is to highlight the importance and consequences of
cough and the effective diagnosis and management
of postnasal drip syndrome/upper airway cough syndrome and postinfectious cough. In preparing this article, PUBMED was searched for studies/guidelines published in the English language using the medical subject heading terms cough, causes of cough, etiology
of cough, postinfectious cough, post-viral cough, upper
airway cough syndrome and postnasal drip. Importance of the cough reflex and complIcatIons of chronIc cough
Cough is an important defense mechanism of the
lungs. It helps in clearing excessive secretions, fluids,
noxious substance or foreign material from the airway.
Both excess as well as a shortfall of cough can have harmful effects on the body. While absence of cough
can cause frequent aspirations leading to infection and
pneumonia, an excessive cough is associated with a variety of physical and psychological complications
(Table 1)7,8 This ultimately reduces the health-related quality-of-life of patients.8
spectrum and frequency of etIologIes Chronic cough can be the key symptom of many respiratory and nonrespiratory conditions. Postnasal drip syndrome, postinfectious cough and asthma are the most common respiratory causes of chronic cough,
Diagnosis and Management of Dry Cough: Focus on
Upper Airway Cough Syndrome and Postinfectious Cough
N HulIRAJ
C
ough is the most common complaint of patients who present to primary care physicians.1 It hasbeen recently identified as the sixth common
reason for hospital outpatient department visits.2
In most of the cases, cough occurs as part of a brief,
self-limiting illness. However, it can become a persistent
symptom in several cases.1
A cough can be arbitrarily classified as acute (that
lasts for <3 weeks), subacute (that lasts between 3 and 8 weeks) and chronic (that lasts for >8 weeks). The
estimated prevalence of chronic cough is between 11%
and 20%.3 In a survey of members of the American
Academy of Allergy, Asthma and Immunology in
2008, it was observed that chronic cough was the chief
complaint in about 20-40% of new patients.3 Chronic
cough occurs more often in females than males. It has been observed that women have a heightened cough
reflex sensitivity compared to men.4 In most of the
cases, chronic cough is dry or minimally productive in
nature.5
The etiology of cough is diverse and commonly includes environmental causes (cigarette smoke, pollutants, etc.) and several respiratory and
non-respiratory disease entities.6 The objective of this article
Professor and HOD of TB and Chest Medicine KIMS Hospital, Bangalore
E-mail: nhuliraj@gmail.com abstract
Cough is an important complaint of respiratory disease and normal defense mechanism of the lungs. It helps in clearing excessive secretions, fluids, infections or foreign material from the airway. In most of the cases, cough occurs as part of a brief, self-limiting illness. However, it can become a persistent symptom in several cases. The etiology of cough is very diverse and commonly includes environmental causes (cigarette smoke, pollutants, dust mites, etc.) and several disease entities, including both respiratory and nonrespiratory causes. Postnasal drip syndrome and postinfectious cough are the most common respiratory causes of chronic cough. The objective of this article is to highlight the importance and consequences of cough and discuss the effective diagnosis and management of upper airway cough syndrome and postinfectious cough. For this article, PUBMED was searched for studies and guidelines published in the English language using the medical subject heading terms cough, causes of cough, etiology of cough, postinfectious cough, post-viral cough, upper airway cough syndrome, and postnasal drip.
