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Cough - Coggle Diagram
Cough
Assessment
History
- Onset
- Duration
- Frequency of cough
- Type of cough (dry/productive)
- Precipitating or exacerbating factors
- Diurnal variation
- Associated symptoms (throat, chest, GI)
- Smoking history
- Environmental factors
- Family history
- Recent RTI
- Recent travel history
Red flag features
- Haemoptysis
- Hoarseness
- Peripheral oedema with weight gain
- Prominent dyspnoea, especially at rest or at night
- Smokers >45 yo with a new cough, change in cough or coexisting voice disturbance
- Smokers 55-80 yo with 30 pack-year history and currently smoke or quit within last 15 years
-Systemic symptoms, such as fever or weight loss
- Trouble swallowing
- Vomiting
Consider comorbidities
- Allergies
- Asthma
- COPD
- Bronchiectasis
- Heart failure
- GORD
- Sleep apnoea syndrome
- medications - ACEi or sitagliptin
Differential diagnosis
Acute cough (<3 weeks)
- Upper RTI - suggested by cough with/without sputum, general malaise and fever. Pain and discharge may be localized to nose, ears, throat or sinuses. Commonly viral such as cold or flu
- COVID-19
- Acute exacerbation of pre-existing condition - asthma, COPD, bronchiectasis
- Acute bronchitis - cough with/without sputum, breathlessness, wheeze, crackles (if present) clear with coughing
- Pneumonia - at least one of breathlessness, sputum, wheeze or pleuritic pain; focal chest signs (dull percussion, bronchial breathing or coarse crackles); plus at least one systemic feature such as fever or myalgia. May be signs of pleural effusion
- Pneumothorax/tension pneumothorax - sudden onset pleuritic pain, breathlessness, reduced chest wall movement and breath sounds. May be tracheal deviation away from pneumothorax, tachycardia hypotension and collapse
- Pulmonary embolism - suggested by acute onset breathlessness, pleuritic pain , haemoptysis, crackles and tachycardia
Chronic cough (>8 weeks duration)
- Upper airway cough syndrome (post nasal drip) - frequent throat clearing, unpleasant sensation in throat, nasal congestion or nasal discharge and sneezing. Seasonal or occupational triggers may be risk factor. May be visible mucus or cobblestone appearance of posterior oropharyngeal wall
- ACEi induced cough - can occur within hours to months of first dose
- Asthma - wheeze, breathlessness, worsening symptoms at night, in morning or with exercise/exposure to allergens. PEF rate reduced during episode. Chronic cough in asthma occurs 24-29%
- Eosinophilic bronchitis - normal chest exam, spirometry and (specialist) airway provocation test
- GORD - cough worse during or after eating, with talking and bending
- Smoking related cough - dry cough worse in mornings
Other causes of chronic cough
- Bronchiectasis - cough with daily sputum production, progressive breathlessness, haemoptysis, non-pleuritic chest pain, coarse crackles on early inspiration in lower lung fields
- Bronchitis - cough with/without sputum, breathlessness, wheeze, or general malaise. Crackles if present clear with coughing
- COPD persistent progressive breathlessness usually with wheezing or chest tightness, hyperinflated chest, possible signs of right-sided HF (ankle oedema, raised JVP)
- Cough-variant asthma - normal chest exam, spirometry and hyper-responsiveness to airway provocation test (specialist)
Environmental or occupational causes - cough may be isolated symptom on exposure to triggers or manifestation of more significant disease. May be worse on week days and better at weekends in occupational exposure
Foreign body aspiration - sudden-onset cough, stridor (upper airway) or reduced chest wall movement on affected side, bronchial breathing and reduced or diminished breath sounds
- Heart failure - significant breathlessness, orthopnoea and/or paroxysmal nocturnal dyspnoea. May be peripheral oedema and raised JVP
- Interstitial lung disease - breathlessness, cough (often dry). May be non-specific signs (fine end-expiratory crackles, finger clubbing, cyanosis, signs of right sided heart failure). May be Hx of recurrent flu-like illness following exposure to allergens; if associated with connective tissue disease, joint pain. Diagnosis confirmed with spirometry (restricted pattern), CXR or high resolution CT
