Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Chronic cough in clinical practice: a practical pathway

  Chronic cough is usually defined as a cough lasting longer than eight weeks in adults. It can be exhausting, disruptive, and socially isolating, yet the symptom is often managed inconsistently because several conditions may produce similar clinical patterns. A structured approach helps clinicians identify serious disease, reduce unnecessary testing, and select treatment according to the likely cause.

  The assessment should combine duration, triggers, associated symptoms, medication history, smoking or vaping exposure, and relevant occupational or environmental risks. Cough frequency and severity matter, but the underlying mechanism remains the central guide for investigation and care.

  Effective management also depends on reviewing the patient’s response over time. A persistent cough may reflect more than one condition, and treatment failure should prompt diagnostic reassessment rather than repeated empirical prescribing.

  Define the symptom before treating it

  A clear history distinguishes acute, subacute, and chronic cough. Acute cough generally follows infection or irritant exposure, while subacute cough may persist after a respiratory infection. Chronic cough requires a broader assessment for asthma, eosinophilic airway disease, upper airway disorders, gastroesophageal reflux, medication effects, smoking-related disease, and structural lung pathology.

  The character of the cough can provide useful clues, although it rarely establishes a diagnosis by itself. Nocturnal symptoms may occur with asthma or reflux, exertional cough can suggest airway or cardiac disease, and cough after meals may point toward aspiration or swallowing dysfunction. Ask about wheeze, breathlessness, nasal symptoms, heartburn, voice change, fever, weight loss, hemoptysis, and recurrent chest infections.

  Triage red flags and urgent causes

  Before pursuing routine evaluation, clinicians should identify warning signs that require prompt investigation. Hemoptysis, unexplained weight loss, persistent fever, severe dyspnea, chest pain, hypoxemia, recurrent pneumonia, abnormal neurological findings, or a new cough in a person with significant cancer risk should raise concern for serious disease.

  Medication review is essential. Angiotensin-converting enzyme inhibitors can cause a persistent dry cough, sometimes beginning months after treatment starts. Stopping the suspected drug under appropriate clinical supervision is often both diagnostic and therapeutic, although symptom resolution may take several weeks.

  Smoking, vaping, occupational dust, fumes, mold, and poorly controlled indoor air quality can maintain airway irritation. Addressing these exposures is part of treatment rather than an optional lifestyle discussion.

  Build a focused diagnostic assessment

  Initial evaluation commonly includes a physical examination, chest radiography, and spirometry when available and appropriate. Spirometry with bronchodilator testing can support a diagnosis of asthma or chronic obstructive pulmonary disease, while normal results do not exclude cough-variant asthma or eosinophilic airway inflammation.

  Additional testing should be guided by the clinical picture. Fractional exhaled nitric oxide, blood eosinophils, bronchial provocation testing, or induced sputum may help in selected patients. Computed tomography is not automatically required when the examination and chest radiograph are unremarkable, but it may be appropriate when symptoms persist, imaging is abnormal, or interstitial, bronchiectatic, malignant, or infectious disease is suspected.

  Upper airway symptoms should be assessed without assuming that every cough originates from sinus disease. Similarly, reflux testing or specialist evaluation may be useful when symptoms and treatment response support that pathway. Broad, unfocused testing can produce incidental findings and delay attention to the most likely cause.

  Match treatment to the underlying mechanism

  For asthma-related cough or eosinophilic airway inflammation, inhaled corticosteroid therapy may be appropriate, with bronchodilator treatment added according to the diagnosed airway condition. An adequate treatment trial should have a defined duration, correct inhaler technique, and a planned review of benefit.

  When upper airway disease contributes, management may include saline irrigation, treatment of allergic rhinitis, or targeted nasal therapy. Reflux measures should be individualized; dietary changes, weight management where relevant, and review of meal timing may be more useful than prolonged acid suppression in patients without typical reflux features.

  Some patients develop cough hypersensitivity, in which ordinary stimuli such as talking, odors, cold air, or minor throat sensations trigger an exaggerated response. Specialist cough control therapy, breathing techniques, and speech-language pathology can help selected patients. Neuromodulatory medicines may be considered by experienced clinicians after treatable causes have been addressed, with careful discussion of adverse effects.

  Clinical pattern	Useful assessment	Possible management direction
  Wheeze, variable airflow, nocturnal cough	Spirometry, bronchodilator response, selected airway inflammation tests	Asthma-directed inhaled therapy and trigger control
  Nasal congestion, throat clearing, postnasal sensation	Nasal and upper airway examination	Treatment of rhinitis or other documented upper airway disease
  Heartburn, regurgitation, cough after meals	Symptom review, selected reflux evaluation	Individualized reflux measures and targeted therapy
  Smoking, vaping, occupational irritants	Exposure and medication history, lung function testing	Exposure reduction, cessation support, disease-specific care
  Normal routine tests with cough triggers	Assessment for cough hypersensitivity	Cough control therapy and specialist review
  Hemoptysis, weight loss, abnormal imaging	Urgent imaging or specialist investigation	Prompt evaluation for infection, malignancy, or structural disease

  Reassess response and avoid common traps

  A cough treatment trial should include a baseline description of frequency, severity, sleep disruption, and activity limitation. Patient-reported outcomes or a simple cough diary can show whether a therapy is producing meaningful improvement. Lack of response should trigger a review of adherence, inhaler technique, diagnosis, exposure history, and the possibility of multiple simultaneous causes.

  Repeated antibiotics are rarely appropriate for an unexplained chronic cough without evidence of bacterial infection. Empirical reflux therapy should also be reconsidered when there are no compatible symptoms or measurable benefit. Opioid antitussives and over-the-counter combinations may cause sedation, constipation, or drug interactions and should not replace a careful diagnostic pathway.

  Referral to respiratory medicine is appropriate for unexplained cough, abnormal imaging or lung function, suspected interstitial or bronchiectatic disease, recurrent aspiration, significant hemoptysis, or symptoms that remain disabling after initial management. Multidisciplinary input may involve allergy, gastroenterology, otolaryngology, speech therapy, or oncology.

  Support patients through long-term care

  Patients often worry that a persistent cough automatically indicates cancer or severe lung disease. Clear explanations about the working diagnosis, planned tests, treatment duration, and warning symptoms can reduce anxiety while preserving clinical vigilance. Written instructions are particularly helpful when several therapies or exposure changes are involved.

  Cough control education may include nasal breathing, relaxed throat techniques, hydration, avoidance of repeated throat clearing, and strategies for handling known triggers. These measures should complement, rather than replace, investigation of an underlying pulmonary or systemic disorder.

  Practical steps for a consistent care pathway

  • Confirm the duration, pattern, triggers, exposures, and medication causes of the cough.
  • Screen early for hemoptysis, weight loss, fever, hypoxemia, chest pain, and abnormal examination findings.
  • Use chest radiography and spirometry as focused first-line tests when clinically appropriate.
  • Treat the most likely mechanism with a time-limited, measurable plan and review inhaler technique.
  • Reassess persistent symptoms for overlapping causes, cough hypersensitivity, or a need for specialist referral.

  A reliable chronic cough pathway turns a vague, frustrating symptom into a sequence of clinical decisions. Respiratory teams and primary care clinicians can improve outcomes by combining early risk assessment, focused investigations, mechanism-based treatment, and regular review. Use this framework to standardize assessment, document response, and ensure that patients with persistent or concerning symptoms receive timely specialist care.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)