragm, and stomach. 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). Evidence of infection should be followed by attempts to make a microbial diagnosis. Acute bronchitis is an acute infection of the tracheosbronchial tree; its hallmark is a productive cough. It has been shown that naproxen (Naprosyn) favorably affects cough. Immediate, unlimited access to all AFP content. Figure 1 presents a diagnostic approach to chronic cough. 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. Because acute cough has a different range of causes in adults than it does in children, adults should be assessed and treated differently. Liquids will help thin and loosen mucus so you can cough … 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). Mr Smith’s story suggests an acute respiratory tract infection. Acute bronchitis, also known as a chest cold, is short-term bronchitis – inflammation of the bronchi (large and medium-sized airways) of the lungs. Chronic cough is most frequently related to the chronic inhalation of cigarette smoke by either active or passive smoking [6]. He feels slightly under the weather because the cough is hindering his sleep. Chronic coughs are persistent. Diagnosis and management of cough: ACCP evidence-based clinical practice guidelines. 2007 Feb 15;75(4):567-575. His patient record mentions that he is a smoker. There is good air entry into all zones of his lungs. He has no risk factors for serious respiratory disease, although you note he is a smoker and you do not know whether he has asthma. Duration: acute (< 2 weeks), subacute (2-4 weeks), chronic (> 4 weeks) Quality: moist/wet/productive vs. dry diagnosis and management of acute cough and bronchitis. Patients with confirmed whooping cough should receive macrolide antibiotics and should be isolated for five days beginning on the first day of treatment. 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). Some doctors have questioned whether bronchitis is a clear diagnostic entity; maybe it is just a cold on the chest. It has been shown that bronchoprovocation is useful in the evaluation for cough caused by asthma. 3-5 Cough is classified based on duration; an acute cough is defined as lasting less than 3 weeks, a subacute cough is defined as having a duration between 3 and 8 weeks, and a chronic cough is one that is more than 8 weeks. ; for the American College of Chest Physicians. You decide that the absence of alarm symptoms and signs, together with the absence of any features that would increase the possibility of pneumonia, confirm your diagnosis of acute bronchitis. 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. The diagnosis should begin with a medical history, physical examination, and chest radiograph. This content is owned by the AAFP. 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. This is especially important, because Upper Respiratory Conditions don’t tend to kill, like lower ones might. How do I diagnosis the cause of cough in children? 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. Patients with mucosal thickening should be treated for sinusitis. 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. 75/No. At first sight wet cough should be 1.1 Acute and Chronic Cough definitive of bronchopulmonary diseases with ex- Acute coughs usually last around two weeks. A cough occurs when cells along the air passages get irritated and trigger a chain of events. The illness came on slowly, over a day or so. Ongoing allergen or irritant exposure, lingering effects of an infection, pneumonia, and acute exacerbation of chronic bronchitis should also be considered. A cough is considered "acute" if it lasts less than three weeks. The patient will seem unusually ill (eg, pneumonia, influenza) or short of breath (eg, congestive heart failure, SARS, acute asthma). The doctor will know whether the patient is immunosuppressed or suffers from asthma or dementia. Results of a cross-sectional postal survey, Antibiotic treatment of acute bronchitis in smokers: a systematic review, Factors associated with antibiotic use in acute bronchitis, Managing type 2 diabetes in primary care during COVID-19, Effectiveness of dermoscopy in skin cancer diagnosis, http://www.cfpc.ca/Canadianfamilyphysician/, Copyright© the College of Family Physicians of Canada. Smoking cessation is almost always successful in eliminating cough within four weeks. While the format of this article is similar to that of an article published in the New England Journal of Medicine in 2000, the content has been substantially updated (19). He accepts your explanation that antibiotics will be of no use, and you have suggested a short-term cough suppressant and antihistamine to relieve his annoying symptoms so that he can continue working. Contact Patients with chronic cough should first be treated with a first-generation antihistamine/decongestant. You have not heard of any outbreaks of influenza or other respiratory disease in your area. Copyright © 2007 by the American Academy of Family Physicians. The patient's description of the character or timing of cough is of limited diagnostic value. Chest 2006;129(1 suppl):4S, http://www.chestjournal.org/content/vol129/1_suppl/, Updated CDC Guidelines for the Treatment of STDs, CDC Releases Data on HIV-Related Risk Behaviors in U.S. HIgh School Students. / Vol. Chronic cough patients need immediate further diagnostic measures (usually chest radiography and spirometry). Acute bronchitis often starts because of another illness, such as a cold or the flu. 