Keywords: Cough, causes of cough, etiology of cough, postinfectious cough, post-viral cough, upper airway cough syndrome, postnasal drip
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880 Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014 Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014 881
Table 1. Potential Complications from Excessive Cough7,8
Central nervous system Cough syncope, headache, cerebral air embolism, cerebrospinal fluid rhinorrhea, acute cervical
radiculopathy, malfunctioning ventriculoatrial shunts, seizures , stroke due to vertebral artery dissection
Respiratory system Pulmonary interstitial emphysema, laryngeal trauma, tracheobronchial trauma, exacerbation of asthma,
intercostal lung herniation, pneumothorax, pneumomediastinum, subcutaneous emphysema
Cardiovascular system Arterial hypotension, loss of consciousness, rupture of subconjunctival, nasal and anal veins,
dislodgement/malfunctioning of intravascular catheters, bradyarrhythmias, tachyarrhythmias
GI system Gastroesophageal reflux events, hydrothorax in peritoneal dialysis, malfunction of gastrostomy button,
splenic rupture, inguinal hernia, esophageal perforation
Genitourinary system Urinary incontinence, inversion of bladder through urethra
Musculoskeletal system Rupture of rectus abdominis muscles, rib fractures, intercostal muscle rupture, cervical disc prolapse
Miscellaneous Disruption of surgical wounds, constitutional symptoms, self-consciousness, hoarseness, dizziness, fear
of serious disease, decrease in the quality-of-life, social embarrassment, depression, petechiae
Table 2. Causes of Chronic Cough9 Respiratory conditions
Common causes Postnasal drip syndrome (upper airway cough syndrome), postinfectious cough,
asthma, acute bronchitis
Other causes Allergic or vasomotor rhinitis, abscess, sinusitis, allergic inflammation, aspiration,
bronchiectasis, bronchitis, chronic obstructive pulmonary disease, cystic fibrosis,
eosinophilic bronchitis, interstitial lung disease, pertussis, primary or metastatic lung tumors, sarcoidosis, tuberculosis
Nonrespiratory conditions
Common causes Gastroesophageal reflux disease, recurrent aspiration
Other causes Left ventricular failure, mitral stenosis, psychological response, pulmonary
infarction
while gastroesophageal reflux disease is a common non-respiratory cause. The non-respiratory and nonnon-respiratory etiologies of chronic cough are summarized in Table 2.9 Postnasal DriP synDrome/UPPer airway CoUgh synDrome: DiagnostiC aPProaChes In general, adults produce about 20-30 mL of nasal mucus every day, which is either expectorated or swallowed with saliva. Very often, patients complain of a sensation of secretions from the nose or paranasal sinuses into the pharynx, leading to throat clearing, coughing or both.3
Postnasal drip syndrome is considered as one of the most common causes of chronic cough with reported incidence between 6% and 73% of a studied population (see Fig 1).10 It is also commonly associated with the
common cold (acute cough).11 Postnasal drip syndrome has been renamed upper airway cough syndrome by the
guideline committee of the American College of Chest Physicians (ACCP) because it is not clear whether the cough is caused by irritation from direct contact with
Figure 1. Postnasal drip syndrome as the cause of chronic cough in various epidemiological studies.10
Number of patients (%) 80 70 60 50 40 30 20 10 0 Irwin RS (1980) Poe (1989) Irwin RS (1990) Mello (1996) Carney IK (1997) Brightling CE (1999) Joo JH (2002) Ayik S (2003) Birring SS (2004) Kastelik JA (2005) Fujimura M (2005) Yang ZM (2005) Lai KF (2006) Lu GL (2009) Lai KF (2012) 29 26 41 38 73 24 33 22 12 18 26.7 24.4 18.6 17 6
postnasal drip or by inflammation of cough receptors in the upper airway.11
Upper airway cough syndrome may result from a number of distinct etiologies, but it commonly arises from rhinitis or rhinosinusitis.11
Diagnosis
As postnasal drip is not a disease, but a symptom, the diagnostic approach should take into consideration a combination of criteria, including symptoms, physical examination findings (including deviated nasal septum, turbinate hypertrophy, polyps, sinusitis), radiographic findings and response to specific therapy.11
 Common symptoms suggestive of upper airway
cough syndrome include throat clearing, sensation of postnasal drip, nasal congestion or discharge, cobblestone appearance of the oropharyngeal mucosa and previous history of upper respiratory illness (e.g., cold).11
 Other symptoms that may help in diagnosing
upper airway cough syndrome include cough triggered by deep breath, laughing or prolonged talking; nasal quality of voice due to concomitant nasal blockade, congestion and hoarseness of voice.
 An empiric trial of antihistamine/decongestant
therapy with a first-generation antihistamine should be administered. Improvement or resolution of cough with this therapy helps in confirming the diagnosis of upper airway cough syndrome.11
 Topical administration of corticosteroid spray with
concomitant use of antibiotics is also recommended. Antibiotics should be initiated in case of sinusitis or mucopurulent sinusitis.
