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Abstract
Cough is an important complaint of respiratory disease and normal defense mechanism of the lungs. It helps in clearing excessive
secretions, fluids, infections or foreign material from the airway. In most of the cases, cough occurs as part of a brief, self-limiting
illness. However, it can become a persistent symptom in several cases. The etiology of cough is very diverse and commonly
includes environmental causes (cigarette smoke, pollutants, dust mites, etc.) and several disease entities, including both respiratory
and nonrespiratory causes. Postnasal drip syndrome and postinfectious cough are the most common respiratory causes of chronic
cough. The objective of this article is to highlight the importance and consequences of cough and discuss the effective diagnosis and
management of upper airway cough syndrome and postinfectious cough. For this article, PUBMED was searched for studies
and guidelines published in the English language using the medical subject heading terms cough, causes of cough, etiology of
cough, postinfectious cough, post-viral cough, upper airway cough syndrome, and postnasal drip.
Keywords: Cough, causes of cough, etiology of cough, postinfectious cough, post-viral cough, upper airway cough
syndrome, postnasal drip
C
ough is the most common complaint of patients is to highlight the importance and consequences of
who present to primary care physicians.1 It has cough and the effective diagnosis and management
been recently identified as the sixth common of postnasal drip syndrome/upper airway cough
reason for hospital outpatient department visits.2 syndrome and postinfectious cough. In preparing this
In most of the cases, cough occurs as part of a brief, article, PUBMED was searched for studies/guidelines
self-limiting illness. However, it can become a persistent published in the English language using the medical
symptom in several cases.1 subject heading terms cough, causes of cough, etiology
A cough can be arbitrarily classified as acute (that of cough, postinfectious cough, post-viral cough, upper
lasts for <3 weeks), subacute (that lasts between 3 and airway cough syndrome and postnasal drip.
8 weeks) and chronic (that lasts for >8 weeks). The
Importance of the Cough Reflex and
estimated prevalence of chronic cough is between 11%
Complications of Chronic Cough
and 20%.3 In a survey of members of the American
Academy of Allergy, Asthma and Immunology in Cough is an important defense mechanism of the
2008, it was observed that chronic cough was the chief lungs. It helps in clearing excessive secretions, fluids,
complaint in about 20-40% of new patients.3 Chronic noxious substance or foreign material from the airway.
cough occurs more often in females than males. It has Both excess as well as a shortfall of cough can have
been observed that women have a heightened cough harmful effects on the body. While absence of cough
reflex sensitivity compared to men.4 In most of the can cause frequent aspirations leading to infection and
cases, chronic cough is dry or minimally productive in pneumonia, an excessive cough is associated with a
nature.5 variety of physical and psychological complications
The etiology of cough is diverse and commonly (Table 1)7,8 This ultimately reduces the health-related
includes environmental causes (cigarette smoke, quality-of-life of patients.8
pollutants, etc.) and several respiratory and non-
respiratory disease entities.6 The objective of this article Spectrum and Frequency of Etiologies
Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014 879
RESPIRATORY INFECTIONs
Cardiovascular system Arterial hypotension, loss of consciousness, rupture of subconjunctival, nasal and anal veins,
dislodgement/malfunctioning of intravascular catheters, bradyarrhythmias, tachyarrhythmias
GI system Gastroesophageal reflux events, hydrothorax in peritoneal dialysis, malfunction of gastrostomy button,
splenic rupture, inguinal hernia, esophageal perforation
Musculoskeletal system Rupture of rectus abdominis muscles, rib fractures, intercostal muscle rupture, cervical disc prolapse
Miscellaneous Disruption of surgical wounds, constitutional symptoms, self-consciousness, hoarseness, dizziness, fear
of serious disease, decrease in the quality-of-life, social embarrassment, depression, petechiae
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coughing or both.3
Postnasal drip syndrome is considered as one of the Figure 1. Postnasal drip syndrome as the cause of chronic
cough in various epidemiological studies.10
most common causes of chronic cough with reported
incidence between 6% and 73% of a studied population
(see Fig 1).10 It is also commonly associated with the guideline committee of the American College of Chest
common cold (acute cough).11 Postnasal drip syndrome Physicians (ACCP) because it is not clear whether the
has been renamed upper airway cough syndrome by the cough is caused by irritation from direct contact with
880 Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014
RESPIRATORY INFECTIONs
postnasal drip or by inflammation of cough receptors Pertussis, also called whooping cough, is a severe and
in the upper airway.11 debilitating disease that can last for weeks to months
Upper airway cough syndrome may result from a and can occur in both children and adults. The cough in
number of distinct etiologies, but it commonly arises adult patients with B. pertussis infection is spasmodic in
from rhinitis or rhinosinusitis.11 nature and occurs more frequently at night. Although
cough generally lasts for 4-6 weeks, it can persist longer
Diagnosis in some patients.13
As postnasal drip is not a disease, but a symptom, the Although, the exact pathophysiology of postinfectious
diagnostic approach should take into consideration a cough is not known, it is believed to occur as a result of
combination of criteria, including symptoms, physical airway inflammation with or without transient airway
examination findings (including deviated nasal septum, hyperresponsiveness.13
turbinate hypertrophy, polyps, sinusitis), radiographic
findings and response to specific therapy.11 Diagnosis
Common symptoms suggestive of upper airway Although, the clinical diagnosis of postinfectious cough
cough syndrome include throat clearing, sensation is by exclusion, a careful history, physical examination,
of postnasal drip, nasal congestion or discharge, as well as serology and sputum culture (if positive) can
cobblestone appearance of the oropharyngeal provide important clues to the diagnosis.13-15
mucosa and previous history of upper respiratory When a patient complains only of cough after a
illness (e.g., cold).11 respiratory tract infection for at least 3 weeks, but
Other symptoms that may help in diagnosing not more than 8 weeks and has a normal chest
upper airway cough syndrome include cough radiograph, a diagnosis of postinfectious cough
triggered by deep breath, laughing or prolonged should be considered.
