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Respiratory

Cough

Last revised in April 2025

Cough is a reflex response to airway irritation. It is triggered by stimulation of airway cough receptors

Cough: Summary

  • Cough is a reflex response to airway irritation. It is triggered by stimulation of airway cough receptors by irritants or conditions causing airway distortion. 
  • Cough can be acute (lasting less than 3 weeks), sub-acute (lasting 3–8 weeks), or chronic (lasting more than 8 weeks).
  • Acute cough is most commonly caused by a viral upper respiratory tract infection. Other causes include: 
    • Acute bronchitis.
    • Pneumonia.
    • Acute exacerbations of asthma, chronic obstructive pulmonary disease, or bronchiectasis.
    • Pneumothorax.
    • Pulmonary embolism.
  • Sub-acute cough is most commonly caused by post-infectious cough (for example, after infection with Mycoplasma pneumonia or Bordetella pertussis).
  • Chronic cough is most commonly caused by smoking, use of angiotensin-converting enzyme inhibitors, upper airway cough syndrome (previously called post-nasal drip), asthma, gastro-oesophageal reflux disease, or eosinophilic bronchitis.
  • Other causes of cough include:
    • Environmental or occupational causes. 
    • Foreign body aspiration. 
    • Heart failure. 
    • Interstitial lung disease. 
    • Lung cancer. 
    • Obstructive sleep apnoea.
    • Pertussis. 
    • Pulmonary tuberculosis. 
    • Somatic cough syndrome. 
    • Thoracic aortic aneurysm. 
  • The cause may be determined by history, examination, and investigation (where appropriate):
    • This should include pulse oximetry (if the person is acutely unwell), peak expiratory flow rate (if asthma is known or suspected), pertussis serology (if whooping cough is suspected), C-reactive protein test (if pneumonia is suspected), and spirometry and chest X-ray (if there is chronic cough of uncertain cause). 
  • Emergency admission should be arranged for people with:
    • Suspected pulmonary embolism or pneumothorax.
    • Clinical features of foreign body aspiration. 
  • Emergency admission should also be arranged for people with signs or symptoms of serious illness:
    • A respiratory rate of more than 30 breaths per minute.
    • Tachycardia greater than 130 beats per minute.
    • Systolic blood pressure less than 90 mmHg.
    • Oxygen saturation less than 92%, or central cyanosis (if no history of chronic hypoxia).
    • Peak expiratory flow rate less than 33% of predicted.
    • Altered level of consciousness.
    • Use of accessory muscles of respiration (particularly if becoming exhausted).
  • Management of people with cough should be based on treating the underlying cause, where it has been identified, or sequential trials of treatment to confirm or refute common causes.
  • Referral to a respiratory physician should be arranged for people with a cough which does not respond to trial of treatment, or if the diagnosis is uncertain.

Have I got the right topic?

From age 18 years onwards.

This CKS topic covers the assessment and management of adults presenting with cough as the predominant symptom.

This CKS topic does not cover the assessment of a person presenting with cough associated with significant breathlessness.

There are separate CKS topics on Asthma, Breathlessness, Bronchiectasis, Chest infections - adult, Chronic obstructive pulmonary disease, Common cold, Cough - acute with chest signs in children, Influenza - seasonal, Lung and pleural cancers - recognition and referral, Palliative cancer care - cough, Smoking cessation, Tuberculosis, and Whooping cough.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

April 2025 — reviewed. A literature search was conducted in April 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone restructuring. No major changes to the recommendations have been made.

Previous changes

August 2023 — minor update. Links to two references have been updated.

May 2021 — minor update. Links have been added within the section on management of sub-acute and chronic cough to the assessment and diagnosis sections.

April 2020 — reviewed. A literature search was conducted in April 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone restructuring. No major changes to the recommendations have been made.

April to June 2015 — reviewed. A literature search was conducted in April 2015 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring. No major changes to the recommendations have been made.

May to September 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 April 2025.

HTAs (Health Technology Assessments)

No new HTAs since 1 April 2025.

Economic appraisals

No new economic appraisals relevant to England since 1 April 2025.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 April 2025.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since the 1 April 2025.

New policies

No new national policies or guidelines since 1 April 2025.

New safety alerts

No new safety alerts since 1 April 2025.

Changes in product availability

No changes in product availability since 1 April 2025.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Assess the person with cough and make a working diagnosis when possible.
  • Admit or refer people with cough as appropriate.
  • Treat people with cough in primary care when appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Cough is a reflex response to airway irritation [Chung, 2022]. It is triggered by stimulation of airway cough receptors, either by irritants or by conditions that cause airway distortion.
  • Cough is defined as [Irwin, 2018]:
    • Acute when present for less than 3 weeks.
    • Sub-acute when present for 3–8 weeks.
    • Chronic when present for more than 8 weeks [BTS, 2023].

