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  • image Cough is classified as acute, subacute, or chronic based on duration of symptoms.

  • image Cough is an essential component for lung health maintenance, but persistent or excessive cough ceases to be protective, is bothersome, and adversely affects quality of life.

  • image Although cough is associated with a variety of diseases, the duration of cough helps narrow the potential etiologies for cough symptoms.

  • image The presence of dyspnea, red flag symptoms, and/or symptoms suggestive of acute bacterial rhinosinusitis indicates the need for referral to the patient’s primary care physician.

  • image Treatment trials (eg, intranasal corticosteroids, first-generation antihistamines, treatments for gastroesophageal reflux disease) can help rule out common causes of chronic cough.


Patient Care Process for Cough



  • Duration of symptoms, red flag symptoms (see Table e12-5), and the presence and severity of symptoms associated with acute bacterial rhinosinusitis (see Tables e12-6 and e12-7)

  • Use validated symptom questionnaires as needed (see text).

  • Current medical conditions, family history, and occupational and environmental (eg, pets, carpet/bedding, mold) history

  • Tobacco and marijuana use, prior allergies, and immunization history and medications

  • Ability to access medications and adherence to current medications


  • Indicators of acute, subacute, or chronic cough (see Table e12-1 and text)

  • Red flag symptoms (see Table e12-5) or symptoms associated with acute bacterial rhinosinusitis (see Tables e12-6 and e12-7) indicating need for referral to primary care provider

  • Active medical problems associated with chronic cough (see Table e12-2)

  • Possibility of cough related to gastroesophageal reflux disease (GERD; see Chapter 49, “Gastroesophageal Reflux Disease”)

  • If applicable, estimate creatinine clearance to assess dosing of current or new medications.

  • If the patient taking any medications associated with cough (especially ACE inhibitors; see Table e12-4)


  • Refer to primary care provider for assessment of cough with dyspnea, red flag symptoms (see Table e12-5), or symptoms related to environmental or occupational exposures.

  • Smoking cessation interventions in those ready to quit smoking (see Chapter 82, “Substance-Related Disorders II: Alcohol, Nicotine, and Caffeine”)

  • Immunizations if not contraindicated (eg, influenza, pneumococcal, diphtheria, tetanus, acellular pertussis; see Chapter 142, “Vaccines and Immunoglobulins”)

  • Step-up therapy in patients with asthma-related cough to improve symptom control (see Chapter 43, “Asthma”)


  • Patient education

  • Recommendations that are within scope of practice

  • Document in health record

  • Instructions and schedule for follow-up

Follow-up: Monitor and Evaluate

  • Reevaluate in 4 to 6 weeks and reassess using validated symptom questionnaires as needed.

  • Adherence to care plan

  • Adverse drug effects

  • Immunizations for those deferred earlier (see Chapter 142)

  • For acute or subacute cough that persists for more than 8 weeks (ie, progresses to chronic cough), trial of an oral first-generation antihistamine and/or intranasal corticosteroid

  • For chronic cough that does not improve with an oral first-generation antihistamine and an intranasal corticosteroid, refer patient to primary care provider for ruling out asthma and nonasthmatic eosinophilic bronchitis before recommending treatment trial for GERD.


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