History Pointers

• Ask the patient: if they perceive their cough to start in their throat or their chest?
• Nocturnal cough, airway sensitivity - commoner in asthma.
• Cough after meals, after talking, on bending, shortly after rising - commoner with GORD.
• Metallic taste, wheeze after coughing, hoarseness post-cough commoner with GORD.

Signs and Symptoms

• Common causes of dry cough are:
  • Post infected irritability may take 8-10 weeks to resolve.
  • Asthma (cough-variant asthma sufferers may have a little wheeze / SOB).
  • COPD.
  • Reflux (may not be accompanied by dyspepsia / heartburn in non-acid reflux). Of note, there is a higher probability of GORD in patients with BMI >30
  • Post-nasal drip (cough stimulus is often referred to the throat).
  • Medication e.g., ACE inhibitors (some authors say resolution of cough can be months).
  • Excessive throat clearing / straining of voice (common in teachers, call centre workers), sometimes referred to as ‘vicious circle cough’.
  • Occupational exposures may sometimes trigger dry cough.

• Less common
  • Lung cancer.
  • Pulmonary fibrosis.

• Rare
  • Inhaled foreign body, auricular pathology, tonsils.

Examination

Respiratory examination including:

• crackles on auscultation
• clubbing

Unexplained:

• Chest pains
• Haemoptysis
• Weight loss
• Clubbing
• Smoking

CXR and spirometry to exclude significant diagnoses. If abnormal refer accordingly

• If no clear diagnosis an empiric trial of treatment based on clinical suspicion:
  • A focused history will assist e.g., Nocturnal cough, airway sensitivity - more common in asthma.
  • Cough after meals, after talking, on bending, shortly after rising - commoner with reflux.
  • Metallic taste, wheeze after coughing, hoarseness post-cough commoner with reflux.
  • Review the probability of the above common conditions and excludes the less common with smoking and occupational history, a CXR and spirometry.
  • Address the most likely condition with an empiric therapeutic trial, consider trials of both types of therapy in succession.

Asthma

• For possible asthma see formulary guidance
• if no response, consider trials of treatment for gastro-oesophageal reflux disease or post-nasal drip

Gastroesophageal Reflux

• For possible gastro-oesophageal reflux disease see formulary guidance
• Lifestyle advice is also helpful
• If no response, consider trials of treatment for asthma or postnasal drip

Postnasal Drip

• For possible postnasal drip a trial of a nasal steroid +/- antihistamine +/- topical nasal decongestant (if not already used)
• If no response, consider trials of treatment for gastroesophageal reflux or asthma

Local administrative info:

New Medicines Service ("NMS")

A free community service to provide early support to patients to maximise the benefits of the medication they have been prescribed.

A free community pharmacy service to help patients use their medications more effectively.

Referral criteria

• In your referral letter please document the following:
  • Smoking history
  • History and response to treatments already instigated – please give details of doses and duration
  • Results of investigations

• If cough resistant to above management, consider referral for consultant assessment.

Referral instructions

To refer to secondary care

e-Referral Service Selection

• Specialty: Respiratory
• Clinic Type: Not otherwise specified
• Service: DRSS-Eastern-Respiratory Medicine-Devon ICB-15N

Referral form

DRSS Referral Form

Patient Information

British Lung Foundation

Asthma UK

Primary Care Respiratory Society

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: February 2021

Date Updated: April 2021