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SUPPLEMENT TO Journal of the association of physicians of india • MAY 2013 • VOL. 61

Diagnostic Approach to Cough

Kalpesh B Vaishnav*
Introduction cancer, pneumoconiosis (asbestosis, silicosis, anthracosis etc.),
mesothelioma of lung, drug induced cough (ACE inhibitors,
C ough is a sudden and often repetitively occurring reflex
which helps to clear the large breathing passages. It is a
protective reflex against foreign material. It is the most common
beta blockers, NSAIDS), drugs causing pulmonary fibrosis as
listed in Table 1.
presenting complaint in outpatient department. Cough may
represent a symptom of simple common cold as well as of fatal Diagnostic Approach to Cough
Lung carcinoma. The etiology can be classified into respiratory An algorithm developed by De Blasio et al1 to diagnose
causes and non respiratory causes. Cough has been classified acute cough is shown in Figure 1. At first, life threatening
into acute (less than three weeks), subacute (three to eight weeks)
causes like pneumonia, asthma, COPD, pulmonary embolism,
and chronic(more than eight weeks).1 It is also classified into
productive or dry cough depending on the presence or absence bronchiectasis, lung abscess, lung cancer, foreign body inhalation
of expectoration respectively. Cough is only a symptom of some or congestive cardiac failure have to be ruled out by investigating
underlying disease and a diagnosis can be reached based on symptoms, signs and laboratory investigations. Patients with
history, physical examination, simple investigations, history pneumonia will be characterized by the presence of cough with
taking being most important step. productive sputum, fever with or without dyspnea. Dyspnea with
wheeze may suggest asthma or COPD. In addition, hemoptysis
Etiology of Cough may characterize the presence of bronchiectasis or lung cancer.
Concurrent pedal edema with or without muffled heart sounds,
The etiology of cough is very diverse and is classified
decreased renal output suggests congestive cardiac failure. In
according to duration of symptom. It is classified into acute,
case of foreign body inhalation, chest x-ray or bronchoscopy
sub-acute and chronic cough.1 It is a real possibility that the
may give evidence on the size and site of the inhaled object.
underlying disease condition may progress in severity and lead
Having ruled these, cough associated with productive sputum
to progression of acute/sub-acute cough to chronic cough.
may be a sign of acute bronchitis due to upper respiratory tract
Acute Cough infections. If cough persists for 8 weeks and above, a diagnosis
Acute cough generally last for less than three weeks. The of chronic cough is made and causes to be investigated5. In all
causes for acute are common cold, Upper respiratory tract the cases of chronic cough and in those with acute atypical
infections (URTI), exacerbation of asthma or Chronic Obstructive cough, a chest x-ray should be performed. Spirometry should
pulmonary disease (COPD), environmental pollution, toxic gas be performed to assess whether and to what extent the airways
inhalation or infective bronchitis, tracheo-bronchitis, laryngitis.2 are obstructed by measuring forced expiratory volume in first
Lower respiratory tract infections, bronchiectasis, pneumonia second (FEV1) when a case of bronchial asthma or COPD is
also cause acute cough, but usually progresses to sub-acute suspected. Presence of low grade fever, productive cough, loss
cough. Non-respiratory causes like congestive heart failure, of weight and appetite with an acid fast bacilli being detected
Gastro-esophageal reflux disease (GERD), etc are also implicated. in sputum smear would give the diagnosis of tuberculosis.6
In case of absent/atypical findings in the chest x-ray that does
Sub-acute Cough
not correlate with clinical picture, a high resolution computed
Cough lasting for three to eight weeks duration is termed tomography of the chest may throw light on the underlying
sub-acute cough. The Respiratory causes include pneumonia cause. History of having worked in a cotton industry or flour
(bacterial, viral, fungal), B. pertusis infection (whooping cough) mill for many years would give a clue towards pneumoconiosis
leading to bronchial hyper-responsiveness,3 bronchiectasis. Non and a typical reticulo nodular pattern may be observed in chest
respiratory causes include GERD and rarely Tourette’s syndrome x-ray or high resolution computed tomography (HRCT). Lastly,
with symptom of paroxysmal cough on presentation. drug induced fibrosis should be suspected in presence of any of
Chronic Cough those agents as mentioned in Table 1.
Any cough lasting for more than 8 weeks is termed
chronic and must be evaluated thoroughly. Chronic cigarette Conclusion
smoking is the most common cause of chronic cough.4 The This algorithmic approach is a useful diagnostic and
respiratory causes include COPD, asthma, tuberculosis, lung therapeutic option for the treatment of cough.
Table 1 : Drugs causing pulmonary fibrosis
Busulphan Carmustine References
1. Blasio FD, Virchow JC, Polverino M, Zanas A, Behrakis PK, Kilinç
Bleomycin Nitrofurantoin
G, et.al. Cough management: a practical approach Cough 2011,
Methotrexate Hydralazine 7:7 doi:10.1186/1745-9974-7-7.
Cyclophosphamide Amiodarone 2. Eccles R: Acute cough: epidemiology, mechanisms and treatment.
Acute Cough
Acute and chronic cough. Lung biology in health and disease.
Redington A, Morice A (eds) 2005, 205:215-236.
3. Harnden A, Grant C, Harrison T, Perera R, Brueggemann AB,
Life-threatening Dx
History,
Examination Non-life-threatening Dx
Mayon-White R, Mant D: Whooping cough in school age children
± Investigations with persistent cough: prospective cohort study in primary care.
BMJ 2006;333:174-177.
Infectious Exacerbation of Environmental/
4. Cerveri I, Accordini S, Corsico A, Zoia MC, Carrozzi L, Cazzoletti
Pneumonia, severe
exacerbation pre-existing condition Occupational L, Beccaria M, Marinoni A, Viegi G, de Marco R, ISAYA Study
of asthma or COPD,
PE, Heart Failure Group:  Chronic cough and phlegm in young adults. Eur Respir
other serious disease
URTI LRTI Asthma Bronchiectasis UACS COPD J 2003;22:413-417.
5. Irwin RS, Corraro WM, Pratter MR. Chronic persistent cough in
(Reproduced from De Blasio et al. Cough 211: 7:7) the adult. The spectrum and frequency of causes and successful
Fig. 1 : Algorithm for differential diagnosis of cough outcome of specific therapy. Am Rev Respir Dis 1981;123:413-17.
*
Bhatia Hospital, Tardeo, Mumbai-400 007 6. Dorman SE. New diagnostic tests for tuberculosis: Bench, bedside
and beyond. Clinical Infectious Diseases 2010;50(S3):S173-S177.