What causes it?

Acute cough (less than 3 weeks duration)

  • Most commonly caused by a viral upper respiratory tract infection (URTI), such as cold or flu.
  • Other causes include coronavirus 2019 (COVID-19), acute bronchitis, tracheobronchitis, pneumonia, acute exacerbations of asthma, chronic obstructive pulmonary disease, bronchiectasis, pulmonary embolism, or pneumothorax.

Sub-acute cough (3–8 weeks duration)

  • Most commonly caused by post-infectious cough (for example, after infection with Mycoplasma pneumonia or Bordetella pertussis [whooping cough]).

Chronic cough (more than 8 weeks duration)

  • A range of diseases are associated with chronic cough, however, the majority of people have a common clinical presentation — sensitivity to inhalation of environmental irritants. Cough hypersensitivity syndrome is the umbrella term used to describe the excessive stimulation of the normal cough reflex caused by thermal, chemical, or mechanical stimulation.
  • Chronic cough is most commonly caused by exposure to cigarette smoke (either actively or passively), upper airway cough syndrome, asthma, eosinophilic bronchitis, gastro-oesophageal reflux disease, or use of an angiotensin-converting enzyme (ACE) inhibitor.
  • More than one cause of chronic cough is often present.

Other causes of cough include:

  [Kardos, 2020; Morice, 2020; Zhang, 2022; BTS, 2023; Jakusova, 2023]

How common is it?

  • Cough is the most common symptom for which people seek medical attention.  
  • Prevalence of chronic cough varies, but it is estimated to be around 10% of the general population.
  • Two-thirds of people with chronic cough are female, with peak prevalence in people in their fifties and sixties. 
  • Cough in people with interstitial lung disease is common with a prevalence of 30–90%. 
  • Cough occurs in approximately 15% of people taking an angiotensin-converting enzyme (ACE) inhibitor. 
    • It is more common in women and people of Chinese ethnicity.

 [Kardos, 2020; Morice, 2021; Chung, 2022; BTS, 2023]

What are the complications?

  • Complications associated with cough include:
    • Cough syncope. 
    • Depression, anxiety, anger/frustration.
    • Difficulties in relationships. 
    • Disturbed sleep. 
    • Dysphonia. 
    • Fatigue. 
    • Reduced quality of life. 
    • Social isolation. 
    • Stress urinary incontinence — one study reported this in 50% of females with chronic cough. 

[Mathur, 2019a; Morice, 2020; BTS, 2023]

Diagnosis

How should I assess a person with cough?

  • Take a full history. In particular, ask about:
    • Onset of symptoms. 
    • Duration of cough. 
    • Frequency of cough.
    • Type of cough (dry or productive).
    • Precipitating or exacerbating factors. 
    • Diurnal variation. 
    • Associated symptoms – throat, chest, gastrointestinal. 
    • Smoking history.
    • Environmental factors. 
    • Occupational history. 
    • Family history. 
    • Recent respiratory tract infection. 
    • Recent travel history. 
  • Ask about other red flag clinical features, such as: 
    • Haemoptysis.
    • Hoarseness.
    • Peripheral oedema with weight gain.
    • Prominent dyspnoea, especially at rest or at night.
    • Smokers aged over 45 years with a new cough, change in cough, or coexisting voice disturbance, and smokers aged 55–80 years who have a 30 pack-year smoking history and currently smoke or who have quit within the past 15 years.
    • Systemic symptoms, such as fever or weight loss.
    • Trouble swallowing.
    • Vomiting. 
  • Use a validated tool to assess the severity of cough or quality of life (for example, the Leicester Cough questionnaire). 
  • Consider comorbid conditions that may cause cough, such as:
  • Review the person's medication, such as use of angiotensin-converting enzyme (ACE) inhibitors, or sitagliptin. 
  • Examine the person paying particular attention to the chest, heart, ears, pharynx, and nose. 
  • Arrange investigations in primary care if appropriate, such as pulse oximetry (if the person is acutely unwell), peak expiratory flow rate (if asthma is known or suspected), pertussis serology (if whooping cough is suspected), C-reactive protein test (if pneumonia is suspected), and spirometry and chest X-ray (for example if there is chronic cough of uncertain cause). 

