Chronic Cough Algorithm

Safety

Red Flags — Exclude Malignancy, TB & Serious Pathology

Done

Chronic cough (>8 weeks) is common but requires systematic exclusion of serious causes before symptomatic management. Arrange or review a chest X-ray for every adult with chronic cough unless an adequate recent film is available and the clinical picture has not changed — repeat it if symptoms or risk profile change.

Thresholds are warning signs, not decision rules. Escalate on the patient's baseline and individualised SpO₂ target (94–98% for most adults, 88–92% if at risk of hypercapnic respiratory failure), the degree of deterioration and the clinical state — not on a single number. Haemoptysis volume may be documented but must not decide the emergency. A normal CXR does not exclude cancer, bronchiectasis or ILD.

Haemoptysis Unexplained haemoptysis aged 40 or over → suspected cancer pathway referral (NG12); smoking is not required for the criterion. At any age it needs prompt assessment of source and cause with a CXR; persistent or recurrent haemoptysis needs urgent respiratory evaluation even if the CXR is normal. Brisk, ongoing or airway-threatening bleeding, haemodynamic compromise, hypoxia or inability to protect the airway → 999 — judge the patient, not a millilitre estimate.

Unintentional weight loss + cough Lung cancer, TB, lymphoma. Weight loss alone does not automatically mean a lung-cancer referral; at 60 or over with unexplained weight loss, assess for other symptoms and consider urgent investigation, a suspected-cancer pathway or the non-specific symptoms pathway. Usually an urgent direct-access CXR (age ≥40 with cough plus another unexplained symptom, or one symptom in an ever-smoker) — suspected cancer pathway referral if the CXR suggests cancer or another NG12 criterion is met.

Abnormal CXR Mass, consolidation, effusion, hilar lymphadenopathy, persistent infiltrate — suspected cancer pathway referral where it suggests cancer, otherwise respiratory referral. A normal film does not close the question if suspicion remains high.

Night sweats + cough + weight loss TB (especially migrant populations, homeless, immunocompromised), lymphoma → urgent CXR, three deep-cough sputum samples (microscopy, culture, molecular testing) and urgent TB-service contact. Advise respiratory hygiene and avoiding vulnerable people and crowded settings while awaiting advice.

Stridor + cough Tracheal obstruction, vocal cord tumour, anaphylaxis — upper airway emergency → 999

Dysphagia + cough Aspiration from oesophageal pathology, pharyngeal pouch, neurological dysphagia. Coughing during or after swallowing needs a swallow (SALT) assessment before any dietary advice; CXR, and the urgency of the upper-GI or ENT route depends on the dysphagia itself and the suspected cause (unexplained dysphagia → suspected cancer pathway referral for oesophageal cancer, NICE NG12 (updated April 2026)).

Immunocompromised + cough HIV, chemotherapy, biologics, long-term steroids, transplant → atypical pneumonia (PCP), fungal, TB. Same-day CXR, FBC and SpO₂ at rest and on exertion, and speak to the specialist team — further immunological testing is specialist-led. PCP may cause disproportionate exertional breathlessness or desaturation with a near-normal CXR — urgent specialist/acute assessment if hypoxic or progressive. Neutropenic fever is an oncological emergency: immediate hospital assessment, 999 if unstable.

New or changed cough at 40 or over Urgent direct-access CXR where there are two or more relevant unexplained symptoms, or one in an ever-smoker (NG12); consider asbestos exposure separately. Do not attribute it to "smoker's cough", COPD or reflux without imaging — and reassess if symptoms persist despite a normal film.

NICE NG12 (Suspected cancer, updated April 2026) sets the routes precisely: unexplained haemoptysis at 40 or over → suspected cancer pathway referral; age 40 or over with unexplained cough plus another relevant unexplained symptom, or one relevant symptom in an ever-smoker → urgent direct-access CXR; a CXR suggesting lung cancer → suspected cancer pathway referral; asbestos exposure with relevant symptoms → urgent CXR and the mesothelioma route. A new cough in a smoker is therefore an imaging decision, not an automatic suspected cancer pathway referral. The 3% PPV threshold used by NG12 means the yield justifies urgent investigation. A CXR misses peripheral and mediastinal pathology — a normal film does not exclude cancer in a high-risk patient, and persisting or unexplained symptoms still need reassessment and referral. UK TB incidence is around 5–6/100,000 but much higher in some urban areas and migrant communities: cough with night sweats and weight loss in a person at risk needs TB assessment, and mycobacterial sputum testing is targeted to those with risk factors or compatible symptoms rather than sent on everyone.

