Cough

Background

• Cough is a common chief complaint in the ED
• Can be classified by duration:
  • Acute: <3 weeks — most commonly viral URI, but must consider life-threatening causes
  • Subacute: 3-8 weeks — often post-infectious
  • Chronic: >8 weeks — consider asthma, GERD, post-nasal drip, ACE inhibitors
• The primary ED goal is to identify and treat emergent causes (PE, pneumothorax, foreign body, anaphylaxis, acute heart failure) and risk-stratify for serious infection

Clinical Features

• Key history elements:
  • Duration, productive vs dry, hemoptysis, fever, dyspnea, chest pain, weight loss
  • Medication history (particularly ACE inhibitors)
  • Smoking status, occupational/environmental exposures
  • Immunocompromised status
• Red flags:
  • Hemoptysis
  • Acute dyspnea or hypoxia
  • Chest pain with cough (consider PE, pneumothorax)
  • Stridor or respiratory distress
  • Fever with toxic appearance
  • Immunocompromised patient with new cough

Differential Diagnosis

Cough

Acute (< 3 wks)

• URI (rhinitis, sinusitis, pertussis)
• LRI (bronchitis, pneumonia)
• Influenza
• Allergy
• Asthma
• Environmental irritants
• Transient airway hyperresponsiveness
• Foreign body
• SARS

Chronic (> 8 wks)

• Postinfectious; pertussis
• Smoking and/or chronic bronchitis
• Postnasal discharge
• Asthma
• GERD
• ACEI/ARB
• CHF
• Lung cancer or intrathoracic mass
• Emphysema
• Interstitial lung disease
• Psychiatric

Evaluation

• Pulse oximetry on all patients
• CXR if:
  • Fever, dyspnea, hypoxia, hemoptysis, or abnormal lung exam
  • Immunocompromised
  • Concern for pneumonia, CHF, pneumothorax, or malignancy
  • Persistent cough >3 weeks without clear cause
• Additional workup as indicated:
  • ECG if cardiac cause suspected
  • CT-PA if concern for PE
  • BNP/NT-proBNP if concern for CHF
  • CBC, blood cultures if sepsis or severe pneumonia suspected
  • Pertussis testing if clinical suspicion (paroxysmal cough, post-tussive emesis, inspiratory whoop)

Management

• Treat underlying cause
• Viral URI: Supportive care; honey (>1 year old) has modest evidence for symptom relief
• Pneumonia: Antibiotics per local guidelines (see Pneumonia (main))
• Asthma/reactive airway: Albuterol nebulizer, consider steroids
• CHF: Diuresis, nitroglycerin (see Congestive heart failure)
• PE: Anticoagulation (see Pulmonary embolism)
• OTC cough suppressants (dextromethorphan, codeine): Limited evidence of efficacy; avoid codeine in children <12 years
• Benzonatate: 100-200 mg PO TID; can cause toxicity if chewed

Disposition

• Admit:
  • Pneumonia with sepsis, hypoxia, or significant comorbidities
  • PE, pneumothorax, CHF exacerbation
  • Massive hemoptysis
• Discharge with follow-up:
  • Uncomplicated URI/acute bronchitis
  • Stable pneumonia meeting outpatient criteria
  • Provide return precautions: worsening dyspnea, hemoptysis, high fever, inability to tolerate PO

See Also

• Hemoptysis
• Pneumonia (main)
• Acute asthma exacerbation
• Bronchitis
• Pertussis
• Croup