Chronic non-productive cough

This guideline applies to adults aged 16 years and over.

Chronic cough in children guideline available here

Introduction

Chronic cough is defined as a cough lasting longer than 8 weeks¹.

In Scope:

Chronic dry cough (lasting longer than 8 weeks), in those with normal clinical examination, chest x-ray and spirometry

Not in scope:

Acute cough (lasting less than 8 weeks)
Patients with additional respiratory symptoms such as copious sputum production, dyspnoea, hoarseness

This list is not exhaustive

Red Flags

Haemoptysis
Weight loss
Suspicious features on chest x-ray
Hoarseness
Systemic Symptoms, E.G. fever, sweats

This list is not exhaustive

Management optimisation

Some common causes include smoking, use of angiotensin-converting enzyme inhibitors, upper airway cough syndrome (post-nasal drip), asthma, gastro-oesophageal reflux disease, or eosinophilic bronchitis¹.

In those with normal clinical examination, chest x-ray and spirometry; there is a low frequency of serious pathology in these patients².

In the absence of red flags, management of chronic dry cough may necessitate sequential trials of treatment (starting with the most likely aetiology first), after a thorough clinical assessment fails to lead to a specific diagnosis, to confirm or refute common causes¹.

Each trial should last a minimum of 2 months and consider a two week ‘washout’ between trials.

Consider stopping any ACE inhibitors or Sitagliptin¹. (Response can take up to 4 weeks, but occasionally cough can persist for several months) Prescribe alternative as appropriate
Stop smoking
Consider occupational/household/pet causes
Consider asthma
Gastro-oesophageal reflux disease (GORD)
- Consider “silent” reflux
- Trial of PPI +- alginates
- See link for further CKS management
Upper Airway Cough Syndrome (post-nasal drip)
- Avoid any known allergic or environmental triggers if possible
- Consider a trial of antihistamine and a decongestant¹, alongside saline irrigation. See CKS cough management
- Symptoms should improve within 1-2 weeks of starting treatment, but resolution may take several weeks, or months¹
- For further information see Rhinosinusitisand Allergic Rhinitis.
Post-infectious cough

Investigations prior to referral

Consider the following investigations as appropriate:
- Spirometry, or peak flow diary if Spirometry not available
- Chest X-ray (within last six months)
- FBC

Advice and Guidance

Advice and Guidance requests can be submitted to respiratory through the e-RS.

Referral Criteria

Routine Referral

Patients who have completed a trial of treatment in Primary Care and the cough significantly impacts their daily lives and they would like a referral to secondary care, consider a referral to Respiratory via e-RS.

Treatment options for people with chronic refractory cough may include a speech and language referral¹. If referrer confident there is no respiratory cause, and examination and investigations are normal, a direct referral to speech and language could be considered.

Referral Instructions

Red Flag Features:

Consider Fast Track Suspected Cancer Pathway referral as appropriate

Routine Referral:

Information required with referral:

Details of prior relevant investigations
Details of prior therapeutic trials, including length of use of medications. Referrals will be returned if therapeutic trials are not complete, or if tried for less than 2 months, unless other concerns are detailed.

Supporting Information

Patients

Professionals

References

Cough | Health topics A to Z | CKS | NICE
Pavord ID, Chung KF; Management of chronic cough. Lancet. 2008 Apr 19;371(9621):1375-84.
British Thoracic Society Clinical Statement on chronic cough in adults | Thorax
Managing chronic cough in adults in primary care | British Journal of General Practice

Page Review Information

Review date: 01 July 2025

Next review date: 01 July 2027

Speciality Lead GP: Dr Kate Northridge

Contributors: Dr Ben Soar, Consultant Respiratory Physician, Royal Cornwall Hospital Trust