Diagnose

History — Characterise the Cough

Done

Duration and onset

Subacute (3–8 weeks — post-infectious, pertussis) vs chronic (≥8 weeks — UACS, GORD, CVA, eosinophilic bronchitis, CHS). Onset after URTI suggests post-infectious cough hypersensitivity.

ACE inhibitor use

ACE inhibitors cause a dry tickly cough in 10–15% of patients (bradykinin accumulation — class effect, not dose-related). Can develop any time during treatment. Stop it if clinically appropriate and substitute an ARB where the indication requires it, with BP, renal function and potassium reviewed per the local prescribing pathway — the prescribing clinician arranges the switch and the monitoring. Improvement is usually over several weeks and occasionally longer; it is not always the cause, so reassess rather than assume.

Character and timing

Dry tickly (ACEi, CVA, UACS, CHS) vs productive (bronchiectasis, infection) vs barking (airway collapse, laryngeal dysfunction, habit cough — may need specialist assessment) vs worse at night (CVA, GORD, post-nasal drip) vs worse in morning (COPD, bronchiectasis, GORD)

Triggers

Cold air, exercise, laughter, perfumes, smoke → airway hyperreactivity / CVA / CHS. Lying flat, eating, alcohol → GORD/LPR. Seasonal/allergen → allergic rhinitis (UACS). Occupational (isocyanates, flour, grain) → occupational asthma.

Associated symptoms

Nasal obstruction, rhinorrhoea, sneezing, post-nasal sensation or throat clearing → rhinitis/chronic rhinosinusitis as a treatable trait. Heartburn / regurgitation → GORD/LPR. Wheeze / breathlessness → asthma / CVA. Sputum production + recurrent infections → bronchiectasis. Persistent hoarseness → do not attribute to LPR without assessment; unexplained at 45+ → NG12 laryngeal pathway.

Smoking history

Pack-year history. Current smoker → COPD, lung cancer, chronic bronchitis. Ex-smoker → persistent risk. Passive smoke exposure. Vaping may cause airway irritation; an acute hypoxic or systemic illness needs assessment for infection, asthma, PE and other causes.

Occupational history

Ask specifically about workplace exposures — flour/grain dust, paint fumes, isocyanates (spray painting), wood dust, laboratory animals. Occupational asthma improves on holiday/weekends — a key diagnostic clue.

ACE inhibitor cough affects 10–15% of patients in UK populations (higher in some South Asian populations) and is the commonest drug-induced cough. The mechanism is bradykinin and substance P accumulation in the respiratory mucosa — a class effect, not dose-related. The BTS 2023 statement supports stopping the ACE inhibitor in chronic cough regardless of the temporal relationship, but it is not always the cause: improvement usually takes several weeks and occasionally longer, so a cough that has not settled by four weeks is a reason for routine reassessment, not an assumption of a second diagnosis. Stopping or switching must account for the indication, renal function, potassium and BP, and is arranged by the prescribing clinician. The occupational history is one of the most neglected areas in chronic cough assessment — a meaningful proportion of adult-onset asthma is occupational in origin and is compensatable if identified and reported. The key question is whether cough or wheeze improves on days away from work.

Diagnose

Differential Diagnosis — The Big Five

Done

Most chronic cough in adults has one of a small number of treatable causes, and they can co-exist. Work by treatable traits, with targeted, sequential trials — one at a time, only where the history or objective tests support that trait (BTS clinical statement 2023). Do not routinely start a nasal steroid, a PPI and an inhaled steroid together: it exposes patients to unnecessary medicines and makes any response impossible to attribute.

Dry or minimally productive cough ACE inhibitor · asthma / eosinophilic airway disease · rhinitis and upper-airway cough syndrome · reflux where reflux features support it · cough hypersensitivity. This is where ICS, intranasal steroid and (selectively) PPI trials belong.

Chronic productive cough Daily sputum, recurrent infections → sputum culture (with mycobacteria where there is risk), bronchiectasis and chronic infection, COPD, airway clearance, and a lower threshold for CT. Do not use ICS, PPI or neuromodulators indiscriminately here.

