Indian Consensus on Diagnosis of Cough 2019

Diagnosis of Cough at Primary Care Setting

#IndianConsensus #2019 


Diagnosis of cough poses a common dilemma during consultations at primary care settings in India. This Expert Opinion document, published in the Journal of The Association of Physicians of India presents a diagnostic algorithm for primary care physicians to distinguish between cough conditions that can be treated at the community level and potentially serious cough that requires specialist care.

The existing international guidelines on cough diagnosis and management are tailored to specialty care, and they do not address challenges encountered in developing countries like India. Following their recommended diagnostic criteria for cough, management appears to be one of the major challenges faced by the primary care physicians in India. The diagnostic tests are either unavailable in the primary care setting or the patients cannot afford them.

This Expert Opinion document presents a diagnostic algorithm for primary care physicians to distinguish between cough conditions that can be treated at the community level and potentially serious cough that requires specialist care. 

The key takeaways from the consensus document are:-

Duration of cough 

Cough is classified into 3 categories on the basis of its duration in adults:-
1. Acute (<3 weeks)
2. Sub-acute cough (3-8 weeks)
3. Chronic cough (>8 weeks)

Causes of acute cough

• Upper respiratory tract infections (bacterial or viral)
• Pneumonia 
• Asthma 
• Congestive heart failure
• Pulmonary embolism
• Foreign body aspiration

Red flag signs

Acute cough of viral origin should be treated empirically and may not require aggressive investigations unless it is characterized by “red flag’ signs, which are:-
• Hemoptysis
• Prominent dyspnea
• Systemic symptoms such as weight loss, fever, sore throat
• Hoarseness of voice
• History of tuberculosis (self or in a person who is in close contact)
• Immunosuppressive state
• Smokers’ cough especially in patients >35 years of age
• Cough syncope

Causes of chronic cough

• Upper respiratory tract infection
• Upper airway cough syndrome
• ACE inhibitor
• Pulmonary TB
• Environmental Factor
• Post infectious
• Eosinophilic bronchitis
• Asthma
• Gastroesophageal reflux disease (GERD)
•  Cardiac origin 

Clinical history and physical examination

Symptom-oriented physical examination (including cough sounds) should be performed for the following: 

• Classification of cough
• Identification of etiological factors
• Evaluation and ruling out of common causes of cough, e.g., GERD, cough variant asthma
• Provisional diagnosis
• Referral to a Cardiologist, if required
• A history of intake of ACE Inhibitors will help Dx drug-induced cough

Algorithm for diagnosis of drug induced cough

Algorithm for diagnosis of pulmonary TB

•  Pulmonary TB should be suspected in cases of patients having contact with persons with tuberculosis, or presence of hemoptysis or fever 
• A positive test with 2 sputum acid-fast bacilli smears and elevated ESR will help diagnose pulmonary tuberculosis
• Presumptive pulmonary tuberculosis refers to a person with any of the symptoms or signs suggestive of tuberculosis:-

-  Cough > 2 weeks
-  Fever > 2 weeks 
-  Significant weight loss 
-  Hemoptysis

Algorithm for diagnosis of cough due to asthma, GERD, UACS, and postinfectious causes 

Gastroesophageal reflux disease (GERD)
• Specialized investigations (pH testing, pH impedance testing, and/or an upper endoscopy) may be required to rule out gastroesophageal reflux disease 
• If empirical treatment for asthma or cough-variant asthma for approximately 4 weeks provides no relief, treatment with proton pump inhibitors for GERD may be added


Upper airway cough syndrome
Signs of upper airway cough syndrome:-
History suggestive of allergic rhinitis, nasal examination
 • Postnasal drip
 • A cobblestone appearance of the posterior part of the pharynx


Environmental factors
• Primary care providers should consider environmental factors as one of the important etiological factors for chronic cough
• Diagnostic investigations are not recommended at primary care settings for suspected GERD, and upper airway cough syndrome (UACS)


Cough of cardiac origin
• Cough of cardiac origin should be suspected based on the following:-
- History of cardiac illness 
- Presenting symptoms like paroxysmal nocturnal dyspnea
- Pulmonary TB, GERD, UACS, asthma, and post-infectious cause are ruled out and the pt has a normal repeat chest radiograph
• Patient should be immediately referred to a cardiologist


Overlapping etiologies
• Evaluation based on history and differential diagnosis will help diagnose cough due to asthma, gastroesophageal reflux disease, upper airway cough syndrome, or postinfectious cough 
• In case of no response to treatment, optimization of treatment should be done considering overlapping etiologies of gastroesophageal reflux disease, upper airway cough syndrome, or postinfectious cough

Recommendations for differential diagnosis of cough

• Cough may be treated empirically and may not require aggressive investigations unless it is characterized by “red flag signs” or persists for > 2 weeks

• Pulmonary TB should be excluded if the cough persists for > 2 weeks after the initial treatment with suggestive signs and symptoms

• Upper airway cough syndrome, GERD, and cough-variant asthma should be diagnosed based on medical history and nasal examination and treated empirically. Referral should be considered for spirometry and    other specialized lung function tests

• Cough of cardiac origin should be suspected based on history of cardiac illness, the use of ACE inhibitors, β-blockers, and amiodarone, and the presence of orthopnea and/or dyspnea, and the patient should be     referred to a specialist

Environmental factors should be considered as one of the significant causes for chronic cough

Any neonatal cough, until an etiology is established, should be suspected for pneumonia

• Referral for bronchoscopy if foreign body aspiration is suspected

Combined algorithm for diagnosis of cough

Note: This list is a brief compilation of some of the key points included in the consensus document and is not exhaustive and does not constitute medical advice. Kindly refer to the original publication here: https://pxmd.co/LocYm


About Author
Dr. Prachi Chhimwal
Dr. Prachi Chhimwal is an Editor at PlexusMD and is a part of the Engagment Team. She curates the Technical Content posted daily on the news feed. She graduated from Army College of Dental Sciences (B.D.S) and went on to pursue her post-graduation (M.D.S) in Oral & Maxillofacial Pathology. After a decade in the field of dentistry she took a leap of faith and joined PlexusMD. A badminton enthusiast, when not working you can find her reading, Netflixing or enjoying stand-up comedy shows.
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Useful in our scenario.
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Excellent article regarding Approach to a case of coug esp for doctors serving in developing country where cost of investigation shd be balanced by clinical accumen.
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