Cough
Patients with cough frequently present toprimary and secondary care facilities. Cough can be classified under acute, sub acute, and chronic categories based on the duration of cough. Often, acute cough will spontaneously resolve without any medical interventions; however,other life threatening, or lethal causes of cough should be ruled out. Similarly, subacute and chronic cough will require further investigationsand careful evaluation because cough can also be caused by extrapulmonary causes. Managing cough as a ‘defense mechanism versus a symptom’ can be a challenging task to primary care practitioners.
Stage 1
Abstract Conceptualization

Stage 2
Active Experimentation

Patient assessment & History collection
Ask relevant questions to find out the duration of cough and verify if it is acute, sub acute or chronic cough. Confirm any history of recent viral infection, smoking, use of ACEI or betablocker, occupational exposure to allergens, environmental or food allergies, asthma, COPD, GERD, cardiac conditions and symptoms such as shortness of breath, chest pain, dysphagia,etc. During physical examination, assess s/s of viral URTI/ rhino sinusitis, evaluate general presentation, perform respiratory assessment, check vital signs, listen to cardiac sounds, and notice cough pattern (3).
Acute cough
Acute cough is defined as cough with a duration of less than 3 weeks and often follows a recent viral upper respiratory tract infection. In the absence of any comorbidities, almost all cases will spontaneously resolve without any interventions. However, in presence of hemoptysis, prominent systemic illness, suspicion of inhaled foreign body, suspicion of lung cancer, pulmonary embolism etc., emergency medical assistance is required.During physical examination, assess s/s of viral URTI, evaluate general presentation, perform respiratory assessment, check vital signs, cardiac sounds, watch for pedal edema, and evaluate cough pattern. When pneumonia is suspected (fever, chills, chest pain with breathing, crackles, egophony or fremitus, and chest examination findings of focal consolidation),offer antibiotics.Verify if any pre-existing h/o COPD, asthma, CAD, or exposure to occupational, environmental or food allergens. If any recent initiation of ACEI or beta blockers is noted, consider switching to another antihypertensive drug class. Similarly, if any shortness of breath with underlying h/o CAD, pedal edema, and abnormal cardiac sounds, initiate an urgent evaluation to rule out CHF. Acute rhino sinusitis under one week should not be treated with antibiotics.Patients report benefit from various over‐the‐counter preparations; there is little evidence of a specific pharmacological effect (6). When cough lasts for more than 2 weeks with paroxysms of coughing, post tussive vomiting, and inspiratory whooping sound, rule out pertussis by doing a nasopharyngeal swab. Hemoptysis, breathlessness, fever, chest pain, weight loss are the signs that indicate possible need for chest x- ray (3).
Subacute Cough
A cough lasting less than 8 weeks, but more than 3 weeks is known as subacute cough. Post infectious cough (after viral URTI) is the most common cause. Physical examination and detailed history collection are required to rule out upper airway cough syndrome, asthma, GERD, bronchitis, pneumonia, and other serious illness. The term upper airway cough syndrome implies cough associated with post nasal drip, direct upper airway irritation, or inflammation of upper airway receptors. Acute bronchitis will present with an acute cough, which is usually productive. The cough lasts for less than 3 weeks in 50% of patients, but for more than 1 month in 25% of patients (5).Sub acute upper respiratory tractions may be treated with first generation antihistamines, oral decongestants, ipratropium, and short acting corticosteroids. Acute sinusitis with subacute cough, will benefit from antibiotic treatment. Similarly, offer asthma, COPD treatment, if an acute flare up of these conditions are suspected. Patients who exhibit s/s of pertussis should be treated with macrolides (1). If any occupational, environmental, dietary allergic causes are suspected, address them accordingly.Stop the medication that is responsible forcough. To learn more about the management of acute bronchitis, refer to the following: http://www.cfp.ca/content/54/2/238
Chronic Cough
A cough that lasts more than 8 weeks is known as chronic cough. Asthma, bronchiectasis, chronic bronchitis, non-asthmatic eosinophilic bronchitis, upper airway cough syndrome, allergic rhinitis, non-allergic rhinitis, chronic rhinosinusitis, gastroesophageal reflex disease, cough and pulmonary neoplasia, cough caused by medication, post infectious cough, and psychogenic cough are the common causes of chronic cough (3). Patients with suspected GERD should be given a trial of PPI with appropriate dietary, lifestyle instructions. Patients who are at risk for tuberculosis need to be thoroughly screened to r/o TB.
Stage-3
Concrete Experimentation