UACS — Upper Airway Cough Syndrome

A common treatable trait (formerly "post-nasal drip"); chronic cough often has several contributing traits. Rhinitis (allergic/non-allergic), sinusitis, deviated septum. Dripping sensation down throat, throat clearing, sneezing, blocked/runny nose. Distinguish allergic rhinitis, non-allergic rhinitis, chronic rhinosinusitis, inducible laryngeal obstruction, laryngeal hypersensitivity and persistent dysphonia. An intranasal steroid is reasonable where rhinitis or rhinosinusitis features are present; evidence for it in nonspecific cough without nasal disease is limited.

GORD / LPR

Reflux can drive cough through vagal afferents. Treat only where heartburn, regurgitation or other convincing reflux features are present, or there is objective evidence — chronic cough without reflux symptoms often does not respond to PPIs, and "silent reflux" should not be presented as an established explanation on the basis of cough, throat clearing or hoarseness alone (BTS 2023). Worse after meals, lying flat or with alcohol. Do not routinely prescribe high-dose or twice-daily PPI for isolated cough.

Cough-variant asthma (CVA)

Cough as the sole asthma manifestation — no wheeze or dyspnoea. Worse at night, triggered by cold air, exercise, allergens. Spirometry is often normal, so if asthma remains suspected use FeNO, bronchodilator reversibility and/or peak-flow variability first (NG245). Consider specialist bronchoprovocation only where diagnostic uncertainty persists — it is not a routine chronic-cough test.

Eosinophilic bronchitis (EB)

Raised FeNO or blood eosinophils suggest eosinophilic / T2 airway inflammation and may support an ICS trial — they do not by themselves diagnose non-asthmatic eosinophilic bronchitis. A raised FeNO may also occur with allergic rhinitis or other type-2 airway disease, and a normal FeNO or eosinophil count does not exclude asthma. Induced sputum eosinophilia is a specialist investigation, and ICS response is supportive rather than diagnostic. EB is usually a specialist diagnosis, particularly with normal spirometry and no demonstrable hyper-responsiveness.

ACE inhibitor cough

Dry tickly cough. Stop it if clinically appropriate before pursuing further investigations (BTS 2023 supports stopping regardless of the temporal relationship), substituting an ARB where the indication requires it with BP, renal function and potassium reviewed. Improvement usually over several weeks, occasionally longer. It is not always the cause — if the cough persists, reassess as a chronic cough rather than assuming a second diagnosis.

Chronic cough hypersensitivity (CHS)

Sensitised cough reflex — triggered by minimal stimuli (cold air, talking, perfume), with no underlying structural cause; a diagnosis made only after treatable traits have been addressed. Management is referral to a respiratory or cough clinic, with specialist cough-control therapy delivered by appropriately trained speech and language therapy. Neuromodulator treatment is a specialist decision after a discussion of benefits and harms — not a routine primary-care step.

COPD / chronic bronchitis

Smoker, productive cough, exertional breathlessness. Post-bronchodilator FEV₁/FVC <0.70 with compatible symptoms and risk factors confirms it (NG115) — a fixed ratio may overdiagnose in older people, and in younger adults a ratio above 0.70 does not exclude disease (consider LLN and specialist assessment). Asthma and COPD can coexist; manage on the NG115 pathway by symptom burden and exacerbations. Cough ± haemoptysis in COPD → rule out lung cancer.

Bronchiectasis

Daily productive cough (mucopurulent), recurrent chest infections, haemoptysis. Childhood infections, CF, COPD, immune deficiency. Thin-section CT is the diagnostic test, with structured assessment via the respiratory pathway. Physiotherapy + airway clearance central to management.

Upper-airway cough syndrome, reflux-related cough and asthma / eosinophilic airway disease account for most chronic cough in non-smoking adults with a normal CXR — but the BTS 2023 clinical statement frames these as treatable traits to be identified and treated, not a package to be prescribed together. Eosinophilic bronchitis is difficult to separate from cough-variant asthma without objective testing, which is why FeNO and blood eosinophils are read as supportive of eosinophilic inflammation rather than diagnostic. Cough hypersensitivity is increasingly recognised as the mechanism behind many cases of unexplained chronic cough — a sensitised reflex arc, analogous to neuropathic pain. Neuromodulators and P2X3 antagonists target that component, but they are off-label or specialist-restricted, with sedation, dizziness, cognitive effects, falls, misuse and withdrawal as the relevant cautions, so the primary-care action is referral plus cough-control therapy.