Basis for recommendation

These recommendations are based on the American College of Chest Physicians (CHEST) guidelines Classification of cough as a symptom in adults and management algorithms: CHEST guideline and expert panel report [Irwin, 2018], and Adult outpatients with acute cough due to suspected pneumonia or influenza: CHEST guideline and expert panel report [Hill, 2019]; the European Respiratory Society (ERS) ERS guidelines on the diagnosis and treatment of chronic cough in adults and children [Morice, 2020]; British Thoracic Society Clinical Statement on chronic cough in adults [BTS, 2023]; the National Institute for Health and Care Excellence (NICE) guidelines Asthma: diagnosis, monitoring and chronic asthma management [NICE, 2024a], Pneumonia in adults: diagnosis and management [NICE, 2023a] and Obstructive sleep apnoea/hypopnoea/obesity hypoventilation syndrome [NICE, 2021]; the British Thoracic Society (BTS) BTS guideline for oxygen use in adults in healthcare and emergency settings [BTS, 2019]; and expert opinion in narrative reviews, Chronic cough: a practical approach to assessment and management [Mathur, 2019a], The management of chronic cough [Mathur, 2019b].

How do I diagnose the cause of cough?

  • The differential diagnosis of cough is wide-ranging and includes many diseases — the cause is determined by clinical features, medical history, elimination of alternative causes, and the response to targeted therapies where appropriate. 
  • The duration of a cough at presentation can help guide diagnosis; however:
    • All coughs are acute at onset. 
    • It is not possible to predict which cough will persist into sub-acute and chronic stages.
    • Recurrent acute coughs can be a manifestation of an undiagnosed chronic disease.
    • All chronic coughs start as sub-acute. 
  • For people with acute cough (less than 3 weeks duration):
    • Assess whether the person has clinical features of the most common cause:
      • Upper respiratory tract infection — suggested by cough with or without sputum, general malaise, and fever. Pain and discharge may be localized to the nose, ears, throat, or sinuses. It is most commonly caused by a viral infection, such as a cold or flu. 
    • Assess whether the person has clinical features of the following other possible causes, including: 
      • Coronavirus disease 2019 (COVID-19) — a potentially severe acute respiratory infection. Signs and symptoms include cough, fever, and shortness of breath. For more information, see the CKS topic on Coronavirus - COVID 19. 
      • Acute exacerbation of a pre-existing condition — for example, asthma, chronic obstructive pulmonary disease (COPD), or bronchiectasis. For more information, see the CKS topics on Asthma, Chronic obstructive pulmonary disease and Bronchiectasis.  
      • Acute bronchitis — suggested by cough with or without sputum, breathlessness, wheeze, or general malaise. Crackles, if present, should clear with coughing. For more information, see the CKS topic on Chest infections - adult.
      • Pneumonia — suggested by at least one symptom of breathlessness, sputum, wheeze, or pleuritic pain, focal chest signs such as dull percussion note, bronchial breathing, or coarse crackles, plus at least one systemic feature such as fever or myalgia. There may be signs of an associated pleural effusion. For more information, see the CKS topic on Chest infections - adult. 
      • Pneumothorax/tension pneumothorax — suggested by sudden-onset pleuritic pain, breathlessness, reduced chest wall movements, and breath sounds. Tension pneumothorax can result in tracheal deviation away from the pneumothorax, tachycardia, hypotension, and collapse. 
      • Pulmonary embolism (PE) — suggested by acute-onset breathlessness, pleuritic pain, haemoptysis, crackles, and sinus tachycardia. For more information, see the CKS topic on Pulmonary embolism.
  • For people with sub-acute cough (3–8 weeks duration): 
    • Assess whether the person has clinical features of the most common cause:
      • Post-infectious cough — for example, after infections with Mycoplasma pneumonia or Bordetella pertussis. This is suggested by persistent dry cough that started with an obvious respiratory tract infection, and the person is systemically well with a normal respiratory examination. 
  • For people with chronic cough (over 8 weeks duration):
    • Assess whether the person has clinical features of the most common cause:
      • Upper airway cough syndrome (post-nasal drip) — suggested by frequent throat clearing, an unpleasant sensation in the throat, nasal congestion, or nasal discharge and sneezing. Upper airway abnormalities are key components and seasonal and occupational triggers are risk factors in some people. On examination, there may be visible mucus and a cobblestone appearance to the posterior oropharyngeal wall and local upper airway structures.
    • Assess whether the person has clinical features of the following common causes: 
