RESPIRATORY INFECTIONs

Diagnosis and Management of Dry Cough: Focus on

Upper Airway Cough Syndrome and Postinfectious Cough
N Huliraj

Abstract
Cough is an important complaint of respiratory disease and normal defense mechanism of the lungs. It helps in clearing excessive
secretions, fluids, infections or foreign material from the airway. In most of the cases, cough occurs as part of a brief, self-limiting
illness. However, it can become a persistent symptom in several cases. The etiology of cough is very diverse and commonly
includes environmental causes (cigarette smoke, pollutants, dust mites, etc.) and several disease entities, including both respiratory
and nonrespiratory causes. Postnasal drip syndrome and postinfectious cough are the most common respiratory causes of chronic
cough. The objective of this article is to highlight the importance and consequences of cough and discuss the effective diagnosis and
management of upper airway cough syndrome and postinfectious cough. For this article, PUBMED was searched for studies
and guidelines published in the English language using the medical subject heading terms cough, causes of cough, etiology of
cough, postinfectious cough, post-viral cough, upper airway cough syndrome, and postnasal drip.
Keywords: Cough, causes of cough, etiology of cough, postinfectious cough, post-viral cough, upper airway cough
syndrome, postnasal drip

C
ough is the most common complaint of patients
who present to primary care physicians.1 It has
been recently identified as the sixth common
reason for hospital outpatient department visits.2
In most of the cases, cough occurs as part of a brief,
self-limiting illness. However, it can become a persistent
symptom in several cases.1
A cough can be arbitrarily classified as acute (that
lasts for <3 weeks), subacute (that lasts between 3 and
8 weeks) and chronic (that lasts for >8 weeks). The
estimated prevalence of chronic cough is between 11%
and 20%.3 In a survey of members of the American
Academy of Allergy, Asthma and Immunology in
2008, it was observed that chronic cough was the chief
complaint in about 20-40% of new patients.3 Chronic
cough occurs more often in females than males. It has
been observed that women have a heightened cough
reflex sensitivity compared to men.4 In most of the
cases, chronic cough is dry or minimally productive in
nature.5
The etiology of cough is diverse and commonly
includes environmental causes (cigarette smoke,
pollutants, etc.) and several respiratory and non-
respiratory disease entities.6 The objective of this article
is to highlight the importance and consequences of
cough and the effective diagnosis and management
of postnasal drip syndrome/upper airway cough
syndrome and postinfectious cough. In preparing this
article, PUBMED was searched for studies/guidelines
published in the English language using the medical
subject heading terms cough, causes of cough, etiology
of cough, postinfectious cough, post-viral cough, upper
airway cough syndrome and postnasal drip.
Importance of the Cough Reflex and
Complications of Chronic Cough
Cough is an important defense mechanism of the
lungs. It helps in clearing excessive secretions, fluids,
noxious substance or foreign material from the airway.
Both excess as well as a shortfall of cough can have
harmful effects on the body. While absence of cough
can cause frequent aspirations leading to infection and
pneumonia, an excessive cough is associated with a
variety of physical and psychological complications
(Table 1)7,8 This ultimately reduces the health-related
quality-of-life of patients.8
Spectrum and Frequency of Etiologies

Chronic cough can be the key symptom of many

respiratory and nonrespiratory conditions. Postnasal
Professor and HOD of TB and Chest Medicine
KIMS Hospital, Bangalore drip syndrome, postinfectious cough and asthma are
E-mail: nhuliraj@gmail.com the most common respiratory causes of chronic cough,

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014 879
RESPIRATORY INFECTIONs

Table 1. Potential Complications from Excessive Cough7,8

Central nervous system Cough syncope, headache, cerebral air embolism, cerebrospinal fluid rhinorrhea, acute cervical
radiculopathy, malfunctioning ventriculoatrial shunts, seizures , stroke due to vertebral artery dissection
Respiratory system Pulmonary interstitial emphysema, laryngeal trauma, tracheobronchial trauma, exacerbation of asthma,
intercostal lung herniation, pneumothorax, pneumomediastinum, subcutaneous emphysema