Diagnose

Targeted Examination & Investigations

Done

Examination

Nasal mucosa (pale/boggy = allergic; erythematous = infective) · post-nasal drip (pharyngeal cobblestoning) · chest auscultation (wheeze, crackles) · BMI (obesity worsens GORD/LPR) · clubbing (bronchiectasis, malignancy)

CXR

Core test — arrange or review one for every adult with chronic cough, unless an adequate recent film exists and the picture has not changed; repeat if symptoms or risk profile change. Mass, consolidation, pleural effusion, hilar nodes, hyperinflation (COPD), honeycomb (fibrosis), infiltrates (TB/PCP). A normal film excludes neither cancer, bronchiectasis nor ILD.

Spirometry

Spirometry + reversibility — supports asthma (FEV₁ ≥12% and ≥200 ml, or ≥10% predicted) in the NG245 sequence, but reversibility does not reliably separate asthma from COPD. COPD needs compatible risk and symptoms plus post-bronchodilator FEV₁/FVC <0.70 (may overdiagnose in the elderly; consider LLN in younger adults). Normal spirometry does NOT exclude CVA or eosinophilic bronchitis.

FeNO

Fractional exhaled nitric oxide — marker of eosinophilic airway inflammation. NG245 diagnostic thresholds: ≥50 ppb in adults 17+, ≥35 ppb at ages 5–16 = asthma confirmed (the 40 / 25–39 bands came from the superseded NG80). Blood eosinophils above the laboratory reference range are the NG245 alternative first test. Below the threshold does NOT exclude asthma — smoking lowers FeNO, and the next tests are spirometry with reversibility, then PEF variability, then referral for bronchial challenge testing if uncertainty persists.

Blood and sputum tests

Core: FBC including eosinophil count (BTS 2023) · Sputum culture where there is purulent/mucopurulent sputum, recurrent infection, suspected bronchiectasis, treatment failure or immunosuppression — not routinely for every productive cough · U&E, TFT, CRP where the picture suggests it · NT-proBNP + ECG if there are cardiac features. Targeted, not routine: three deep-cough sputum samples for mycobacterial microscopy and culture, with molecular testing per local laboratory practice, only with TB risk factors or compatible symptoms · allergy or IgE testing only where allergic disease is suspected. Not a chronic-cough investigation: serum ACE level.

Peak flow diary

2-week peak flow chart (twice daily) with symptom diary — variability ≥20% supports asthma/CVA (NG245). Also correlates cough to work exposures (occupational asthma).

NOT routinely in primary care

CT chest — reserved for the suspected-cancer pathway, a normal CXR with high cancer suspicion, suspected bronchiectasis or ILD, or unexplained cough despite a negative work-up; not for uncomplicated chronic cough with a normal CXR and no red flags. Bronchoprovocation (methacholine) — specialist and selective; FeNO, reversibility and PEF variability come first. Serum ACE level — no role here. Indiscriminate allergy testing. 24-hour oesophageal pH/impedance — gastroenterology. Bronchoscopy — respiratory.

FeNO is the recommended first objective test for suspected asthma or cough-variant asthma in primary care (BTS/SIGN/NICE NG245, 2024): a FeNO at or above the NG245 threshold (≥50 ppb adults 17+, ≥35 ppb ages 5–16) confirms asthma and predicts ICS response, while a value below it excludes nothing — smoking lowers FeNO. Normal spirometry is present in a substantial minority of cough-variant asthma, so a normal spirogram must not be used to exclude it; peak-flow variability (diurnal variation >20%) is an alternative criterion, and bronchoprovocation is reserved for specialist-level uncertainty that persists. Ambulatory pH/impedance is the reference test for reflux-related cough but is invasive and rarely needed in primary care — and because cough without reflux symptoms frequently fails to respond, a PPI trial is not a reliable diagnostic test for reflux-related cough (BTS 2023). The BTS-supported core work-up is CXR, FBC, diagnostic spirometry and FeNO where available.

