Cough for more than 2 weeks

If the cough is post-exercise or nocturnal, or there is a wheeze on examination then consider asthma as cause of chronic cough. Take a peak flow reading and trial of bronchodilator.

If the cough is worse at night and there are crepitations on examination +/- a history of pink, frothy sputum then consider left ventricular failure. The cause should be sought. Trial of diuretic therapy.

If there is no clue from the history and the chest is clear consider allergy, drug induced cough e.g. ACE inhibitors. A paroxysmal cough in a child may be due to pertussis.

In this category the patient must be reviewed. If there is no improvement then further investigation (e.g. chest X-ray, sputum culture/ cytology, blood tests) as appropriate. There may be a need for this patient to be referred - always consider NICE urgent cancer related guidance for referral for CXR and referral for urgent specialist review (see linked items).

Notes:

• chronic cough in children
  • in a study of children with protracted cough (1):
    • the most common aetiology was protracted bacterial bronchitis (40%). About 20% of children had natural resolution of cough before diagnosis. No other cause of accounted for > 6% of cases of children with a chronic cough. The most common causes of chronic adult cough (e.g. asthma, gastro-oesophageal reflux) were found < 10% of the children
    • a commentary with respect to this study suggested that (2)
      • "..This study seems to support empirical antibiotic treatment as a first strategy, followed by careful review, given that this might temporarily alleviate some more serious diagnoses. The same might be said of a trial of inhaled bronchodilator and steroid therapy..."
  • a systematic review investigating the use of antibiotics for prolonged moist cough in children concluded (3):
    • antibiotics are likely to be beneficial in the treatment of children with chronic moist cough. This evidence is however limited by study quality, study design and sensitivity analysis data

Reference:

1. Marchant JM et al. Evaluation and outcome of young children with chronic cough. Chest. 2006 May;129(5):1132-41.
2. Wacogne I. Commentary. Evidence Based Medicine 2006;11:187.
3. Marchant JM et al. Antibiotics for prolonged moist cough in children. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004822