      • Angiotensin-converting enzyme (ACE) inhibitor-induced cough — suggested by bouts of coughing associated with the perception of airway irritation occurring within hours to months of the first dose. 
      • Asthma — suggested by wheeze, breathlessness, worsening symptoms at night, in the morning, or with exercise and exposure to allergens. Peak expiratory flow rate is reduced during an episode. The prevalence of asthma in people with chronic cough ranges from 24–29%. For more information, see the CKS topic on Asthma. 
      • Eosinophilic bronchitis — suggested by normal chest examination, normal spirometry, and normal response to airway provocation test (only available to a specialist). 
      • Gastro-oesophageal reflux disease — suggested by cough that is worse during or after eating, with talking, and with bending. For more information, see the CKS topic on Dyspepsia - proven GORD. 
      • Smoking-related cough — suggested by dry cough that is worse in the mornings.
  • Other possible causes of cough include:
    • Bronchiectasis — suggested by cough with daily sputum production, progressive breathlessness, haemoptysis, non-pleuritic chest pain, and coarse crackles in early inspiration in the lower lung fields. For more information, see the CKS topic on Bronchiectasis. 
    • Bronchitis — suggested by cough with or without sputum, breathlessness, wheeze, or general malaise. Crackles, if present, should clear with coughing. For more information, see the CKS topic on Chest infections - adult. 
    • Chronic obstructive pulmonary disease  — suggested by persistent progressive breathlessness usually associated with wheezing or chest tightness, hyperinflated chest, possibly with signs of right-sided heart failure such as ankle oedema and increased jugular venous pressure. For more information, see the CKS topic on Chronic obstructive pulmonary disease. 
    • Cough-variant asthma — suggested by normal chest examination, normal spirometry, and hyper-responsiveness to airway provocation test (only available to a specialist).
    • Environmental or occupational causes — cough can be an isolated symptom as a result of exposure to triggers (for example, perfume, dust, chemicals, pollutants) or manifestation of a more significant disease. Cough may be worse on weekdays and better at weekends for occupational causes.
    • Foreign body aspiration — suggested by sudden-onset cough, stridor (upper airway) or reduced chest wall movement on the affected side, bronchial breathing, and reduced or diminished breath sounds (lower airway). 
    • Heart failure — suggested by significant breathlessness, orthopnoea, and/or paroxysmal nocturnal dyspnoea. There may be peripheral oedema and raised jugular venous pressure. For more information, see the CKS topic on Heart failure - chronic.
    • Interstitial lung disease (ILD) — suggested by breathlessness and cough (often dry). Although breathlessness is typical, people often present with non-specific signs and symptoms. There may be fine-end inspiratory crackles (indicative of fibrosis), finger clubbing, cyanosis, and signs of right-sided heart failure. 
      • When the ILD is caused by sensitization to allergens, there may be a history of recurrent episodes of flu-like illness following exposure. 
      • When the ILD is associated with connective tissue disease, there may be symptoms such as joint pain. 
      • Diagnosis is confirmed by spirometry with a restrictive pattern, chest X-ray or high resolution computed tomography (HRCT).
    • Lung cancer — suggested by haemoptysis, persistent chest and/or shoulder pain, breathlessness, weight loss, hoarseness, finger clubbing, and cervical or supraclavicular lymphadenopathy. For more information, see the CKS topic on Lung and pleural cancers - recognition and referral. 
    • Obstructive sleep apnoea syndrome  — suggested by cough associated with features such as excessive daytime somnolence and obesity. For more information, see the CKS topic on Obstructive sleep apnoea syndrome.
    • Pertussis (whooping cough) — suggested by cough lasting more than 14 days with paroxysms of coughing. There may be vomiting after coughing, or an inspiratory whoop. For more information, see the CKS topic on Whooping cough. 
    • Pulmonary tuberculosis — suggested by sputum, breathlessness, haemoptysis, weight loss, fever, night sweats, anorexia, general malaise, and finger clubbing. This should be considered in all patients complaining of cough in endemic areas, regardless of cough duration. For more information, see the CKS topic on Tuberculosis. 
    • Sitagliptin-induced cough — suggested by cough accompanied with rhinorrhoea, dyspnoea, or fatigue.
    • Somatic cough syndrome — the diagnosis of somatic cough disorder can only be made after an extensive evaluation has been performed that includes ruling out tic disorders and uncommon causes and the person meets the DSM-5 criteria for a somatic symptom disorder.
  • Initial investigations recommended by most guidelines include:
    • Chest X-ray.
    • Full blood count.
    • Diagnostic spirometry.
    • Fractional exhaled nitric oxide (if available).