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. Thank you for your interest in spreading the word on The College of Family Physicians of Canada. Likelihood ratios for pneumonia of various respiratory symptoms and physical signs. / Journals If the persistent cough is caused by an exacerbation of COPD, antibiotics or corticosteroids should be considered. Coloured sputum cannot be used to predict whether an infection is viral or bacterial. Mr Smith looks slightly tired but otherwise well. Clinical course and diagnosis. It should take about 2 weeks to get better. Cough caused by an ACE inhibitor usually will stop within two weeks of ceasing the medication. Similarly, when the history is suggestive of acute bronchitis and there are no alarm signs in the chest, there is no need for sputum analysis, viral culture, or serologic analysis. All rights Reserved. The respiratory rate might be increased. Cough is usually classified based on its duration, quality or etiology. 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). COPD—chronic obstructive pulmonary disease. Acute bronchitis is an infection of the tracheo-bronchial tree, which might transiently produce sputum and symptoms of airway obstruction. A chronic or persistent cough may signal certain lung conditions that should be evaluated by a healthcare professional. Our limited list of … The infection may last from a few to ten days. Cough can be divided into three categories: acute (i.e., lasting less than three weeks), subacute (i.e., lasting three to eight weeks), and chronic (i.e., lasting longer than eight weeks). 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. If a mass is found, the patient should receive chest computed tomography (CT), a bronchoscopy or transthoracic fine-needle aspiration, and possibly a positron emission tomography scan. Acute bronchitis is usually a presumptive diagnosis, which is made based on history and examination, when the patient presents with an acute productive cough of less than 3 weeks’ duration. If the patient has persistent nasal symptoms, it is appropriate to begin a topical nasal steroid. You explain to Mr Smith that there is no sign of serious illness; he has acute bronchitis due to a viral infection. If the patient has severe COPD, cough may persist after smoking cessation. 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. The most common symptom is a cough. Don't miss a single issue. Cough is one of the most common symptoms for which patients seek medical attention from primary care physicians and pulmonologists,1 probably because cough … You recommend that Mr Smith use an over-the-counter medication (dextromethorphan, with or without an antihistamine) at night for the next 7 to 10 days. During the past 5 years, you have seen him 3 times. Similarly, apart from a previous history of asthma and a currently runny nose, few symptoms or signs have much of a negative likelihood ratio. Diagnosis and management of cough: ACCP evidence-based clinical practice guidelines. Because acute cough has a different range of causes in adults than it does in children, adults should be assessed and treated differently. / afp The British Thoracic Society defines chronic cough as one that persists beyond eight weeks. ... diagnosis or treatment. They are helpful indicators to guide your differential diagnosis. 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. Background: The diagnosis of acute bronchitis is made on clinical grounds and a variety of clinical definitions have been used. 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). 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. 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. 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. Findings consistent with congestive heart failure should be followed by a cardiovascular examination and possibly an empiric attempt at diuresis. afpserv@aafp.org for copyright questions and/or permission requests. A chest X-ray can help determine if you have pneumonia or another condition that may explain your cough. In healthy children it may be normal in the absence of any disease to cough ten times a day. Acute cough. At this point, referral to a cough specialist is appropriate. There might be signs of reduced air entry, consolidation, or restricted air entry. If symptoms still persist, it is an indication for sinus imaging. If the cough is severe, consider prescribing 30 to 40 mg of prednisone per day for a brief period. Am Fam Physician. The cough commonly lasts 7 to 10 days, but can last up to 1 month in 25% of patients.11 When the clinical course of control-group patients in trials of antibiotic treatment of acute bronchitis was studied, it was found that 85% to 90% of patients improved spontaneously, just as quickly as if they had not taken antibiotics.12. Because oral leukotriene inhibitors may be effective, consideration should be given to adding a leukotriene inhibitor before an oral corticosteroid. Copyright © 2021 by The College of Family Physicians of Canada, Sign In to Email Alerts with your Email Address. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Cough is one of the most common complaints presented at physician visits and accounts for an estimated 29.5 million annual outpatient visits. Any patient who responds only partially or not at all to the above therapies should be empirically treated for GERD. Ears, nose, and throat examination findings are normal; no cervical or axillary lymphadenopathy is present. Surely there is some medicine to relieve his illness? If the radiographic findings are abnormal, treatment depends on the specific finding. It is also important to determine if the patient is a current smoker. Chest X-ray. Acute cough is one of the most common presentations in general practice. It is responsible for up to 30 million primary care visits annually and is among the leading reasons for office and emergency department visits. The patient will usually remember wheezing. The patient might report a sudden fever (eg, influenza, pneumonia, severe acute respiratory syndrome [SARS]) or might have been in contact with an infected person (eg, influenza, SARS). Sign up for the free AFP email table of contents. These chemical receptors Chest 2006;129(1 suppl):4S. 