Chronic cough

Cough is a normal reflex with protective mechanisms. Most people will cough 18-20 times a day NORMALLY. When people come with chronic cough the goal of symptomatic treatment is not to get RID of the cough but to improve it and their QoL. The cause of a cough can be varied, but cough by itself can be a 'cause' of cough; you become hypersensitive and cough triggers another cough

Duration Severity (important to trend over time) Frequency Impact Triggers Dry vs wet (determines whether you might send for sputum) Red flags Medication causes (ie ACEi) Occupational Smoking GERD Asthma AR PNDS symptoms Previous treatment trials Current treatment

Ddx: 5 main categories then idiopathic Asthma UACS (clearing of throat is a suggestive sign) GERD Structural lung disease (ie COPD) post infectious (months to a yearish) Then if all else is neg: cough hypersensitivity syndrome

Ix: CBC, IgE CXR CT chest PFTs, maybe MCT Sputum eos / FeNO bronch is rarely ever helpful

Tx: First line (not kitchen sink, do one at a time for a month or two to see what will happen first) Basic: ICS trial Nasal steroids and sinus rinse PPI trial Prednisone short trial consider Cough diary (ie count the coughs per day so patients understand level of improvement?)

Advanced treatments if things haven't worked already or sig QoL impairments: Gabapentoids ie Pregabalin 25-75mg PO BID titrate weekly to target dose of 150mg BID ie. gabapentin start 100mg TID titrate to 300mg TID target dose x 12 weeks Opioids: morphine typically Hycodan syrup Gefapixant (new cough blockers not yet in Can yet)

because it's a feedback loop there is likely going to be improvement after these drugs are taken away too less cough = less cough, feedback loop