Refer

Referral Pathways

Done

Suspected cancer pathway

Unexplained haemoptysis aged 40 or over · a chest X-ray suggesting lung cancer · persistent unexplained hoarseness at 45 or over → head and neck pathway (not a lung rule) · unexplained dysphagia → suspected cancer pathway referral for oesophageal cancer. Urgent direct-access CXR instead for: age ≥40 with unexplained cough plus another relevant unexplained symptom, or one relevant symptom in an ever-smoker; asbestos exposure with relevant symptoms (mesothelioma route). Weight loss or chest pain with cough is usually an urgent CXR decision unless another NG12 criterion is met. NICE NG12.

Same-day hospital

Brisk, ongoing or airway-threatening haemoptysis · respiratory failure — severe hypoxia, a fall below the patient's individualised target, exhaustion, cyanosis or altered consciousness · suspected TB with systemic compromise · stridor with cough · ongoing or significant haemoptysis · severe breathlessness · syncope · suspected PE · sepsis · immunocompromised with hypoxia or rapidly progressive symptoms. Do not delay urgent hospital care for these.

Respiratory — routine

Diagnostic uncertainty · suspected bronchiectasis (CT required) · suspected ILD or TB · significant haemoptysis · recurrent focal pneumonia · unexplained desaturation · disproportionate symptoms · frequent COPD exacerbations despite optimised treatment (most stable COPD stays in primary care) · suspected occupational asthma (challenge testing) · cough unexplained after systematic assessment and adequate targeted treatment. Refer earlier than 3–6 months where there is: an abnormal CXR · suspected bronchiectasis, ILD, TB or chronic infection · persistent haemoptysis · significant breathlessness or desaturation · recurrent focal pneumonia · immunosuppression · an unclear diagnosis despite initial testing · persistence despite appropriate targeted treatment (BTS 2023).

Gastroenterology

Reflux-related cough with convincing reflux features not responding to an appropriate PPI trial and lifestyle measures → pH/impedance study ± endoscopy · suspected eosinophilic oesophagitis · NG12 upper-GI criteria (dysphagia at any age; 55+ with weight loss and upper abdominal pain, reflux or dyspepsia)

ENT

Allergic rhinitis/UACS not responding to topical treatment · nasal polyps requiring surgical assessment · sinusitis refractory to antibiotics and nasal steroids (CT sinuses)

Specialist cough clinic

Refractory or unexplained cough hypersensitivity after treatable traits have been addressed → respiratory or tertiary cough clinic (FeNO, bronchoprovocation, impedance, cough-control therapy). Specialist clinicians may consider neuromodulator treatment after discussing benefits and harms — it is not a primary-care step.

NG12 separates two actions that are easily conflated: urgent direct-access CXR (age 40 or over with unexplained cough plus another relevant symptom, or one relevant symptom in an ever-smoker) and suspected cancer pathway referral (unexplained haemoptysis at 40 or over, or a CXR suggesting cancer). A new cough in a smoker is an imaging decision; the referral follows the film or another criterion. A normal CXR does not exclude lung cancer and must not be used as a reason to stop assessing a high-risk patient — CT is more sensitive for peripheral tumours, and persisting or unexplained symptoms justify respiratory referral. Specialist cough clinics provide multidisciplinary assessment (respiratory, gastroenterology, ENT and speech and language therapy) with objective testing, and are the right destination once treatable traits have been addressed without resolution.

Treat

Cause-Directed Treatment

Done

UACS / Allergic rhinitis

Mometasone 2 sprays each nostril OD

Intranasal corticosteroid where rhinitis features are present — product and dose per the local formulary. Demonstrate technique (aim away from the septum), allow several weeks (4–6) for response, and review epistaxis, dryness and adherence. Saline nasal irrigation (Neilmed) as adjunct. Add antihistamine if allergic rhinitis (cetirizine 10 mg OD). Ipratropium nasal spray only for troublesome watery rhinorrhoea, not nasal blockage. Check doses against current product information.

