Chronic cough: Seeking the cause and the solution

In the vast majority of non-smokers who are not receiving angiotensin converting-enzyme inhibitors and who have no evidence of active disease on chest radiographs, chronic cough is caused by postnasal drip syndrome (recently renamed upper airway cough syndrome [UACS]), asthma, non-asthmatic eosinophilic bronchitis, or gastroesophageal reflux disease (GERD), alone or in combination. A high index of suspicion is required, because each of these conditions may present with cough as the sole symptom. Because UACS may be the most common cause of chronic cough, it appears reasonable to initially give empiric UACS therapy to patients in whom other causes are not evident at initial evaluation. In many cases, the combination of a first-generation antihistamine and a decongestant may be most effective. In general, the therapeutic approach to cough-variant asthma is similar to that of the typical form of asthma. Many patients have symptomatic improvement after 1 week of therapy with inhaled bronchodilators, but most will require inhaled corticosteroid therapy for full resolution of cough. Initial empiric therapy with a proton pump inhibitor and implementation of anti-reflux lifestyle measures may be appropriate for patients in whom GERD-induced cough is suspected.