talking; nasal quality of voice due to concomitant In case of suspected M. pneumoniae infection, a high
nasal blockade, congestion and hoarseness of voice. cold agglutinin titer or acute and convalescent-
An empiric trial of antihistamine/decongestant specific serologic studies could help confirm the
therapy with a first-generation antihistamine diagnosis.
should be administered. Improvement or resolution When a patient has a cough lasting for >2
of cough with this therapy helps in confirming the weeks without any other apparent cause and is
diagnosis of upper airway cough syndrome.11 associated with, post-tussive vomiting and/or
Topical administration of corticosteroid spray with an inspiratory whooping sound, the diagnosis
concomitant use of antibiotics is also recommended. of B. pertussis infection should be made.
Antibiotics should be initiated in case of sinusitis The confirmatory diagnosis of B. pertussis infection
or mucopurulent sinusitis. can be made by detection of the organism from
Plain sinus radiography and computed tomography nasopharynx secretions.
imaging are used for the evaluation of postnasal
drip if it is the suspected cause for chronic cough.12 Management of Dry Cough
Recent guidelines published by the ACCP recommend
Postinfectious Cough: Diagnostic
the use of a first-generation antihistamine in
Approaches
combination with a decongestant for the treatment of
Postinfectious cough is suspected when a patient with chronic cough due to upper airway cough syndrome.11
a normal chest radiograph complains of persistent Nonpharmacological approach such as nasal breathing
cough (>3 weeks) after an upper respiratory tract exercises may also be useful in patients with upper airway
infection. It occurs in about 11-25% of patients with cough syndrome. In patients with postinfectious cough,
persistent cough. Increased frequency of postinfectious ACCP recommends that if cough persists despite use of
cough (between 25% and 50%) has been observed inhaled ipratropium, then use of inhaled corticosteroids
during outbreaks of Mycoplasma pneumoniae and can be considered. Use of macrolides is recommended
Bordetella pertussis infections. Common pathogens that in patients with B. pertussis or M. pneumoniae infection.
cause chronic cough in children include respiratory ACCP also recommends use of antitussive agents such
viruses (particularly respiratory syncytial virus and as codeine and dextromethorphan in the management of
parainfluenza), M. pneumoniae, Chlamydia pneumoniae postinfectious cough when the cough adversely affects
(strain TWAR), and B. pertussis.13 the patients quality-of-life despite all other measures.15
Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014 881
RESPIRATORY INFECTIONs
Antitussive agents including codeine, pholcodine 4. Kelsall A, Decalmer S, McGuinness K, Woodcock A, Smith
and dextromethorphan are widely used alone or JA. Sex differences and predictors of objective cough
in combination with antihistamines, decongestants frequency in chronic cough. Thorax 2009;64(5):393-8.
and expectorants for effective symptomatic relief of 5. OConnell F. Management of persistent dry cough. Thorax
dry cough. Codeine, in addition to antitussive effect, 1998;53(9):723-4.
possesses analgesic and minor sedative effects, which 6. Vaishnav KV. Diagnostic approach to cough. Supplement
can be especially beneficial in relieving painful cough.16 to JAPI 2013;61:8.
7. Singh S, Singh V. Combating coughetiopathogenesis.
Conclusion
Supplement to JAPI 2013;61:6-7.
Cough, a common symptom for which patients visit 8. Irwin RS. Complications of cough: ACCP evidence-based
primary care physicians, is normally a self-limiting clinical practice guidelines. Chest 2006;129(1 Suppl):
illness. However, it can become a persistent symptom 54S-58S.
in several cases. Persistent cough is associated with 9. DUrzo A, Jugovic P. Chronic cough. Three most common
several physical and psychological complications. causes. Can Fam Physician 2002;48:1311-6.
Upper airway cough syndrome, postinfectious cough,
10. Lai K, Pan J, Chen R, Liu B, Luo W, Zhong N. Epidemiology
asthma and acute bronchitis are the most common
of cough in relation to China. Cough 2013;9(1):18.
respiratory causes of chronic cough. Diagnosis of
upper airway cough syndrome requires consideration 11. Pratter MR. Chronic upper airway cough syndrome
secondary to rhinosinus diseases (previously referred
of a combination of criteria, including symptoms,
to as postnasal drip syndrome): ACCP evidence-based
physical examination findings, radiographic findings
clinical practice guidelines. Chest 2006;129(1 Suppl):
and response to specific therapy. The clinical diagnosis
63S-71S.
of postinfectious cough is usually made by exclusion.
A first-generation antihistaminic agent in combination 12. Morice AH, Fontana GA, Sovijarvi AR, Pistolesi M,
with a decongestant is recommended for the treatment Chung KF, Widdicombe J, et al; ERS Task Force. The
diagnosis and management of chronic cough. Eur Respir J
of chronic cough due to upper airway cough syndrome.
2004;24(3):481-92.
When cough adversely affects a patients quality-of-life,
centrally-acting antitussive agents such as codeine and 13. Irwin RS, Boulet LP, Cloutier MM, Fuller R, Gold PM,
dextromethorphan should be considered. Hoffstein V, et al. Managing cough as a defense mechanism
and as a symptom. A consensus panel report of the
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882 Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014
Healthcare
PHEISEIYl
Codeine Phosphate IP 10 mg and Chlorpheniramine Maleate IP 4 mg per 5 ml