Reflux-related cough with reflux features

Appropriate PPI trial — only where reflux is supported

Where heartburn, regurgitation or other convincing reflux features are present, consider a PPI trial (for example omeprazole 20 mg daily before food) with lifestyle measures, and reassess at the end of it. Do not routinely use high-dose or twice-daily PPI for isolated cough, and do not treat cough, throat clearing or hoarseness alone as "silent reflux" (BTS 2023). An alginate at bedtime may help symptomatic reflux. Treat typical reflux per NICE CG184 — full-dose PPI for 4–8 weeks, then review and step down to the lowest effective dose. H. pylori testing is not part of a chronic-cough work-up: only where there are dyspepsia or upper-GI indications, after a 2-week PPI washout.

CVA / Eosinophilic bronchitis

Time-limited low-dose ICS trial (local formulary)

A targeted ICS trial where FeNO, reversibility or peak-flow variability supports eosinophilic or asthmatic airway disease — low-dose ICS per the local asthma formulary, review at about 4 weeks (adherence, technique) and stop if no meaningful benefit. Confirmed asthma → NG245 treatment (ICS-containing reliever/MART), not a cough regimen. Add a short-acting beta agonist only if there is wheeze. Rinse the mouth after use to prevent candidiasis and dysphonia. Not an automatic treatment for every dry cough.

Step 1Stop the ACE inhibitor if clinically appropriate — the BTS statement supports stopping it in chronic cough regardless of the temporal relationship, but it is not always the cause. Substitute an ARB where the indication requires it, and review BP, renal function and potassium per the local prescribing pathway; the prescribing clinician arranges the switch and the monitoring. Improvement may take several weeks and occasionally longer — do not attribute residual cough to another cause too early.

Step 2Targeted, sequential trials — never all three together. Treat only the traits the history or objective tests support: rhinitis or upper-airway cough syndrome with an intranasal corticosteroid (4–6 weeks, technique demonstrated); eosinophilic or asthmatic airway disease with an ICS trial where FeNO, reversibility or PEF variability supports it; reflux only where reflux features are present. One at a time, each for its own appropriate length, each documented with drug, dose, duration, adherence, technique, response and adverse effects. Routine empirical triple therapy is not recommended — it medicates unnecessarily and makes response impossible to attribute.

Step 3 — refractoryRefer; do not start a neuromodulator in primary care. Refractory or unexplained cough hypersensitivity → respiratory or cough clinic, with cough-control therapy delivered by appropriately trained speech and language therapy. Gabapentin and pregabalin are off-label for cough, carry sedation, dizziness, cognitive effects, falls, misuse and withdrawal risks, and are specialist-led decisions after treatable causes have been addressed. Specialist cough clinics may also consider low-dose slow-release morphine or P2X3 antagonists where available (BTS 2023).

Step 4 — refractorySpecialist options only. P2X3 receptor antagonists are not a routine NHS primary-care option — check current national and local guidance rather than quoting a licensing or appraisal status. Persisting, disabling cough belongs in a cough clinic with objective reassessment, not in further empirical primary-care trials.

Productive coughCOPD: the NG115 pathway, chosen on symptom burden, exacerbations and asthma features. Bronchiectasis: physiotherapy and airway clearance (ACBT, oscillating devices) twice daily, sputum culture, vaccination and an exacerbation plan. Long-term azithromycin is a specialist decision only — after confirmed bronchiectasis or another appropriate indication, optimisation of airway clearance and inhalers, sputum culture including assessment for non-tuberculous mycobacteria, ECG/QTc, liver tests, interaction review and hearing/balance assessment. Exacerbation frequency helps identify potential eligibility, but initiation requires a confirmed diagnosis, optimisation of standard treatment, exclusion of reversible factors, review of antimicrobial resistance risk and specialist review (local azithromycin guidance).

The BTS 2023 clinical statement describes a treatable-traits approach: identify and treat what the assessment supports — smoking, ACE-inhibitor exposure, rhinitis, reflux where there are reflux features, eosinophilic airway disease — rather than prescribing a fixed package. Concurrent triple therapy is attractive because it is quick, but it exposes patients to three medicines they may not need, makes attribution impossible, and drives inappropriate PPI and ICS continuation. Cough hypersensitivity is best understood as a sensitised vagal reflex, which is why neuromodulators have been studied in it — but they are off-label, with sedation, dizziness, cognitive effects, falls, misuse and withdrawal risks, so the evidence-based primary-care action is referral plus cough-control therapy, with neuromodulators reserved for a specialist discussion of benefits and harms. Long-term macrolides have real benefit in selected bronchiectasis but require mycobacterial assessment, QTc, liver monitoring and interaction review — hence specialist-only.

