Chronic Cough: Evaluation and Management

Charlie Michaudet, MD; John Malaty, MD


Am Fam Physician. 2017;96(9):575-580. 

In This Article

Assessment of Chronic Cough

The initial evaluation should focus on identifying potential triggers, such as the use of an angiotensin-converting enzyme (ACE) inhibitor, environmental exposures, smoking status, and chronic obstructive pulmonary disease (COPD). It should also rule out red flags (e.g., fever, weight loss, hemoptysis, hoarseness, excessive dyspnea or sputum production, recurrent pneumonia, smoking history of 20 pack-years, or smoker older than 45 years) that suggest a serious underlying cause of cough.[6] The patient's description of the cough (character, timing, presence or absence of sputum production) should not determine the clinical approach; sequential or concomitant treatment of common causes is still recommended.[4] Unless a likely cause is identified, chest radiography should be obtained to rule out most infectious, inflammatory, and malignant thoracic conditions. When physical examination findings are normal and no red flags are present, routine computed tomography of the chest and sinuses is not necessary, nor is initial bronchoscopy.[2]

The diagnostic approach should focus on detection and treatment of the four most common causes of chronic cough in adults: upper airway cough syndrome (UACS), asthma, nonasthmatic eosinophilic bronchitis, and gastroesophageal reflux disease (GERD)/laryngopharyngeal reflux disease.[4,5] After evaluation and empiric management of these etiologies, less common causes should be considered (Table 1[7] and Table 2[8]). A suggested primary care approach to the evaluation of chronic cough for immunocompetent adults is shown in Figure 1.[9]


Figure 1.

Algorithm for assessment of chronic cough in immunocompetent adults. (GERD = gastroesophageal reflux disease.)
Adapted with permission from Iyer VN, Lim KG. Chronic cough: an update. Mayo Clin Proc. 2013;88(10):1118.