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Diagnosis and Management of Dry Cough: Focus on

Upper Airway Cough Syndrome and Postinfectious Cough
N Huliraj

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

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

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

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

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

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
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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of a sensation of secretions from the nose or paranasal


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sinuses into the pharynx, leading to throat clearing,




coughing or both.3
Postnasal drip syndrome is considered as one of the Figure 1. Postnasal drip syndrome as the cause of chronic
cough in various epidemiological studies.10
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 guideline committee of the American College of Chest
common cold (acute cough).11 Postnasal drip syndrome Physicians (ACCP) because it is not clear whether the
has been renamed upper airway cough syndrome by 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 Pertussis, also called whooping cough, is a severe and
in the upper airway.11 debilitating disease that can last for weeks to months
Upper airway cough syndrome may result from a and can occur in both children and adults. The cough in
number of distinct etiologies, but it commonly arises adult patients with B. pertussis infection is spasmodic in
from rhinitis or rhinosinusitis.11 nature and occurs more frequently at night. Although
cough generally lasts for 4-6 weeks, it can persist longer
Diagnosis in some patients.13
As postnasal drip is not a disease, but a symptom, the Although, the exact pathophysiology of postinfectious
diagnostic approach should take into consideration a cough is not known, it is believed to occur as a result of
combination of criteria, including symptoms, physical airway inflammation with or without transient airway
examination findings (including deviated nasal septum, hyperresponsiveness.13
turbinate hypertrophy, polyps, sinusitis), radiographic
findings and response to specific therapy.11 Diagnosis
Common symptoms suggestive of upper airway Although, the clinical diagnosis of postinfectious cough
cough syndrome include throat clearing, sensation is by exclusion, a careful history, physical examination,
of postnasal drip, nasal congestion or discharge, as well as serology and sputum culture (if positive) can
cobblestone appearance of the oropharyngeal provide important clues to the diagnosis.13-15
mucosa and previous history of upper respiratory When a patient complains only of cough after a
illness (e.g., cold).11 respiratory tract infection for at least 3 weeks, but
Other symptoms that may help in diagnosing not more than 8 weeks and has a normal chest
upper airway cough syndrome include cough radiograph, a diagnosis of postinfectious cough
triggered by deep breath, laughing or prolonged should be considered.
talking; nasal quality of voice due to concomitant In case of suspected M. pneumoniae infection, a high
nasal blockade, congestion and hoarseness of voice. cold agglutinin titer or acute and convalescent-
An empiric trial of antihistamine/decongestant specific serologic studies could help confirm the
therapy with a first-generation antihistamine diagnosis.
should be administered. Improvement or resolution When a patient has a cough lasting for >2
of cough with this therapy helps in confirming the weeks without any other apparent cause and is
diagnosis of upper airway cough syndrome.11 associated with, post-tussive vomiting and/or
Topical administration of corticosteroid spray with an inspiratory whooping sound, the diagnosis
concomitant use of antibiotics is also recommended. of B. pertussis infection should be made.
Antibiotics should be initiated in case of sinusitis The confirmatory diagnosis of B. pertussis infection
or mucopurulent sinusitis. can be made by detection of the organism from
Plain sinus radiography and computed tomography nasopharynx secretions.
imaging are used for the evaluation of postnasal
drip if it is the suspected cause for chronic cough.12 Management of Dry Cough
Recent guidelines published by the ACCP recommend
Postinfectious Cough: Diagnostic
the use of a first-generation antihistamine in
combination with a decongestant for the treatment of
Postinfectious cough is suspected when a patient with chronic cough due to upper airway cough syndrome.11
a normal chest radiograph complains of persistent Nonpharmacological approach such as nasal breathing
cough (>3 weeks) after an upper respiratory tract exercises may also be useful in patients with upper airway
infection. It occurs in about 11-25% of patients with cough syndrome. In patients with postinfectious cough,
persistent cough. Increased frequency of postinfectious ACCP recommends that if cough persists despite use of
cough (between 25% and 50%) has been observed inhaled ipratropium, then use of inhaled corticosteroids
during outbreaks of Mycoplasma pneumoniae and can be considered. Use of macrolides is recommended
Bordetella pertussis infections. Common pathogens that in patients with B. pertussis or M. pneumoniae infection.
cause chronic cough in children include respiratory ACCP also recommends use of antitussive agents such
viruses (particularly respiratory syncytial virus and as codeine and dextromethorphan in the management of
parainfluenza), M. pneumoniae, Chlamydia pneumoniae postinfectious cough when the cough adversely affects
(strain TWAR), and B. pertussis.13 the patients quality-of-life despite all other measures.15

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014 881

Antitussive agents including codeine, pholcodine 4. Kelsall A, Decalmer S, McGuinness K, Woodcock A, Smith
and dextromethorphan are widely used alone or JA. Sex differences and predictors of objective cough
in combination with antihistamines, decongestants frequency in chronic cough. Thorax 2009;64(5):393-8.
and expectorants for effective symptomatic relief of 5. OConnell F. Management of persistent dry cough. Thorax
dry cough. Codeine, in addition to antitussive effect, 1998;53(9):723-4.
possesses analgesic and minor sedative effects, which 6. Vaishnav KV. Diagnostic approach to cough. Supplement
can be especially beneficial in relieving painful cough.16 to JAPI 2013;61:8.
7. Singh S, Singh V. Combating coughetiopathogenesis.
Supplement to JAPI 2013;61:6-7.
Cough, a common symptom for which patients visit 8. Irwin RS. Complications of cough: ACCP evidence-based
primary care physicians, is normally a self-limiting clinical practice guidelines. Chest 2006;129(1 Suppl):
illness. However, it can become a persistent symptom 54S-58S.
in several cases. Persistent cough is associated with 9. DUrzo A, Jugovic P. Chronic cough. Three most common
several physical and psychological complications. causes. Can Fam Physician 2002;48:1311-6.
Upper airway cough syndrome, postinfectious cough,
10. Lai K, Pan J, Chen R, Liu B, Luo W, Zhong N. Epidemiology
asthma and acute bronchitis are the most common
of cough in relation to China. Cough 2013;9(1):18.
respiratory causes of chronic cough. Diagnosis of
upper airway cough syndrome requires consideration 11. Pratter MR. Chronic upper airway cough syndrome
secondary to rhinosinus diseases (previously referred
of a combination of criteria, including symptoms,
to as postnasal drip syndrome): ACCP evidence-based
physical examination findings, radiographic findings
clinical practice guidelines. Chest 2006;129(1 Suppl):
and response to specific therapy. The clinical diagnosis
of postinfectious cough is usually made by exclusion.
A first-generation antihistaminic agent in combination 12. Morice AH, Fontana GA, Sovijarvi AR, Pistolesi M,
with a decongestant is recommended for the treatment Chung KF, Widdicombe J, et al; ERS Task Force. The
diagnosis and management of chronic cough. Eur Respir J
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 13. Irwin RS, Boulet LP, Cloutier MM, Fuller R, Gold PM,
dextromethorphan should be considered. Hoffstein V, et al. Managing cough as a defense mechanism
and as a symptom. A consensus panel report of the
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882 Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

patients every minute1 get

confident cough relief

In Persistent Dry Cough

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:
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
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,
D-Mart Bldg Goregaon Mulund Link Road Mulund (W) Mumbai 400080. A Promise for Life