Treat

Cough-Control Therapy — Specialist Speech and Language Therapy

Done

Consider specialist cough-control therapy, commonly delivered by speech and language therapy, for refractory cough hypersensitivity once treatable traits have been addressed. It is a useful specialist option with a favourable side-effect profile; the components below describe what such a programme involves, not a proprietary protocol.

What the programme involves

Therapist-led cough-control therapy typically has four components: (1) education about cough-reflex sensitisation, (2) cough-suppression manoeuvres (a firm swallow at the urge to cough, nasal breathing), (3) breathing control (nasal rather than mouth breathing), (4) psychoeducation and relaxation. Delivered by a therapist trained in cough control rather than as a self-taught technique.

Breathing retraining

Diaphragmatic breathing, nasal breathing retraining. Hyperventilation (mouth breathing) dries laryngeal mucosa, sensitises cough receptors. 4–7–8 breathing during cough urge suppression.

Laryngeal comfort measures

Humming and frequent small sips of water. Menthol sweets for short-term relief. Steam inhalation is not recommended — scald risk with limited evidence. There is no need to prohibit caffeine.

Cough suppression manoeuvres

Hard swallow (most effective) — actively suppresses urge to cough by inhibiting cough reflex. Sniff–swallow–sip sequence. Stifle cough behind closed lips. These techniques retrain the sensitised reflex arc.

Referral route

GP referral to community SALT or to a specialist cough clinic with cough-control expertise. Session number per local service (often 4–6). Randomised evidence supports speech-pathology-based cough-control intervention in refractory chronic cough.

Next steps: see Asthma · COPD · Bronchiectasis · Allergic rhinitis · GORD and acid reflux · Smoking cessation

Randomised evidence supports speech-pathology-based cough-control intervention in chronic refractory cough, with the attraction that it carries none of the sedation, dizziness, cognitive or misuse risks of neuromodulators. The mechanism is top-down modulation of the cough reflex — the programme teaches patients to manage the urge-to-cough sensation (mediated by cortical and limbic circuits) rather than only suppressing the mechanical cough. Coughing itself further irritates laryngeal mucosa and worsens hypersensitivity, so breaking the cough–irritation–cough cycle is the therapeutic goal. The intervention is underused in primary care and is worth considering alongside, rather than after, the treatable-trait work — but it belongs to trained therapists, and should not be presented as a branded standalone protocol or as equivalent to any drug.

Lifestyle

Trigger Avoidance, Reflux & Vocal Hygiene

Done

Smoking cessation The single most impactful intervention — smoking causes direct airway irritation and COPD, and is the dominant cause of lung cancer. Cough from chronic bronchitis often improves within weeks of stopping. NHS Stop Smoking referral at every consultation.

Reflux measures — where reflux features are present Raise head of bed 15–20 cm, avoid eating 3 hours before bed, reduce alcohol, fatty foods and other identified triggers, small frequent meals, avoid tight waistbands. Offer these alongside — not instead of — deciding whether reflux is actually driving the cough.

Allergen measures — targeted, not universal Where a specific allergy is identified: reduce that exposure (for example keeping pets out of the bedroom). Do not recommend air purifiers, mattress protectors or humidifiers routinely — consider targeted allergen avoidance only where a relevant sensitisation or exposure is established. Nasal saline irrigation is the useful adjunct in allergic rhinitis.

Vocal hygiene Avoid throat clearing — it damages laryngeal mucosa; substitute a firm swallow. Keep reasonably hydrated, individualised to age, heart failure, CKD or any fluid restriction rather than a fixed litre target. No need to avoid caffeine.

Weight management Obesity is a risk factor for reflux, sleep apnoea and asthma severity, so weight loss may help a cough driven by those — offer it as a possible benefit, not a guaranteed cough treatment. Refer per local weight-management eligibility.

Occupational triggers If cough improves on holiday → workplace trigger. Discuss occupational-health referral and workplace risk assessment — controlling the exposure matters more than PPE alone. Respiratory surveillance for occupational asthma workers. Consider redeployment if uncontrollable exposure.

Cold air protection CVA/CHS patients: a scarf or face covering in cold air may reduce triggered cough in some (limited evidence). Nasal breathing (not mouth) warms and humidifies air before reaching larynx.