Basis for recommendation

These recommendations are based on the American College of Chest Physicians (CHEST) guidelines Classification of cough as a symptom in adults and management algorithms: CHEST guideline and expert panel report [Irwin, 2018], Somatic cough syndrome (previously referred to as psychogenic cough) and tic cough (previously referred to as habit cough) in adults and children: CHEST guideline and expert panel report [Vertigan, 2015], Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnatal drip syndrome) [Pratter, 2006a], and Occupational and environmental contributions to chronic cough in adults: chest expert panel report [Tarlo, 2016]; the European Respiratory Society (ERS) ERS guidelines on the diagnosis and treatment of chronic cough in adults and children [Morice, 2020]; British Thoracic Society Clinical Statement on chronic cough in adults [BTS, 2023]; the National Institute for Health and Care Excellence (NICE) guidelines Cough (acute): antimicrobial prescribing [NICE, 2022]; National Institute for Health and Care Excellence (NICE) guidelines Pneumonia in adults: diagnosis and management [NICE, 2023a]; National Institute for Health and Care Excellence (NICE) guidelines Idiopathic pulmonary fibrosis [NICE, 2024b], National Institute for Health and Care Excellence (NICE) guidelines Asthma: diagnosis, monitoring and chronic asthma mangement [NICE, 2024a]; Chronic cough management: Practical guidelines and PICO-based evidence for screening and investigation [Kanjanawasee, 2024]; Hypersensitivity pneumonitis [Raghu, 2020], and Connective tissue disease-associated interstitial lung disease [Oliveira, 2022]; and expert opinion in narrative reviews Methods of cough assessment and objectivisation [Jakusova, 2023], Chronic cough [Kruger, 2022], Chronic cough: a practical approach to assessment and management [Mathur, 2019a].

Management

Scenario: Management

From age 18 years onwards.

When should I arrange emergency admission for someone with cough?

Arrange emergency admission for people with cough who have:

  • Clinical features of suspected pulmonary embolism or pneumothorax. For more information, see the CKS topic on Pulmonary embolism.
  • Signs or symptoms of serious illness.
    • In community-acquired pneumonia, use clinical judgement and CRB65 score to assess the need for hospital admission.
    • CRB65 is assessed by giving one point for each positive sign of:
      • Confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time).
      • Raised respiratory rate (30 breaths per minute or more).
      • Low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg).
      • Age 65 years or more.
    • Consider admission if score is 2 or greater.
  • Other concerning signs include:
    • Tachycardia greater than 130 beats per minute.
    • Oxygen saturation less than 92%, or central cyanosis (if the person has no history of chronic hypoxia).
    • Peak expiratory flow rate less than 33% of predicted. 
    • Use of accessory muscles of respiration (particularly if the person is becoming exhausted). 
  • Clinical features of foreign body aspiration, or arrange urgent referral using clinical judgement.

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Venous thromboembolic diseases: diagnosis, management and thrombophilia testing [NICE, 2023b]; National Institute for Health and Care Excellence guidelines Asthma: diagnosis, monitoring and chronic asthma management [NICE, 2024a]; National Institute for Health and Care Excellence guidelines Pneumonia in adults: diagnosis and management [NICE, 2023a], and the original paper Defining community‑acquired pneumonia severity on presentation to hospital: an international derivation and validation study [Lim, 2003], and expert opinion in the German Respiratory Society guidelines for diagnosis and treatment of adults suffering from acute, subacute and chronic cough [Kardos, 2020].

How should I manage someone with acute cough?

If the person with acute cough does not need emergency admission and has clinical features of:

  • Upper respiratory tract infection
    • Advise them: 
      • That acute cough usually persists for up to 3 or 4 weeks. 
      • How to manage their symptoms with self-care (for example, paracetamol or ibuprofen for any associated pain). Be aware that some people may wish to try honey, pelargonium (a herbal medicine), or over-the-counter medicines that contain the expectorant guaifenesin or cough suppressants.  
      • To seek medical advice if symptoms worsen rapidly or significantly, do not improve in 3–4 weeks, or they become systemically very unwell. 
      • That if they smoke, they should stop. For more information, see the CKS topic on Smoking cessation.
    • Do not offer the following treatments unless the person has an underlying airways disease (for example, asthma):
      • An oral or inhaled bronchodilator (for example, salbutamol).
      • An oral or inhaled corticosteroid. 
    • Do not offer a mucolytic (for example, acetylcysteine or carbocisteine).
    • Do not offer an antibiotic to people who are not systemically very unwell or at higher risk of complications.
      • Give advice about why an antibiotic was not given. 
    • For people identified at a face-to-face clinical examination as systemically very unwell, offer an immediate antibiotic — doxycycline 200 mg on the first day, then 100 mg once daily for 4 days (avoid in pregnancy). Or if this is not suitable, alternatives are:
      • Amoxicillin 500 mg three times daily for 5 days.
      • Clarithromycin 250 mg to 500 mg twice daily for 5 days.
      • Erythromycin 250 mg to 500 mg four times daily (or 500 mg to 1000 mg twice daily) for 5 days.
    • For people identified as at higher risk of complications, consider:
      • An immediate antibiotic.
      • A back-up antibiotic prescription — give advice that it is not needed immediately and to use it if symptoms worsen rapidly or significantly at any time.
    • When an antibiotic is given, give advice about possible adverse effects, particularly diarrhoea and nausea.
  • COVID-19 — follow the Public Health England advice for managing people with COVID-19 in primary care. For information on management, see the CKS topic on Coronavirus - COVID 19.
  • Acute bronchitis or pneumonia — see the CKS topic on Chest infections - adult for information on management.
  • Acute exacerbation of asthma, chronic obstructive pulmonary disease (COPD), or bronchiectasis — see the CKS topics on Asthma, Chronic obstructive pulmonary disease, or Bronchiectasis for information on management.

Reassess people with an acute cough if their symptoms worsen rapidly or significantly, taking into account:

  • Alternative diagnoses.
  • Any symptoms or signs suggesting a more serious illness or condition, such as cardiorespiratory failure or sepsis.
  • Previous antibiotic use, which may have led to resistant bacteria. 

Basis for recommendation

These recommendations are largely based on the (NICE) guideline Cough (acute): antimicrobial prescribing [NICE, 2022]. 

How should I manage someone with sub-acute or chronic cough?

Management of chronic 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 causes.  

  • If the person with sub-acute cough does not need emergency admission and has clinical features of post-infectious cough — explain that the cough is often self-limiting and usually lasts for no longer than 8 weeks (advise the person to re-attend for assessment if the cough does not improve after 2 months). Consider:
    • A trial of inhaled ipratropium. 
    • Inhaled corticosteroids if quality of life is affected and the cough persists despite use of inhaled ipratropium. 
    • Oral prednisolone 30 mg to 40 mg daily for a short, finite period of time for severe paroxysms of post-infectious cough when other common causes of cough have been ruled out.
    • Centrally acting antitussives (such as codeine, or dextromethorphan) if other treatments fail. 
  • If the person with chronic cough does not need emergency admission and has clinical features of:
    • Angiotensin-converting enzyme (ACE) inhibitor-induced cough — stop the ACE inhibitor treatment and prescribe an alternative. For most people, the cough resolves within 1 month, but occasionally may persist for several months. For further information on alternative treatments, see the CKS topic on Hypertension. 
    • Asthma — see the CKS topic on Asthma for information on management.
    • Eosinophilic bronchitis — prescribe an inhaled corticosteroid first line. If symptoms do not improve, increase the dose of inhaled corticosteroid and consider prescribing a leukotriene inhibitor (for example, montelukast) after reconsidering other possible diagnoses.
    • Gastro-oesophageal reflux disease — see the CKS topic on Dyspepsia - proven GORD for information on management.  
    • Smoking-related cough — advise people to stop smoking, but warn them that there may be a transient increase in coughing. For more information, see the CKS topic on Smoking cessation.
    • Upper airway cough syndrome (post-nasal drip) — prescribe an antihistamine (for example, chlorphenamine) and a decongestant (for example, pseudoephedrine). Advise the person to avoid allergic or environmental triggers if possible, and that symptoms should improve within 1–2 weeks of starting treatment, but resolution may take several weeks and occasionally as long as a few months.
      • If sinusitis coexists, manage appropriately. Treatment options include an intranasal corticosteroid (for example, mometasone) or antibiotic. For more information on management, see the CKS topic on Sinusitis.
      • If rhinitis coexists, manage appropriately. First-line treatments include intranasal corticosteroids (for example, mometasone), intranasal antihistamines (for example, azelastine), or intranasal sodium cromoglicate. For more information, see the CKS topic on Allergic rhinitis. 
  • If the person with cough does not need admission and has clinical features of:
    • Bronchiectasis — see the CKS topic on Bronchiectasis for information on management.
    • Bronchitis — see the CKS topic on Chest infections - adult for information on management.
    • Chronic obstructive pulmonary disease — see the CKS topic on Chronic obstructive pulmonary disease for information on management.
    • Cough-variant asthma — prescribe an inhaled corticosteroid first line. If symptoms do not improve, consider an alternative cause of cough, then increase the dose of inhaled corticosteroid, and consider: 
      • A therapeutic trial of a leukotriene inhibitor (for example, montelukast), or
      • A beta-agonist (for example, salbutamol) in combination with the inhaled corticosteroid.   
    • Environmental or occupational causes — refer people to specialists with expertise in environmental and occupational disease to arrange appropriate objective tests to confirm an association between exposure and chronic cough. This may include methacholine challenge, sputum cytology, or immunologic tests.
    • Heart failure — see the CKS topic on Heart failure - chronic for information on management.
    • Interstitial lung disease (ILD) — refer people with ILD to secondary care for specialist management. 
    • Lung cancer — see the CKS topic on Lung and pleural cancers - recognition and referral for information on management. 
    • Obstructive sleep apnoea  — see the CKS topic on Obstructive sleep apnoea syndrome for information on management. 
    • Pertussis (whooping cough) — see the CKS topic on Whooping cough for information on management. 
    • Pulmonary tuberculosis — see the CKS topic on Tuberculosis for information on management. 
    • Sitagliptin-induced cough — stop sitagliptin treatment. For more information on alternative treatments, see the CKS topic on Diabetes - type 2. 
    • Somatic cough syndrome — refer the person for specialist assessment. 
  • If the cough does not respond to the trials of treatment, or partially responds (possibly indicating more than one cause), or the diagnosis is uncertain, refer the person to a respiratory physician for assessment.
    • Treatment options for people with chronic refractory cough may include a trial of low dose morphine (5 mg to 10 mg twice daily), a trial of gabapentin, or a speech and language intervention. 