Cardiovascular system Arterial hypotension, loss of consciousness, rupture of subconjunctival, nasal and anal veins,
dislodgement/malfunctioning of intravascular catheters, bradyarrhythmias, tachyarrhythmias

GI system Gastroesophageal reflux events, hydrothorax in peritoneal dialysis, malfunction of gastrostomy button,
splenic rupture, inguinal hernia, esophageal perforation

Genitourinary system Urinary incontinence, inversion of bladder through urethra

Musculoskeletal system Rupture of rectus abdominis muscles, rib fractures, intercostal muscle rupture, cervical disc prolapse
Miscellaneous Disruption of surgical wounds, constitutional symptoms, self-consciousness, hoarseness, dizziness, fear
of serious disease, decrease in the quality-of-life, social embarrassment, depression, petechiae

Table 2. Causes of Chronic Cough9

Respiratory conditions
Common causes Postnasal drip syndrome (upper airway cough syndrome), postinfectious cough,
asthma, acute bronchitis
Other causes Allergic or vasomotor rhinitis, abscess, sinusitis, allergic inflammation, aspiration,
bronchiectasis, bronchitis, chronic obstructive pulmonary disease, cystic fibrosis,
eosinophilic bronchitis, interstitial lung disease, pertussis, primary or metastatic
lung tumors, sarcoidosis, tuberculosis
Nonrespiratory conditions
Common causes Gastroesophageal reflux disease, recurrent aspiration
Other causes Left ventricular failure, mitral stenosis, psychological response, pulmonary
infarction

while gastroesophageal reflux disease is a common non- 80 73

respiratory cause. The respiratory and nonrespiratory 70
Number of patients (%)

etiologies of chronic cough are summarized in Table 2.9 60

50
41 38
Postnasal Drip Syndrome/Upper Airway 40 33
29 26 26.7
Cough Syndrome: Diagnostic Approaches 30 24 22 24.4
18 17 18.6
20
12
In general, adults produce about 20-30 mL of nasal 10 6
mucus every day, which is either expectorated or 0
swallowed with saliva. Very often, patients complain
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coughing or both.3
Postnasal drip syndrome is considered as one of the
most common causes of chronic cough with reported
incidence between 6% and 73% of a studied population
(see Fig 1).10 It is also commonly associated with the
common cold (acute cough).11 Postnasal drip syndrome
has been renamed upper airway cough syndrome by the
Figure 1. Postnasal drip syndrome as the cause of chronic
cough in various epidemiological studies.10
guideline committee of the American College of Chest
Physicians (ACCP) because it is not clear whether the
cough is caused by irritation from direct contact with

