Key Clinical Practice Points on Managing Chronic Cough in Adults: Insights from the British Thoracic Society

Clinical Practice Points on Chronic Cough Management

Overview:
Chronic cough (CC) predominantly affects middle-aged females and significantly impairs quality of life (QoL). It is associated with increased healthcare costs and often lacks effective management strategies in routine clinical practice.

Diagnosis and Referral

Initial Assessment:

Obtain a detailed history to identify possible underlying diseases and treatable traits.
Perform essential tests including a chest X-ray (CXR), full blood count (FBC), diagnostic spirometry, and fractional exhaled nitric oxide (FeNO) if available.

Referral Criteria:

Refer patients to secondary care if cough persists despite treatment, if the diagnosis remains unclear, or if there is suspicion of underlying conditions such as bronchiectasis, interstitial lung disease, tuberculosis, or heart failure.
Urgent referral is required for red flag symptoms suggestive of malignancy, following NICE guidelines.
For predominant upper airway symptoms, consider referring to an ENT service.

Management Strategies

Smoking Cessation

Encourage smoking cessation as it resolves chronic bronchitis and reduces cough. Nicotine replacement therapy may prevent rebound cough sensitivity.

ACE Inhibitors

Discontinue ACE inhibitors in all patients with CC. If needed, switch to an angiotensin II receptor blocker (A2RB). Improvement may take up to 4 weeks.

Airway Disease

For productive cough, investigate possible infections, smoking, or airway diseases such as bronchiectasis. Optimize airway clearance and consider low-dose macrolide therapy, like Azithromycin.

Eosinophilic Airway Disease

In the absence of airway disease features, avoid inhaled corticosteroids (ICS) and explore alternative causes. In cases with airway disease, manage according to disease-specific guidelines. Consider a 1-month trial of ICS for elevated T2 biomarkers.

Gastro-oesophageal Reflux Disease (GERD)

Treat with PPIs only if there is clear evidence of acid reflux, such as heartburn. PPIs are not recommended for isolated cough symptoms. Fundoplication is not advised for cough alone.

Upper Airway Symptoms

For chronic rhinosinusitis (CRS), an empirical trial of a nasal steroid may be beneficial. Avoid using PPIs for throat symptoms.

Obstructive Sleep Apnoea (OSA)

Consider OSA as a treatable trait in refractory cough. CPAP treatment may improve cough if OSA is confirmed by a sleep study.

Obesity

Recommend weight loss for obese patients, as it may improve chronic cough.

Cough Hypersensitivity

Recognize cough hypersensitivity as a treatable trait. It often requires specific treatments, including non-pharmacological approaches, low-dose morphine, or gabapentin.

Specialist Care

Establish secondary care cough clinics and consider integrating specialist speech and language therapy and physiotherapy into a multidisciplinary team (MDT) for comprehensive management.

Future Directions