Basis for recommendation

These recommendations are based on the American College of Chest Physicians (CHEST) guidelines Classification of cough as a symptom in adults and management algorithms: CHEST guideline and expert panel report [Irwin, 2018], Somatic cough syndrome (previously referred to as psychogenic cough) and tic cough (previously referred to as habit cough) in adults and children [Vertigan, 2015], Managing chronic cough due to asthma and NAEB in adults and adolescents [Côté, 2020], Occupational and environmental contributions to chronic cough in adults: chest expert panel report [Tarlo, 2016]; the European Respiratory Society (ERS) guidelines on the diagnosis and treatment of chronic cough in adults and children [Morice, 2020]; British Thoracic Society Clinical Statement on chronic cough in adults [BTS, 2023]; French respiratory society guidelines for the management of chronic cough in adults [Guilleminault, 2023]; National Institute for Health and Care Excellence guidelines Idiopathic pulmonary fibrosis [NICE, 2024b], National Institute for Health and Care Excellence guidelines Asthma: diagnosis, monitoring and chronic asthma management [NICE, 2024a]; National Institute for Health and Care Excellence guidelines Obstructive sleep apnoea/hypopnoea and obesity hypoventilation syndrome [NICE, 2021] and expert opinion in narrative reviews Connective tissue disease-associated interstitial lung disease [Oliveira, 2022]; Chronic cough [Kruger, 2022], Therapeutic landscape in chronic cough [Smith, 2024] and Chronic cough: a practical approach to assessment and management [Mathur, 2019a].

