The National Association for Medical Direction of Respiratory Care

NAMDRC Blog 6-1-17: Successfully managing chronic cough: It’s as obvious as the nose on your face!

Do you cringe when your medical assistant tells you that your next patient is here to be evaluated for a cough that has been present for 5 years? Making matters worse, they have already seen numerous specialists, none of whom “cured” them. In their own words, you are their last resort, compounding the anxiety you may already be experiencing.

Cough is responsible for approximately 30 million clinician visits annually in the U.S. Similar to the adage “all that wheezes isn’t asthma”, not all coughs mean lung pathology. Keeping an open mind to non-pulmonary etiologies will increase the likelihood of a successful outcome both for you and your patients.

Traditional teaching states that more than 98% of chronic coughs fall into 1 (rarely more) of 4 distinct disease categories. These include chronic bronchitis, gastroesophageal reflux disease (GERD), cough variant asthma and rhinosinusitis (post-nasal drainage). Of these, I believe the overwhelming majority of persistent or chronic cough is due to rhinosinusitis that has been incorrectly diagnosed as sinusitis, bronchitis or asthma.

Chronic bronchitis is clinically straightforward, characterized by cough with purulent sputum, normally associated with smokers or those with chronic underlying lung disease. This is typically antibiotic responsive and should not present a diagnostic dilemma. Likewise, GERD is readily apparent to most patients, given that their symptoms are postprandial, exacerbated by the supine position, and responsive to antireflux measures as well as proton pump inhibitors [PPIs], histamine-2 blockers, and antacid medications. Cough variant asthma, in my experience, is the least likely diagnosis which when entertained, should prompt consideration of an alternative etiology. Instead of “classical” wheezing, the clinical presentation is cough, which may be worsened by exposure to cold air, exercise or allergens. Bronchodilators and/or anti-inflammatory inhalants should be beneficial in this condition. Lastly, though probably the most important consideration, is the role of the nose and sinuses in chronic cough. In my practice, using the diagnostic framework above, coupled with the management strategies which follow, success rates for resolving or significantly improving annoying cough exceeds 90%.

So what are the key signs and symptoms pointing to rhinosinusitis as the etiology? I always inquire about frequent throat clearing or sniffling. One or both of these will invariably be present, along with the sensation of a “tickle or scratch” in the back of the throat or base of the neck. Always ask about the frequency of nose blowing and look for the telltale crumpled tissue being carried around. Cough in this setting is frequently non-productive or at worst, minimally productive of sputum. Normally it does not result in nocturnal awakening, although it is common that there is a need to clear the throat and expectorate sputum in the morning. Once the diagnosis of rhinosinusitis is suspected, management is easy, inexpensive and rewarding (for you as well as for your patient)!

I believe the cornerstone of management, and a wonderful lifetime practice, is vigorous use of nasal saline. I stress using this a minimum of 3-4 times daily, whether by Neti pot, mist or any other delivery device. On top of this, I recommend a non-sedating antihistamine without a decongestant component. Lastly, I routinely prescribe a nasal steroid spray, an antihistamine nasal spray, or an anticholinergic nasal spray or some combination product. I strongly recommend using all 3 categories of medications initially and simultaneously, and would not try them one at a time. Your mission at the outset is to prove that this problematic cough can be controlled – and in this instance, “more is better”. Don’t worry about decelerating medications until later on.

For patients with coughs of months and years duration, I am upfront in letting them know that cough resolution will not occur overnight. In the few cases of refractory cough, I would consider adding Monteleukast at the follow-up visit. Only as a last resort would I try a brief, tapering course of oral corticosteroids (no more than 10-14 days) to reduce pharyngeal hypersensitivity and hyperirritability. Recent studies advocate considering Gabapentin to control chronic cough, presumably by its effect upon neural pathways. I never prescribe antibiotics unless there is incontrovertible evidence of infection. Should the cough fail to improve in a reasonable period of time (within several weeks), be certain to check the chest radiograph and consider CT imaging of the chest and sinuses as diagnostic next steps.

This algorithm will not be found in any textbook and reflects decades of clinical trial and error. Keep in mind that if your patient tells you that their ENT doctor said the sinuses were “fine”, this only means there was nothing requiring surgery that was identified and that mechanical nasal drainage may still be present.

In patients with chronic cough, be suspicious about rhinosinusitis. When the appropriate signs and symptoms are present, management will be both simple and rewarding, with grateful patients more than happy to return to see you and tell you of their success. Good luck…and remember, “those in the know, know it’s the nose”!

Robert Albin, M.D. [NAMDRC Board Member]
Atlanta, GA

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