- Lung cancer - haemoptysis, persistent chest/shoulder pain, breathlessness, weight loss, hoarseness, finger clubbing and cervical/supraclavicular lymphadenopathy
- Obstructive sleep apnoea - cough associated with excessive daytime somnolence and obesity
- Pertussis - cough >14 days with paroxysms of coughing. May be vomiting after coughing or inspiratory whoop
- Pulmonary tuberculosis - sputum, breathlessness, haemoptysis, weight loss, night sweats, anorexia, general malaise and finger clubbing. Should be considered in patients with cough in endemic areas regardless of duration
- Sitagliptin-induced cough - cough with rhinorrhoea, dyspnoea or fatigue
- Somatic cough syndrome - only after extensive evaluation ruling out other uncommon causes
Management
Acute cough
Emergency Admission
- Suspect pneumothorax or PE
- Severe illness:
- RR >30bpm
- HR >130bpm
- SBP <90mmHg
- SpO2 < 92% or central cyanosis (if no hx of chronic hypoxia)
PEF <33% of predicted
- altered consciousness level
- Use of accessory muscles
- Suspected foreign body aspiration
URTI
- Advice: - may persist 3-4 weeks; self-care advice; seek medical advise if worsening, persist >3-4 weeks or become systemically unwell; suggest smoking cessation
- Do not offer (unless underlying airway disease):
- SABA or ICS
- mucolytic
- antibiotic if not systemically very unwell or risk of complications
- If systemically unwell on F2F assessment offer immediate antibiotic - doxycycline 200mg (day 1, 100mg OD 4 days, avoid in pregnancy)
- or amoxicillin 500mg TDS 5 days
- or clarithromycin 250mg-500mg BD 5 days
- If risk of complications consider either immediate antibiotic or delayed prescription
Manage other acute causes of cough according to identified underlying cause e.g. GORD, asthma, COPD, COVID-19, bronchitis or pneumonia
Acute bronchitis
- admit or refer to secondary care if signs of serious condition (sepsis, PE, pneumothorax, or lung cancer)
- advise on self-care - fluid intake, simple analgesia, may also want to try honey, pelargonium (herbal), OTC cough medicine containing guaifenesin (expectorant) or cough suppressant
- smoking cessation advise
- Do not routinely offer antibiotic unless systemically unwell or higher risk of complications
- usually self-limiting and can last 3-4 weeks
- antibiotics do not make difference in duration (on average only 1/2 day)
- adverse effects with antibiotics and resistance
- Offer immediate antibiotic if systemically unwell
- Consider either immediate antibiotic or delayed antibiotic if risk of complications
- Antibiotics
18yo: First line doxycycline (200mg day 1 then 100mg OD 4 days), not in pregnant women; other first line choices: amoxicillin 500mg TDS 5days, clarithromycin 250-500mg BD 5 days, erythromycin (preferred in pregnancy) 250-500mg QDS or 500-1000mg BD 5 days
- 12-17 yo: First line amoxicillin (preferred if pregnant) 500mg TDS 5 days; or clarithromycin 250mg-500mg BD 5 days, erythromycin 250mg-500mg QDS or 500mg-1000mg BD 5 days, doxycycline 200mg first day then 100mg OD 4 days
- Do not offer SABA/ICS (unless underlying asthma/COPD) or mucolytic
Community acquired pneumonia
- Admit to hospital if severe systemic illness, signs of serious underlying condition or CRB65 score 1-2 or urgently if > 3
- CRB65:
- Confusion
- RR >30bpm; age > 65yo
- SBP < 90mmHg or DBP < 60mmHg
- other factors to consider if need for admission: person's wishes, social support, comorbidities and frailty, pregnancy and SpO2
- If not admitted to hospital - self-care advise (rest, fluid intake, simple analgesia)
- Offer antibiotic to people with CAP, consider severity, risk of complications, recent antimicrobial use or microbiology results
- low severity (CRB65 0) - first choice amoxicillin 500mg TDS 5 days; or clarithromycin 250mg-500mg BD 5 days, erythromycin 250mg-500mg QDS or 500mg-1000mg BD 5 days, doxycycline 200mg first day then 100mg OD 4 days
- Moderate severity (CRB65 1-2) - amoxicillin 500mg TDS 5 days and clarithromycin 500mg BD 5 days or erythromycin (in pregnancy) 500mg QDS 5 days (if penicillin allergy doxycycline 200mg day one then 10mmg OD 4 days
- smoking cessation advise
-
Investigations
- Pulse oximetry
- Peak expiratory flow rate (if known or suspected asthma
- Pertussis serology (if whooping cough suspected)
- CRP (if pneumonia suspected)
- Spirometry
- CXR