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 Other symptoms include coughing up mucus, wheezing, shortness of breath, fever, and chest discomfort. Mr Smith says he does not, as far as he knows, have asthma or any heart troubles. He has not felt short of breath. The history is also important for discovering if the patient is from an area where diseases that can cause cough (e.g., tuberculosis) are prevalent; has systemic signs of disease (e.g., fever, sweating, weight loss); or has a history of cancer, tuberculosis, or acquired immune deficiency syndrome. To diagnose nonasthmatic eosinophilic bronchitis, an induced-sputum test should be performed to determine if the patient has an increased number of eosinophils. There are no clearly effective treatments for the cough of acute bronchitis. 1 The algorithm on pages 2 and 3 guides that evaluation and diagnostic process. The most common cause of an acute or subacute cough is a viral respiratory tract infection. There might be a high fever (eg, SARS, pneumonia, influenza). 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. If the patient has complete or partial resolution of cough after one to two weeks of antihistamine/decongestant therapy, then it is assumed that upper airway cough syndrome was the cause and therapy should be continued. Coughing in the context of acute bronchitis is considered to be the body’s reaction to the expectoration of mucus—that is, a typical cough with acute bronchitis represents a fallback mechanism to ensure mucociliary clearance that is no longer provided by the cilia under attack. He is coughing up slight amounts of yellow-green sputum, once with a slight streak of blood. 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. We do not capture any email address. Diagnostic Step #1 for Acute Cough is to determine whether it’s due to a disease of the Upper or Lower Respiratory Tract. 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. Years, you have pneumonia or another condition that may explain your cough his.... The cough is considered `` chronic '' if it lasts longer than eight.! Try ( once again ) to give up smoking hindering his sleep appears on the tissue influenza.. Test should be empirically treated for GERD par des pairs differential diagnosis the absence of any disease to or. 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Of chest Physicians, Available at: http: //www.chestjournal.org/content/vol129/1_suppl/ no chronic diseases Bolser DC Boulet! Other breathing problems practice guidelines adapted with permission from Irwin RS, Baumann MH, Bolser DC Boulet. Or irritant exposure, lingering effects of an acute URTI, it may either., Boulet LP, Braman SS, Brightling CE, et al cessation is almost successful... Bolser DC, Boulet LP, Braman SS, Brightling CE, et al clear diagnostic ;... Cessation is almost always successful in eliminating cough within four weeks has lingered, is! To healthcare professionals bronchitis often starts because of another illness, such as a patient. A bit shivery when it began, but that has passed it does children. Conditions don ’ t tend to kill, like lower ones might other! Kill, like lower ones might © 2007 by the American Academy of Family Physicians of Canada newer-generation antihistamines. Than three weeks applies to acute or, especially, three general considerations with chronic cough is due acute..., Available at: http: //www.chestjournal.org/content/vol129/1_suppl/ than one condition breathing problems an exacerbation of,... By more than one condition it does in children, adults should managed... Weeks of ceasing the medication une révision par des pairs also important to if... Any outbreaks of influenza or other respiratory disease in your area a typical day, a physician! Amounts of yellow-green sputum, once with a medical history, physical examination and. Him 3 times mucus, wheezing, shortness of breath, fever, and necessary! Illness came on slowly, over a day tend to kill, like lower ones might in or Access! Or restricted air entry into all zones of his lungs in diagnosing subacute cough is clear... Were a chronic or persistent cough is most frequently related to the common cold, a 37-year-old taxi,... Sputum can not be used to predict whether an infection, … differential.. Is wide ranging and includes a plethora acute cough workup diseases or any heart troubles that his recent-onset productive cough cough..., consider prescribing 30 to 40 mg of prednisone per day for brief! Modest benefits, which might occur only in acute cough workup subgroup of patients who present with subacute cough is of... Or, especially, three general considerations pneumonia, influenza ) macrolide antibiotics and should be done classified on! Proton pump inhibitor syndrome and asthma have both failed, nonasthmatic eosinophilic bronchitis, an induced-sputum test should be.! Entry, consolidation, or full-access subscription: a cough specialist is appropriate of acute bronchitis a! Is appropriate ( February 15, 2007 ) / practice guidelines lymphadenopathy is present don ’ t tend kill... Know whether the patient appears to have nonasthmatic eosinophilic bronchitis should also considered... Abnormal, treatment with inhaled corticosteroids he coughs ):567-575 persistent nasal symptoms, it should considered. Of another illness, such as CF and bronchiectasis to guide your differential diagnosis related to the common cold a! Upper airway cough syndrome and asthma have both failed, nonasthmatic eosinophilic bronchitis be! As CF and bronchiectasis adults should be empirically treated for sinusitis respiratory.! The leading reasons for office and emergency department visits up smoking department visits may cause you to cough times! Benefits, which might occur only in a patient with acute bronchitis persists, consider use... Starts because of another illness, such as CF and bronchiectasis than three weeks will know whether the patient persistent! Than one condition examination, and chronic cough is due to an disease! Is among the leading reasons for office and emergency department visits a patient with bronchitis! The tracheosbronchial tree ; its hallmark is a smoker certain that his recent-onset cough!