 Plain sinus radiography and computed tomography
imaging are used for the evaluation of postnasal drip if it is the suspected cause for chronic cough.12
PostinfeCtioUs CoUgh: DiagnostiC aPProaChes
Postinfectious cough is suspected when a patient with a normal chest radiograph complains of persistent cough (>3 weeks) after an upper respiratory tract infection. It occurs in about 11-25% of patients with persistent cough. Increased frequency of postinfectious cough (between 25% and 50%) has been observed during outbreaks of Mycoplasma pneumoniae and
Bordetella pertussis infections. Common pathogens that
cause chronic cough in children include respiratory viruses (particularly respiratory syncytial virus and parainfluenza), M. pneumoniae, Chlamydia pneumoniae
(strain TWAR), and B. pertussis.13
Pertussis, also called whooping cough, is a severe and debilitating disease that can last for weeks to months and can occur in both children and adults. The cough in adult patients with B. pertussis infection is spasmodic in nature and occurs more frequently at night. Although cough generally lasts for 4-6 weeks, it can persist longer in some patients.13
Although, the exact pathophysiology of postinfectious cough is not known, it is believed to occur as a result of airway inflammation with or without transient airway hyperresponsiveness.13
Diagnosis
Although, the clinical diagnosis of postinfectious cough is by exclusion, a careful history, physical examination, as well as serology and sputum culture (if positive) can provide important clues to the diagnosis.13-15
 When a patient complains only of cough after a
respiratory tract infection for at least 3 weeks, but not more than 8 weeks and has a normal chest radiograph, a diagnosis of postinfectious cough should be considered.
 In case of suspected M. pneumoniae infection, a high
cold agglutinin titer or acute and convalescent-specific serologic studies could help confirm the diagnosis.
 When a patient has a cough lasting for >2
weeks without any other apparent cause and is associated with, post-tussive vomiting and/or an inspiratory whooping sound, the diagnosis
of B. pertussis infection should be made.
The confirmatory diagnosis of B. pertussis infection can be made by detection of the organism from nasopharynx secretions.
management of Dry CoUgh
Recent guidelines published by the ACCP recommend the use of a first-generation antihistamine in combination with a decongestant for the treatment of chronic cough due to upper airway cough syndrome.11 Nonpharmacological approach such as nasal breathing exercises may also be useful in patients with upper airway cough syndrome. In patients with postinfectious cough, ACCP recommends that if cough persists despite use of inhaled ipratropium, then use of inhaled corticosteroids can be considered. Use of macrolides is recommended in patients with B. pertussis or M. pneumoniae infection. ACCP also recommends use of antitussive agents such as codeine and dextromethorphan in the management of postinfectious cough when the cough adversely affects the patient’s quality-of-life despite all other measures.15
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882 Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014 Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014 883
Antitussive agents including codeine, pholcodine
and dextromethorphan are widely used alone or in combination with antihistamines, decongestants
and expectorants for effective symptomatic relief of dry cough. Codeine, in addition to antitussive effect, possesses analgesic and minor sedative effects, which
can be especially beneficial in relieving painful cough.16
conclusIon
Cough, a common symptom for which patients visit
primary care physicians, is normally a self-limiting
illness. However, it can become a persistent symptom in several cases. Persistent cough is associated with several physical and psychological complications.
Upper airway cough syndrome, postinfectious cough, asthma and acute bronchitis are the most common respiratory causes of chronic cough. Diagnosis of upper airway cough syndrome requires consideration of a combination of criteria, including symptoms,
physical examination findings, radiographic findings and response to specific therapy. The clinical diagnosis
of postinfectious cough is usually made by exclusion.
A first-generation antihistaminic agent in combination
with a decongestant is recommended for the treatment of chronic cough due to upper airway cough syndrome.