880 Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

postnasal drip or by inflammation of cough receptors
in the upper airway.11
Upper airway cough syndrome may result from a
number of distinct etiologies, but it commonly arises
from rhinitis or rhinosinusitis.11
Diagnosis
As postnasal drip is not a disease, but a symptom, the
diagnostic approach should take into consideration a
combination of criteria, including symptoms, physical
examination findings (including deviated nasal septum,
turbinate hypertrophy, polyps, sinusitis), radiographic
findings and response to specific therapy.11
Common symptoms suggestive of upper airway
cough syndrome include throat clearing, sensation
of postnasal drip, nasal congestion or discharge,
cobblestone appearance of the oropharyngeal
mucosa and previous history of upper respiratory
illness (e.g., cold).11
Other symptoms that may help in diagnosing
upper airway cough syndrome include cough
triggered by deep breath, laughing or prolonged
talking; nasal quality of voice due to concomitant
nasal blockade, congestion and hoarseness of voice.
An empiric trial of antihistamine/decongestant
therapy with a first-generation antihistamine
should be administered. Improvement or resolution
of cough with this therapy helps in confirming the
diagnosis of upper airway cough syndrome.11
Topical administration of corticosteroid spray with
concomitant use of antibiotics is also recommended.
Antibiotics should be initiated in case of sinusitis
or mucopurulent sinusitis.
Plain sinus radiography and computed tomography
imaging are used for the evaluation of postnasal
drip if it is the suspected cause for chronic cough.12
Postinfectious Cough: Diagnostic
Approaches
Postinfectious cough is suspected when a patient with
a normal chest radiograph complains of persistent
cough (>3 weeks) after an upper respiratory tract
infection. It occurs in about 11-25% of patients with
persistent cough. Increased frequency of postinfectious
cough (between 25% and 50%) has been observed
during outbreaks of Mycoplasma pneumoniae and
Bordetella pertussis infections. Common pathogens that
cause chronic cough in children include respiratory
viruses (particularly respiratory syncytial virus and
parainfluenza), M. pneumoniae, Chlamydia pneumoniae
(strain TWAR), and B. pertussis.13
RESPIRATORY INFECTIONs
Pertussis, also called whooping cough, is a severe and
debilitating disease that can last for weeks to months
and can occur in both children and adults. The cough in
adult patients with B. pertussis infection is spasmodic in
nature and occurs more frequently at night. Although
cough generally lasts for 4-6 weeks, it can persist longer
in some patients.13
Although, the exact pathophysiology of postinfectious
cough is not known, it is believed to occur as a result of
airway inflammation with or without transient airway
hyperresponsiveness.13
Diagnosis
Although, the clinical diagnosis of postinfectious cough
is by exclusion, a careful history, physical examination,
as well as serology and sputum culture (if positive) can
provide important clues to the diagnosis.13-15
When a patient complains only of cough after a
respiratory tract infection for at least 3 weeks, but
not more than 8 weeks and has a normal chest
radiograph, a diagnosis of postinfectious cough
should be considered.
In case of suspected M. pneumoniae infection, a high
cold agglutinin titer or acute and convalescent-
specific serologic studies could help confirm the
diagnosis.
When a patient has a cough lasting for >2
weeks without any other apparent cause and is
associated with, post-tussive vomiting and/or
an inspiratory whooping sound, the diagnosis
of B. pertussis infection should be made.
The confirmatory diagnosis of B. pertussis infection
can be made by detection of the organism from
nasopharynx secretions.
Management of Dry Cough
Recent guidelines published by the ACCP recommend
the use of a first-generation antihistamine in
combination with a decongestant for the treatment of
chronic cough due to upper airway cough syndrome.11
Nonpharmacological approach such as nasal breathing
exercises may also be useful in patients with upper airway
cough syndrome. In patients with postinfectious cough,
ACCP recommends that if cough persists despite use of
inhaled ipratropium, then use of inhaled corticosteroids
can be considered. Use of macrolides is recommended
in patients with B. pertussis or M. pneumoniae infection.
ACCP also recommends use of antitussive agents such
as codeine and dextromethorphan in the management of
postinfectious cough when the cough adversely affects
the patients quality-of-life despite all other measures.15
Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014 881
RESPIRATORY INFECTIONs
Antitussive agents including codeine, pholcodine
and dextromethorphan are widely used alone or
in combination with antihistamines, decongestants
and expectorants for effective symptomatic relief of
dry cough. Codeine, in addition to antitussive effect,
possesses analgesic and minor sedative effects, which
can be especially beneficial in relieving painful cough.16
Conclusion
Cough, a common symptom for which patients visit
primary care physicians, is normally a self-limiting
illness. However, it can become a persistent symptom
in several cases. Persistent cough is associated with
several physical and psychological complications.
Upper airway cough syndrome, postinfectious cough,
asthma and acute bronchitis are the most common
respiratory causes of chronic cough. Diagnosis of
upper airway cough syndrome requires consideration
of a combination of criteria, including symptoms,
physical examination findings, radiographic findings
and response to specific therapy. The clinical diagnosis
of postinfectious cough is usually made by exclusion.
A first-generation antihistaminic agent in combination
with a decongestant is recommended for the treatment
of chronic cough due to upper airway cough syndrome.
When cough adversely affects a patients quality-of-life,
centrally-acting antitussive agents such as codeine and
dextromethorphan should be considered.
References
1. Simpson CB, Amin MR. Chronic cough: state-of-the-art
review. Otolaryngol Head Neck Surg 2006;134(4):693-700.
2. National Hospital Ambulatory Medical Care Survey:
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a t : h t t p : / / w w w. c d c . g o v / n c h s / d a t a / a h c d / n h a m c s
outpatient/2010_opd_web_tables.pdf. Accessed on
Jan. 8, 2014.
3. Goldsobel AB, Kelkar PS. The adults with chronic cough.
J Allergy Clin Immunol 2012;130:825e1-825e6.
882 Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014
4. Kelsall A, Decalmer S, McGuinness K, Woodcock A, Smith
JA. Sex differences and predictors of objective cough
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5. OConnell F. Management of persistent dry cough. Thorax
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6. Vaishnav KV. Diagnostic approach to cough. Supplement
to JAPI 2013;61:8.
7. Singh S, Singh V. Combating coughetiopathogenesis.
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8. Irwin RS. Complications of cough: ACCP evidence-based
clinical practice guidelines. Chest 2006;129(1 Suppl):
54S-58S.
9. DUrzo A, Jugovic P. Chronic cough. Three most common
causes. Can Fam Physician 2002;48:1311-6.
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of cough in relation to China. Cough 2013;9(1):18.
11. Pratter MR. Chronic upper airway cough syndrome
secondary to rhinosinus diseases (previously referred
to as postnasal drip syndrome): ACCP evidence-based
clinical practice guidelines. Chest 2006;129(1 Suppl):
63S-71S.
12. Morice AH, Fontana GA, Sovijarvi AR, Pistolesi M,
Chung KF, Widdicombe J, et al; ERS Task Force. The
diagnosis and management of chronic cough. Eur Respir J
2004;24(3):481-92.
13. Irwin RS, Boulet LP, Cloutier MM, Fuller R, Gold PM,
Hoffstein V, et al. Managing cough as a defense mechanism
and as a symptom. A consensus panel report of the
American College of Chest Physicians. Chest 1998;114(2
Suppl Managing):133S-181S.
14. Malowany J, Popat N, Kirchhof M. Chronic cough is
a common symptom in children What is the cause?
UWOMJ 2006;74(2):7-10.
15. Braman SS. Postinfectious cough: ACCP evidence-based
clinical practice guidelines. Chest 2006;129(1 Suppl):
138S-146S.
16. Padma L. Current drugs for the treatment of dry cough.
Supplement to JAPI 2013;61:9-13.
 Healthcare

