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An Algorithmic Approach to Chronic Cough

Melvin R. Pratter, MD; Thaddeus Bartter, MD; Stephen Akers, MD; and James Dubois, MHA
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From Cooper Hospital/University Medical Center, UMDNJ/Robert Wood Johnson Medical School at Camden, Camden, New Jersey. Requests for Reprints: Melvin R. Pratter, MD, Suite 312, 3 Cooper Plaza, Camden, NJ 08103. Acknowledgments: The authors thank Gary Young and Patricia Gregory for statistical support.

Copyright 2004 by the American College of Physicians

Ann Intern Med. 1993;119(10):977-983. doi:10.7326/0003-4819-119-10-199311150-00003
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Objectives: To evaluate a stepwise approach to chronic cough that emphasized initial treatment of all patients with an antihistamine-decongestant for postnasal drip and to determine the value of routine bronchoprovocation challenge in the evaluation of chronic cough.

Design: Prospective trial using an algorithm for chronic cough in immunocompetent nonsmoking outpatients.

Setting: University-based pulmonary practice.

Patients: Forty-five patients met the inclusion criteria. The mean duration of cough was 140 weeks (range, 3 to 2080 weeks), and the mean severity of cough as assessed by patients on a four-point scale was severe.

Results: Marked improvement and resolution (mean, 3.1 and 7.1 weeks, respectively), with resolution in 96% of patients. Antihistamine-decongestant therapy was beneficial in 39 of 45 patients and was the only therapy needed for 16 patients. Bronchoprovocation challenge had a negative predictive value of 100% and a positive predictive value of 74% for cough caused by asthma. No significant relationship was found between the time to cough resolution and duration or severity of cough. Eighteen percent of patients experienced a recurrence of cough at a follow-up interval of 3 months.

Conclusions: A sequential approach to chronic cough that emphasizes initial treatment with an antihistamine-decongestant is effective. Bronchoprovocation challenge is useful in evaluating patients with chronic cough but can be delayed until the initial response to antihistamine-decongestant therapy has been assessed. The 18% incidence of recurrence highlights the fact that cough often is the manifestation of a chronic or recurring process that requires chronic or episodic therapy.


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Figure 1.
Response to 1 week of antihistamine-decongestant therapy.
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Figure 2.
Cough response to the treatment algorithm.

Marked improvement included patients with resolution. Note the gap between weeks 21 and 61.

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Figure 3.
The breakdown of diagnoses in the study sample.

GER = gastroesophageal reflux; PND = the postnasal drip syndrome.

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Figure 4.
Medications used to achieve resolution of cough.

Those medications required to achieve cough resolution were not always the same as those used for maintenance therapy after the cough had resolved. A/D = antihistamine-decongestant; GER = gastroesophageal reflux; NCS = nasal corticosteroids; PND = the postnasal drip syndrome.

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