Before working up a chronic cough as a lung problem, close off the causes that are not. An ACE inhibitor can start a cough months after it was first prescribed, so 'she has been on it for years' does not exclude it — stop it and wait four weeks, because the cough can take that long to settle and the trial is worthless if abandoned at two.
Then the two other common culprits: unrecognised reflux, and upper airway cough syndrome from post-nasal drip, both of which produce a cough with a normal chest examination and a normal chest radiograph. And ask whether the patient smokes anything other than tobacco, and what they do at work — occupational and environmental exposure is the question most reliably left out of a cough history.
Where the cough belongs to a known fibrotic or airways disease and every treatable cause has been excluded, it becomes a symptom in its own right and deserves treating as one, rather than being accepted as part of the illness.
- Stop an ACE inhibitor and allow a full four weeks before judging the trial, whatever the duration of use
- Consider reflux and upper airway cough syndrome before escalating imaging
- Ask about occupation, biomass cooking fuel and non-tobacco smoking at the first consultation
- A normal chest radiograph does not close the question in a persistent cough
- Treat refractory cough in established lung disease as a symptom to manage, not a feature to accept
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