Links To And Excerpts From #241 Chronic Cough By The Curbsiders

Note to myself: When I review again this post be sure to also review:

In this post I link to and excerpt from the Curbsiders‘ podcast and show notes, #241 Chronic Cough, NOVEMBER 9, 2020 By Dr. CYRUS ASKIN:

Listen as our phenomenal guest Dr. Brad Hayward @bradleyjhayward (Weill Cornell Medicine) demystifies chronic cough for the primary care provider.

Clinical material begins at 7:30.

Here are excerpts:

Cough Pearls

  1. Subacute/chronic cough is one of the most common primary care complaints seen by providers
  2. The most common cause for acute (and subacute cough) is active or recent viral infection (“post-viral cough syndrome”) for which a trial of inhaled corticosteroid is reasonable
  3. Other common causes for cough include gastroesophageal reflux disease, post-nasal drip / upper-airway cough syndrome, cough-variant asthma and non-asthmatic eosinophilic bronchitis
  4. The first step in evaluating cough should not be labs and imaging, but rather a thorough history focusing on things like onset, aggravating/alleviating factors, quality of the cough and exposure history
  5. Chest X-ray can be useful to identify major anatomic abnormalities, CT can be used later on if cough persists to rule out more subtle disease states
  6. Basic spirometry can be helpful to identify obstruction early on in a patient’s course – save full pulmonary function testing for later
  7. Don’t be afraid to try empiric therapies! Proton pump inhibitors, antihistamines, intranasal steroids and even inhaled corticosteroids are generally low-risk and will treat many cases of chronic cough
  8. Feel empowered to refer these patients to pulmonary… but also feel empowered to try the aforementioned therapies and start an initial work up

Basic Definitions

Cough can be defined as follows (Irwin, 2017):

  • Acute: < 3 weeks
    • Usually seen in the setting of a viral infection causing airway hyperreactivity
    • Drs. Watto & Hayward recommend setting expectations with these patients: This will be an irritating, annoying process and the cough is often the last thing to go
    • [The post-viral cough can last up to 8 weeks, the speaker reminds us. So let the patient know that.]
  • Subacute: 3 –  8 weeks
  • Chronic: >8 weeks

Approaching “undifferentiated” cough when there isn’t an obvious cause… 

As mentioned earlier, history is king! And always screen for post-viral cough.


Consider in any patient, the most common causes for subacute / chronic cough and, if you are comfortable, a trial of empiric therapy is certainly reasonable in the right clinical context (Michaudet 2017):

  • Upper airway cough syndrome (aka post-nasal drip, can be allergic, non-allergic, etc.)
    • Empiric treatment: intranasal steroids +/- systemic antihistamines, reasonable to trial empiric therapy
  • Gastroesophageal reflux disease / laryngopharyngeal reflux disease
    • Empiric treatment: trial of PPI – can be as long as 2-3 months, and some recommend twice-daily dose (Smith 2016)
  • Asthma (cough-variant asthma)
    • Empiric treatment: initially with inhaled corticosteroid with close-interval follow up for clinical response (Côté 2020)
  • … and non-asthmatic eosinophilic bronchitis (NAEB)- an emerging cause for unexplained cough in adults!
    • Empiric treatment: Also inhaled corticosteroid with close-interval follow up (Côté 2020)
    • Will often need intermittent inhaled corticosteroid (ICS) if a trigger/triggers cannot be identified and avoided


    • Chest X-Ray: Can help us identify significant abnormalities, or may suggest airway disease if clear
    • Pulmonary Function Testing: Spirometry up front (tells us if there is obstruction, or evidence for restriction) – Dr. Hayward doesn’t feel Full PFTs (spirometry + body plethysmography + DLCO testing) is required up front
  • Look at the flow-volume loop!
    • Concern for allergies or environmental etiology? Dr Hayward recommends:
      • CBC with differential (looking for elevated eosinophils)
      • IgE level
  • Serum allergy screen
  • [For two articles on allergies please see


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