An algorithmic approach to chronic cough

Ann Intern Med. 1993 Nov 15;119(10):977-83. doi: 10.7326/0003-4819-119-10-199311150-00003.


Objectives: To evaluate a stepwise approach to chronic cough that emphasized initial treatment of all patients with an antihistamine-decongestant for postnasal drip and to determine the value of routine bronchoprovocation challenge in the evaluation of chronic cough.

Design: Prospective trial using an algorithm for chronic cough in immunocompetent nonsmoking out-patients.

Setting: University-based pulmonary practice.

Patients: Forty-five patients met the inclusion criteria. The mean duration of cough was 140 weeks (range, 3 to 2080 weeks), and the mean severity of cough as assessed by patients on a four-point scale was "severe."

Results: Marked improvement and resolution (mean, 3.1 and 7.1 weeks, respectively), with resolution in 96% of patients. Antihistamine-decongestant therapy was beneficial in 39 of 45 patients and was the only therapy needed for 16 patients. Bronchoprovocation challenge had a negative predictive value of 100% and a positive predictive value of 74% for cough caused by asthma. No significant relationship was found between the time to cough resolution and duration or severity of cough. Eighteen percent of patients experienced a recurrence of cough at a follow-up interval of 3 months.

Conclusions: A sequential approach to chronic cough that emphasizes initial treatment with an antihistamine-decongestant is effective. Bronchoprovocation challenge is useful in evaluating patients with chronic cough but can be delayed until the initial response to antihistamine-decongestant therapy has been assessed. The 18% incidence of recurrence highlights the fact that cough often is the manifestation of a chronic or recurring process that requires chronic or episodic therapy.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Algorithms*
  • Asthma / complications
  • Asthma / diagnosis
  • Bronchial Provocation Tests
  • Chi-Square Distribution
  • Chronic Disease
  • Cough / etiology*
  • Cough / prevention & control
  • Cyproheptadine / analogs & derivatives
  • Cyproheptadine / therapeutic use
  • Drug Combinations
  • Ephedrine / therapeutic use
  • Evaluation Studies as Topic
  • Female
  • Follow-Up Studies
  • Gastroesophageal Reflux / complications
  • Humans
  • Male
  • Middle Aged
  • Prospective Studies
  • Recurrence
  • Regression Analysis
  • Rhinitis / complications
  • Sinusitis / complications
  • Syndrome


  • Drug Combinations
  • Cyproheptadine
  • azatadine
  • Ephedrine