Table 10

Investigation and management of chronic cough

Investigations	Potential results	Clinical management plan
Actions from history, medication and dietary assessment
History findings	After food	Follow guideline for dysphagia (see tables 14 and 16).
	Allergic rhinitis	Refer the patient to GP for further management.
	Smoking	Advise smoking cessation.
	COPD	Refer the patient to the GP for further management.
	Obstructive sleep apnoea	Refer the patient to the GP for further management.
	Upper airway conditions: Chronic tonsil enlargement Irritation of external meatus Laryngeal problems	Refer to ENT team.
	Cough with excess secretions in pharynx or globus	OGD, look specifically for inlet patch. SLT assessment including a contrast swallow.
Medication findings	ACE inhibitors	Reassure patient and suggest discussing possible alternatives with the GP or cardiology team.
First line
Auscultation chest and heart	Cardiac conditions eg, left ventricular failure, tachycardia	Discuss immediately with supervising clinician.
	Respiratory conditions:
	Aspiration	▸ Nil by mouth. ▸ SLT assessment. ▸ Alternative feeding.
	Other respiratory causes	Discuss with supervising clinician within 24 hours.
Routine and additional blood tests	Abnormal results	Follow treatment for abnormal blood results (p. 2).
CXR	Cardiac causes:
CXR	▸ Left ventricular failure	Refer to GP/cardiology/acute medicine.
	▸ Thoracic aortic aneurysm	Refer to cardiothoracic surgery.
	Malignancy/tumour recurrence	Refer to appropriate MDT requesting an appointment within 2 weeks.
	Aspiration	▸ Nil by mouth. ▸ SLT assessment. ▸ Alternative feeding.
	Radiation pneumonitis	Refer to respiratory physician.
	Pulmonary embolism	This is an emergency. Contact the on-call medical team.
	Other respiratory causes	Discuss with supervising clinician within 24 hours.
Second line
OGD	Vocal cord abnormality, eg, polyp	Refer to ENT.
	GORD	Start PPI or H2 antagonist. If following oesophagectomy, consider promotility agents (see p. 26).
	Anastomotic stricture±pyloric stenosis	Consider dilatation (p. 25) with careful biopsy only after agreement from the appropriate MDT.
	Malignancy/tumour recurrence	Refer to appropriate MDT requesting an appointment within 2 weeks.
	Cervical inlet patch	Treat with PPI or ablation.
Trial of PPI	GORD	Consider GORD
Trial of mucaine/sucralfate	Bile reflux	Consider prokinetics (p. 26).
Third line
CT chest/CTPA	Pulmonary embolism	This is an emergency. Contact the on-call medical team.
	Cardiac causes: Left ventricular failure	Refer to GP/cardiology/acute medicine.
	Thoracic aortic aneurysm	Refer to cardiothoracic surgery.
	Malignancy/tumour recurrence	Refer to appropriate MDT requesting an appointment within 2 weeks.
	Other respiratory causes	Discuss with supervising clinician within 24 hours.
Fourth line
Oesophageal manometry/pH/impedance studies	Spasm	Start PPI or H2 antagonist. Calcium antagonist. Low dose antidepressant, eg, citalopram. Refer to gastroenterology.
	Scleroderma	Start PPI or H2 antagonist. Refer to rheumatology.
Fifth line
If normal investigations/no response to intervention		Reassure.

ACE, angiotensin converting enzyme; COPD, chronic obstructive pulmonary disease; CT, computerised tomography; CTPA, CT pulmonary angiography; CXR, chest X-ray; ENT, ear, nose and throat; GORD, gastro-oesophageal reflux disease; GP, general practitioner; H2, histamine -2; MDT, multidisciplinary team; OGD, upper GI endoscopy (oesophago-gastroduodenoscopy); PPI, proton pump inhibitor; SLT, speech and language therapy.