When cough adversely affects a patient’s quality-of-life, centrally-acting antitussive agents such as codeine and
dextromethorphan should be considered. references
1. Simpson CB, Amin MR. Chronic cough: state-of-the-art review. Otolaryngol Head Neck Surg 2006;134(4):693-700. 2. National Hospital Ambulatory Medical Care Survey:
2010 Outpatient Department Summary Tables. Available at:http://www.cdc.gov/nchs/data/ahcd/nhamcs outpatient/2010_opd_web_tables.pdf. Accessed on Jan. 8, 2014.
3. Goldsobel AB, Kelkar PS. The adults with chronic cough. J Allergy Clin Immunol 2012;130:825e1-825e6.
4. Kelsall A, Decalmer S, McGuinness K, Woodcock A, Smith JA. Sex differences and predictors of objective cough frequency in chronic cough. Thorax 2009;64(5):393-8. 5. O’Connell F. Management of persistent dry cough. Thorax
1998;53(9):723-4.
6. Vaishnav KV. Diagnostic approach to cough. Supplement to JAPI 2013;61:8.
7. Singh S, Singh V. Combating cough–etiopathogenesis. Supplement to JAPI 2013;61:6-7.
8. Irwin RS. Complications of cough: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 Suppl): 54S-58S.
9. D’Urzo A, Jugovic P. Chronic cough. Three most common causes. Can Fam Physician 2002;48:1311-6.
10. Lai K, Pan J, Chen R, Liu B, Luo W, Zhong N. Epidemiology of cough in relation to China. Cough 2013;9(1):18. 11. Pratter MR. Chronic upper airway cough syndrome
secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 Suppl): 63S-71S.
12. Morice AH, Fontana GA, Sovijarvi AR, Pistolesi M, Chung KF, Widdicombe J, et al; ERS Task Force. The diagnosis and management of chronic cough. Eur Respir J 2004;24(3):481-92.
13. Irwin RS, Boulet LP, Cloutier MM, Fuller R, Gold PM, Hoffstein V, et al. Managing cough as a defense mechanism and as a symptom. A consensus panel report of the American College of Chest Physicians. Chest 1998;114(2 Suppl Managing):133S-181S.
14. Malowany J, Popat N, Kirchhof M. Chronic cough is a common symptom in children – What is the cause? UWOMJ 2006;74(2):7-10.
15. Braman SS. Postinfectious cough: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 Suppl): 138S-146S.
16. Padma L. Current drugs for the treatment of dry cough. Supplement to JAPI 2013;61:9-13.
Healthcare
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In Persistent Dry Cough
PHEISEIYl
Codeine Phosphate IP 10 mg and Chlorpheniramine Maleate IP 4 mg per 5 mlAbridged Prescribing Information
Phensedyl cough linctus
Composition: Each 5 ml contains: Codeine phosphate IP 10mg, Chlorpheniramine maleate IP 4mg. Indications: For the symptomatic mllof ol 111prodldlve cough. Dosage:
Adults&chlldrenabove10years:5-10ml,twotothreeUmesaday.Chlldran:6-10years:2.5-5ml,twotothreetbnesaday.Tllerecommend<ddoaeBsllolJdnotbeBICOOdad. Contra-indications: Known hypersensitivity to any of the components of the formulation, pregnancy ~irsttrimester), cough...,_ with asthma and MAO lnh-then!py within the pravlous 14 days. PrecauUons & Warnings: Keep out of raach of chlklren. To be used during pragnency only ~tha potential -outweigh the poten1lal r1olal. Not
recommended in nursing mothers. n is not advisable to take the drug except under medical supervision. Undesirable effecls: Generallywelltolora1Bd. l.lldesiable e1foc1& seen ara sedation, nausea, vommng, diarrhoea, urinary retention, dryness of mouth and CNS depreeslon, partlcularty resplre1ory ~-lnteractlona: Coocom1ant
administration of chlorpheniramine can lead to phenytoin toxicity. Concurrentadminisbation with hypnotics, anxiolytk:s. psychotropics and alcohol may causa polBntlation of drowsiness. Presentations: BoUle of 50 ml and 100 ml. Revised version: 2/05, 23.9.05 1/03
