Chapter e12: Cough and Other Nonspecific Respiratory Symptoms

KEY CONCEPTS

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

• 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.

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

• 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.

• 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

Collect

• 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

Assess

• 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)

Plan^*

• 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”)

Implement^*

• 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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