Clinical management of cough

Refer to the following link for Asthma management guideline: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527232/
COPD management: https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-g
GERD management: http://www.topalbertadoctors.org/cpgs/?sid=14&cpg_cats=52
URTI (viral) | Antihistamines+ oral decongestant If subacute: ipratropium and short acting corticosteroids |
Acute sinusitis | First generation antihistamines, oral decongestant, antibiotics |
Asthma | ICS, b2-agonists, oral corticosteroids (if severe) |
Chronic bronchitis | Smoking cessation, avoid irritant, bronchodilator, Corticosteroid |
Acute bronchitis | Broncho dilator- mixed evidence, antibiotics-minimal result |
Non-asthmatic eosinophilic bronchitis | ICS |
Post infectious cough | Resolves its own, decongestants, ICS, nasal ipratropium |
GERD | PPI, antacids, h2 receptor antagonists |
Upper airway cough syndrome | Antihistamines, oral decongestants, nasal ipratropium |
Diagnostic evaluation
CT chest is the golden test to rule outCa lungs, interstitial lung disease, pulmonary embolism
TB, pneumonia, pneumothorax pleural effusion, —chest x ray is the fist step
GERD- barium upper GI series may give an indication if diagnosis is unclear
COPD- refer for spirometry
Dysphagia-ENT/ SLP consult required
Echocardiogram- if CHF suspected
SOAP notes
S: URTI symptoms X 1 week
cough: productive
breathing problems: no
fevers: low grade x last1 week; no fever since today morning
coryza: yes
sore throat: no
ear pain: no
sinus pain- nil
throat clearing- mild
history of asthma/copd: no
H/o GERD: nil
using inhalers: nil
travel history- nil
O: T: 37.6 C HR: 82
General: NAD, looks well, alert & oriented, no jaundice/palor/cyanosis/diaphoresis
Resp: no distress, no increased work of breathing, AE=AE, no wheeze/crackles/rales
CVS: radial pulse strong/reg, S1S2 n, no S3S4, no murmurs/rubs/clicks, no ankle edema
A: Viral URTI
P: Reassurance given that symptoms will resolve spontaneously
In case of worsening of symptoms, sob, neck stiffness, rashes fever, cough more than 3 weeks, should rtc
Stage 4
Reflection

Student Activity
Write a reflection on your learning experience with assessing and diagnosing patients with cough.Illustrate your experience by using Kolb’s learning cycle?
Reference
Goldman, R (2011). Treating cough and cold: Guidance for caregivers of children and youth. Pediatric Child Health 2011;16(9):564-6. Retrieved from https://www.cps.ca/en/documents/position/treating-cough-cold
Canadian Thoracic Society (2019). Diagnosis and management of Asthma. Retrieved from https://cts-sct.ca/guideline-library/
Canadian Thoracic Society (2019). Chronic refractory cough. Retrieved from https://cts-sct.ca/guideline-library/
Canadian Thoracic Society (2019). Diagnosis and management of COPD. Retrieved from https://cts-sct.ca/guideline-library/
Worrall, G (2008). Acute bronchitis.Canadian Family Physician. February 54 (2) 238-239 http://www.cfp.ca/content/54/2/238
Morice, A. H., McGarvey, L., Pavord, I., British Thoracic Society Cough Guideline Group (2006). Recommendations for the management of cough in adults. Thorax, 61 Suppl 1(Suppl 1), i1-24. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2080754/