Cough causes
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2] ; M.Umer Tariq [3] Abiodun Akanmode,M.D.[4] Alberto Castro Molina, M.D.
Overview
A cough is a protective reflex that helps clear secretions and foreign material from the airways. In adults, cough is commonly classified by duration as acute (less than 3 weeks), subacute (3 to 8 weeks), and chronic (more than 8 weeks).[1]
A persistent cough can be debilitating, socially distressing, and adversely impair quality of life(Qol). One of the more common presentations to a medical practitioner is a dry cough. The common causes of chronic dry coughing include post-nasal drip, gastroesophageal reflux disease, asthma, post viral cough and certain drugs such as beta blockers, ACE inhibitors and aspirin. If a cough lasts for more than three weeks, multiple causes are likely and symptoms will abate only when all the causes are treated will the patient be symptom-free. Individuals who smoke often have a smoker's cough, a loud, hacking cough which often results in the expiration of phlegm.
Coughing may also be used for psychological or social reasons, such as the coughing before giving a speech. This is known as psychogenic, habit or tic coughing, and may increase in frequency in social situations featuring conflict.
Causes
Given its irritant nature to mammal tissues, capsaicin is widely used to determine the cough threshold and as a tussive stimulant in clinical research of cough suppressants.[2][3]
Common Causes
Chronic cough in adults: common causes and diagnostic considerations
Chronic cough often has more than one contributing cause, and symptoms may not resolve until all contributing conditions are addressed.[1]
Common or important causes to consider in adults with chronic cough include:
- **Upper airway cough syndrome** (often related to rhinitis or sinus disease)
- Upper airway symptoms may be minimal or absent. Consider allergic rhinitis, nonallergic rhinitis, and chronic rhinosinusitis. First generation antihistamines with anticholinergic effects and intranasal therapies are often used as initial management in appropriate clinical contexts.[1]
- **Asthma and cough variant asthma**
- Cough can be the predominant symptom. Bronchoprovocation testing may support the diagnosis, but response to anti inflammatory therapy is also important clinically.[1]
- **Nonasthmatic eosinophilic bronchitis**
- Presents with chronic cough and airway eosinophilia without variable airflow obstruction. It may respond to inhaled glucocorticoids. Fractional exhaled nitric oxide or induced sputum (when available) can support the diagnosis in the right setting.[1]
- **Gastroesophageal reflux and reflux related cough**
- Reflux can contribute even without classic reflux symptoms. Acid suppression alone may be insufficient, and non acid reflux may play a role. Improvement can require an adequate therapeutic trial, and cough may take weeks to months to abate after effective control of contributing reflux mechanisms.[1]
- **Medication related cough**
- ACE inhibitor cough is a classic cause. Medication reconciliation is essential, especially when cough began after a new medication was started or intensified.[1]
- **Smoking related disease and chronic airway disease**
- Smoking can cause chronic bronchitis and contribute to cough. Evaluate for Chronic Obstructive Pulmonary Disease and other smoking related airway disease based on history and spirometry findings.[1]
- **Interstitial lung disease**
- Consider when there is dyspnea, crackles, abnormal imaging, or systemic features. Importantly, common non ILD causes of cough can coexist in patients with ILD, so the presence of ILD does not exclude other treatable contributors.[1]
- **Airway lesions and less common structural disease**
- Tracheobronchial disease, bronchial obstruction, or aspirated foreign body should be considered when there are focal findings, recurrent pneumonia, hemoptysis, or unexplained symptoms. Bronchoscopy may be considered in selected patients, including those with persistent cough despite guideline based evaluation and management, even when imaging is not clearly diagnostic.[1]
Unexplained or refractory chronic cough
After evaluation and appropriate treatment trials for common and relevant causes, some patients have persistent cough that is either:
- **Refractory chronic cough**: cough persists despite treatment of identified causes
- **Unexplained chronic cough**: no cause is identified after a systematic evaluation
A key concept is **cough hypersensitivity**, in which cough reflex pathways are overly sensitive and cough can be triggered by low level mechanical, chemical, or thermal stimuli. Patients may report throat tickle, laryngeal paresthesia, or cough triggered by talking, odors, cold air, or eating. This diagnosis is typically considered only after other etiologies have been reasonably excluded and treated.[1]
Causes by Organ System
Causes in Alphabetical Order
Causes of Nonproductive Cough
- Smoker's cough
- Aspiration
- Congestive heart failure
- Postnasal drip
- Most common cause of chronic cough in nonsmokers
- GERD
- Second most common cause of chronic cough in nonsmokers
- Asthma/reactive airway disease
- ACE inhibitor use
- Pneumonia
- Typical pneumonia is characterized by acute or subacute onset of fever, dyspnea, fatigue, pleuritic chest pain, and cough
- Atypical pneumoniais characterized by more gradual onset, dry cough,headache, fatigue, and minimal lung signs
- Acute bronchitis
- Most commonly caused by viruses
- Postviral bronchitis may last beyond 6 weeks
- Aspirated foreign body
- Lung cancer
- COPD
- Sarcoidosis
- Cryptogenic organizing pneumonia
- Filarial disease
Productive Cough
- Postnasal drip
- Tuberculosis
- COPD
- Lung cancer
- Smoker's cough
- Asthma with secondary infection
- Pneumonia
- Bronchitis
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Richard S. Irwin and J. Mark Madison (2025). "Unexplained or Refractory Chronic Cough in Adults". The New England Journal of Medicine. 392: 1203–1214. doi:10.1056/NEJMra2309906.
- ↑ Omar S. Usmani, Maria G. Belvisi, Hema J. Patel, Natascia Crispino, Mark A. Birrell, Marta Korbonits, Dezso Korbonits, and Peter J. Barnes (2005). "Theobromine inhibits sensory nerve activation and cough" (pdf). The FASEB Journal. 19: 231–233.
- ↑ Arella, A. (nd), Coughing as an Indicator of Displacement Behaviour (PDF) (Unpublished thesis)