Coughs

 

Cough is a reflex response to airway irritation. It is triggered by stimulation of airway cough receptors, either by irritants or by conditions that cause airway distortion.  It is defined as acute (when present for less than 3 weeks), sub-acute (when present for 3 to 8 weeks), or chronic (when present for more than 8 weeks).  An acute cough is most commonly caused by upper respiratory tract infection (URTI).  A sub-acute cough is most commonly caused by airway hyper-responsiveness following specific infections including Mycoplasma pneumonia.  Chronic cough is most commonly caused by exposure to cigarette smoke (either actively or passively), use of an angiotensin-converting enzyme (ACE) inhibitor, upper airway cough syndrome (previously referred to as post-nasal drip syndrome), asthma, or gastro-oesophageal reflux disease

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Diagnosis

Assessment

The following assessments in primary care should be undertaken if a patient presents with a cough:

  1. Take a full history; in particular ask about:
    1. Duration of cough
    2. Type of cough (dry or productive)
    3. Precipitating or exacerbating factors
    4. Diurnal variation
    5. Smoking history
    6. Occupational history
    7. Recent respiratory tract infection
  2.  Ask about other clinical features such as breathlessness, wheeze, indigestion, reflux, chest or shoulder pain, haemoptysis (coughing up of blood), weight loss, and fever
  3.  Consider co-morbid conditions that may cause cough, such as:
    1. Allergies
    2. Asthma
    3. Chronic obstructive pulmonary disease (COPD)
    4. Bronchiectasis
    5. Heart failure
  4. Review the person's medication such as use of angiotensin-converting enzyme (ACE) inhibitors
  5. Examine the person paying particular attention to the chest, heart, pharynx, nose and ears
  6. Arrange investigations in primary care if appropriate, such as:
    1. pulse oximetry (if the person is acutely unwell)
    2. peak expiratory flow rate (if asthma is known or suspected)
    3. pertussis serology (if whooping cough is suspected)
    4. spirometry and chest x-ray (e.g. if there is chronic cough of uncertain cause)

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Management

Acute cough (less than 3 weeks' duration)

Arrange emergency admission for people with:

  • Clinical features of suspected pulmonary embolism or pneumothorax
  • Signs of symptoms of serious illness, including:
    • Respiratory rate > 30 breaths per minute
    • Tachycardia > 130 beats per minute
    • Systolic blood pressure < 90 mmHg, or diastolic blood pressure < 60 mmHg (unless this is normal for them)
    • Oxygen saturation < 92%, or central cyanosis (if the person has no history of chronic hypoxia)
    • Peak expiratory flow rate (PEFR) < 33% of predicted
    • Altered level of consciousness
    • Use of accessory muscles of respiration (particularly if the person is becoming exhausted)

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Arrange emergency admission or urgent referral using referral using clinical judgement for people with clinical features of foreign body aspiration

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If the person does not need admission and has clinical features of upper respiratory tract infection, advise them to:

  • Use paracetamol or ibuprofen as required
  • Stop smoking if appropriate
  • Seek medical advise if symptoms deteriorate significantly or other symptoms develop

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If the person does not need admission but have clinical features of the following, please follow the management and treatment processes for the conditions, at the links below:

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Sub-acute cough (3-8 weeks' duration)

Arrange emergency admission for people with clinical features of serious illness, including:

  • Respiratory rate > 30 breaths per minute
  • Tachycardia > 130 beats per minute
  • Systolic blood pressure < 90 mmHg, or diastolic blood pressure < 60 mmHg (unless this is normal for them)
  • Oxygen saturation < 92%, or central cyanosis (if the person has no history of chronic hypoxia)
  • Peak expiratory flow rate (PEFR) < 33% of predicted
  • Altered level of consciousness
  • Use of accessory muscles of respiration (particularly if the person is becoming exhausted)

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If the person has clinical features of any of the following conditions, please follow the given instructions or follow the management and treatment processes for the conditions at the links below:

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Chronic cough (more than 8 weeks' duration)

Arrange emergency admission for people with clinical features of serious illness, including:

  • Respiratory rate > 30 breaths per minute
  • Tachycardia > 130 beats per minute
  • Systolic blood pressure < 90 mmHg, or diastolic blood pressure < 60 mmHg (unless this is normal for them)
  • Oxygen saturation < 92%, or central cyanosis (if the person has no history of chronic hypoxia)
  • Peak expiratory flow rate (PEFR) < 33% of predicted
  • Altered level of consciousness
  • Use of accessory muscles of respiration (particularly if the person is becoming exhausted)

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If the person has clinical features of any of the following conditions, please follow the given instructions or follow the management and treatment processes for the conditions at the links below:

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If the diagnosis is unclear and no cause is identified following initial investigations, arrange sequential trials of treatment for:

  • Upper airway cough syndrome - prescribe a nasal corticosteroid and review after 2-8 weeks
  • Asthma - prescribe an inhaled β2-agonist or corticosteroid and review after 6-8 weeks
  • GORD - prescribe a proton pump inhibitor and review after 8 weeks

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If the person does not respond to the trials of treatment, or partially responds (possibly indicating more than one cause), refer the person to a respiratory physician

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Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

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Chest radiography

For chest x-rays, you can refer the patient to the Radiology Department at East Kent Hospitals (find details here)

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Spirometry

In combination with undertaking structured clinical assessment of the patient's signs and symptoms, GPs should carry out quality-assured spirometry.  Spirometry is performed in primary care and must be carried out by suitably trained nurses accredited to ARTP standards.  Please click on the Spirometry map register for a full list of those practices where spirometry is being undertaken to the accredited standard

Further information:

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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