patients every minute1 get

confident cough relief

In Persistent Dry Cough

PHEISEIYl
Codeine Phosphate IP 10 mg and Chlorpheniramine Maleate IP 4 mg per 5 ml

Abridged Prescribing Information

Phensedyl cough linctus
Composition: Each 5 ml contains: Codeine phosphate IP 10mg, Chlorpheniramine maleate IP 4mg. Indications: For the symptomatic mllof ol 111prodldlve cough. Dosage:
Adults&chlldrenabove10years:5-10ml,twotothreeUmesaday.Chlldran:6-10years:2.5-5ml,twotothreetbnesaday.Tllerecommend<ddoaeBsllolJdnotbeBICOOdad.
Contra-indications: Known hypersensitivity to any of the components of the formulation, pregnancy ~irsttrimester), cough......,_ with asthma and MAO lnh-then!py
within the pravlous 14 days. PrecauUons &Warnings: Keep out of raach of chlklren. To be used during pragnency only ~tha potential -outweigh the poten1lal r1olal. Not
n
recommended in nursing mothers. is not advisable to take the drug except under medical supervision. Undesirable effecls: Generallywelltolora1Bd. l.lldesiable e1foc1& seen
ara sedation, nausea, vommng, diarrhoea, urinary retention, dryness of mouth and CNS depreeslon, partlcularty resplre1ory ~- lnteractlona: Coocom1ant
administration of chlorpheniramine can lead to phenytoin toxicity. Concurrentadminisbation with hypnotics, anxiolytk:s. psychotropics and alcohol may causa polBntlation of
drowsiness. Presentations: BoUle of 50 ml and 100 ml. Revised version: 2/05, 23.9.05 1/03
Please read the lull prescribing information before usage. Additional information available on request with the Medical Services Division, Abbott Heath Gare Pvt Limited,
Abbott
D-Mart Bldg Goregaon Mulund Link Road Mulund (W) Mumbai 400080. A Promise for Life