Nasal saline irrigation Where rhinitis or upper-airway cough syndrome is the trait being treated: twice-daily saline irrigation reduces nasal mucosal oedema and clears post-nasal secretions, with modest but consistent benefit for chronic sinonasal symptoms (Cochrane). Kits are available over the counter.

Nasal saline irrigation is underused but evidence-based for upper-airway cough syndrome — a Cochrane review confirmed modest but consistent benefit for chronic sinonasal symptoms. Throat clearing is a self-perpetuating habit that worsens cough by repeatedly traumatising vocal fold mucosa: every throat clear adducts the folds, irritating the epithelium and further sensitising the cough reflex, so patients must be explicitly taught to substitute a firm swallow. Cold air-triggered cough is mediated by sensory receptors on the laryngeal mucosa — warming inhaled air by nasal breathing or a scarf may reduce this trigger in some patients (limited evidence). The general environmental measures often recommended for cough — air purifiers, mattress covers, humidifiers, fixed fluid targets, avoiding caffeine, steam inhalation — are either unsupported or carry their own risks, and are better replaced by targeted action on an identified trigger.

Safety

Review Strategy, Escalation & Safety-Netting

Done

At the end of each trial

There is no universal 8-week review point — match the review to the intervention: ACE-inhibitor cessation reviewed over several weeks (occasionally longer); intranasal steroid for rhinitis typically several weeks; a targeted ICS trial, not automatic treatment; reflux treatment only where reflux features support it. Reassess earlier if symptoms persist or worsen. At each review document: the suspected trait, drug, dose and duration, adherence, inhaler or spray technique, response, adverse effects, and the next diagnostic or referral action.

If a trial has not worked

Reassess the diagnosis rather than adding another medicine. Check the CXR has been done, and repeat it if not recent or if the picture has changed. Stop a treatment that has not helped. Refer to respiratory — earlier than 3–6 months where there is an abnormal CXR, suspected bronchiectasis, ILD, TB or chronic infection, persistent haemoptysis, breathlessness or desaturation, recurrent focal pneumonia, immunosuppression, or an unclear diagnosis despite initial testing. Review smoking-cessation progress.

Refractory cough

Cough persisting despite appropriate targeted treatment → specialist cough clinic, with cough-control therapy through speech and language therapy. Neuromodulator treatment is a specialist decision, not a GP escalation step. Reassess for new red flags at each contact. Do not continue repeated empirical trials indefinitely without a documented diagnosis, objective testing or specialist review.

Repeat CXR

If cough pattern changes (becomes productive, haemoptysis, associated weight loss, new respiratory symptoms) → repeat CXR regardless of when last performed. Low threshold in smokers.

Psychosocial impact

Chronic cough significantly impairs quality of life — consider the psychosocial impact (PHQ-9/GAD-7 optional). Sleep disruption, social embarrassment, urinary incontinence (women), rib fractures (severe cases). Address holistically; CBT can help in CHS.

999 safety-net

Brisk or airway-threatening haemoptysis · respiratory failure — severe hypoxia or a fall below the patient's individualised target, exhaustion, cyanosis or drowsiness · stridor · any acute severe or life-threatening asthma features (cough alone is not a marker of severity) · anaphylaxis

Same-day GP

New haemoptysis · a significant change in the character of the cough · new weight loss · new systemic features such as fever or night sweats · new breathlessness. A cough that has not yet settled after stopping an ACE inhibitor is a routine review, not an urgent one, unless new concerning features appear.

The commonest reasons a targeted trial appears to fail are technique and adherence, not resistance: a nasal steroid aimed at the septum (causing nosebleeds with no therapeutic effect — it must be aimed laterally), an inhaler used without a spacer so most of the dose lands in the oropharynx, or a trial stopped before its intended length. Confirm the treatment was actually taken correctly before escalating investigation — and stop treatments that have not helped rather than accumulating them. Cough itself causes real morbidity that is frequently unreported: sleep disruption, social embarrassment, urinary incontinence (particularly in women, where pelvic floor physiotherapy should be offered) and, in severe cases, rib stress fractures. Chronic cough measurably impairs quality of life, so mood and anxiety are worth assessing alongside the physical work-up.