Sequential treatment
  • Even after a thorough clinical assessment, it may be impossible to identify which of the treatable traits is most likely to underlie the person's chronic cough [Morice, 2020]. 
    • The ERS guideline recommends short-term trials (2–4 weeks) of inhaled corticosteroid (ICS) in adults with chronic cough, a leukotriene inhibitor (especially for people with asthmatic cough), and an ICS and long-acting bronchodilator combination in adults with chronic cough and fixed airflow obstruction.
    • The guideline panel considered that it was preferable to undertake sequential therapeutic trials of each agent in turn and stop therapy if no responses were observed.
    • If treatment is successful it can be continued for several months after which it can be withdrawn to determine whether remission has occurred.
  • If clinical review, chest X-ray, and spirometry fail to lead to a specific diagnosis, sequential trials of treatment may be considered to confirm or refute common causes [Mathur, 2019a].
    • Following clinical assessment, treatment for the most likely diagnosis (or diagnoses) should be started.
    • It may be preferable to initiate only one treatment at a time to determine its effects on follow up.
    • If clinical evaluation does not lead to an obvious cause, a sequential treatment trial for asthma, gastro-oesophageal reflux disease, and then upper airway cough syndrome should be considered.
  • A careful history, along with selected therapeutic trials and/or diagnostic evaluations performed in a systematic and informed way, may satisfactorily resolve cough in over 90% of cases [BTS, 2023].
Post-infectious cough
  • The CHEST guideline on Postinfectious cough recommends considering [Braman, 2006]:
    • A trial of inhaled ipratropium as it may attenuate the cough.
    • Inhaled corticosteroids if quality of life is adversely affected and the cough persists despite use of inhaled ipratropium.
    • Oral prednisolone 30 mg to 40 mg daily for a short, finite period of time for severe paroxysms of post-infectious cough.
    • Centrally acting antitussives (such as codeine or dextromethorphan) if other treatments fail. 
  • Persistent inflammation is one of the possible mechanisms causing postinfectious cough. Patients with persistent inflammation respond well to inhaled corticosteroids in contrast to those with for example, a pertussis infection [Kardos, 2020].
  • The recommendation to advise the person to return if post-infectious cough does not resolve after 8 weeks is pragmatic as it is normally self-limiting. If the cough persists for longer than 8 weeks further evaluation is indicated to consider alternative diagnoses.
Eosinophilic bronchitis
  • The recommendation to prescribe an inhaled corticosteroid or leukotriene inhibitor is based on the CHEST guideline Managing chronic cough due to asthma and NAEB in adults and adolescents [Côté, 2020], and the ERS guideline [Morice, 2020].
    • Cough due to non-asthmatic eosinophilic bronchitis (NAEB) should be offered a 4 week course of inhaled steroids [Kardos, 2020; BTS, 2023], however, ERS recommends that if there has been no treatment response in 2–4 weeks the empirical trial should be stopped [Morice, 2020].
  • A narrative review advises that eosinophilic bronchitis may partially respond to inhaled corticosteroids, but a systemic steroid trial (oral prednisolone) may be required to establish the diagnosis [Mathur, 2019a]. 

Upper airway cough syndrome (UACS) [Pratter, 2006b; BTS, 2023]

  • The CHEST guideline and BTS statement recommend using a first-generation antihistamine and a decongestant to treat UACS. However, if an underlying cause is identified (such as allergic rhinitis or sinusitis), specific therapy should be directed at treating those conditions.  
  • Noticeable improvement in cough is usually seen within days to 1–2 weeks of initiating therapy. Marked improvement or resolution of cough may take several weeks and occasionally as long as a few months.

Cough-variant asthma

  • These recommendations are based on the CHEST guideline Managing chronic cough due to asthma and NAEB in adults and adolescents [Côté, 2020] and the ERS guideline [Morice, 2020].
    • ERS recommends that if there has been no treatment response in 2–4 weeks the empirical trial should be stopped [Morice, 2020].
    • Cough-variant asthma requires the same treatment as other types of asthma [NICE, 2024a].
Environmental or occupational causes
  • These recommendations are based on the CHEST guideline Occupational and environmental contributions to chronic cough in adults, and expert opinion in a narrative review.
    • It would be appropriate to consider allergy testing as well as an evaluation of the patient’s home and workplace if there is a potential environmental cause for persistent upper airway symptoms [Pratter, 2006b].
    • CHEST recommends that [Tarlo, 2016]:
      • If the history is suggestive of an occupational or environmental association it should be confirmed when possible by objective testing, in order to maximize favourable patient outcomes and determine the incidence of occupational and environmental causes of chronic cough.
      • For people with chronic cough and occupational or environmental exposure history, appropriate objective tests should be performed to elucidate potential mechanistic associations between cough and the suspected exposure.
      • People with chronic cough and a high suspicion of cough due to environmental and/or occupational exposures should be managed according to evidence-based guidelines for these exposures and/or be referred to specialists with expertise in environmental and occupational disease. 
Interstitial lung disease
  • The recommendation to refer people with suspected interstitial lung disease to secondary care is based on the National Institute for Health and Care Excellence (NICE) guideline Idiopathic pulmonary fibrosis in adults: diagnosis and management [NICE, 2024b].
Somatic cough

  • The CHEST guideline on Somatic cough syndrome makes no treatment recommendations for adults with somatic cough [Vertigan, 2015]. CKS recommends referring people with features of somatic cough for specialist evaluation.

Refractory cough
  • The CHEST guideline Treatment of unexplained chronic cough recommends referral to a specialist cough clinic as an option for difficult to treat cough.
    • Other options include speech and language intervention, or a trial of gabapentin treatment [Gibson, 2016]. 
  • The British Thoracic Society statement recommends that people with chronic cough should be referred to a specialist centre if the diagnosis is in doubt, or when there has been a failure of empirical treatment [BTS, 2023].
  • People who do not respond to empirical treatment may merit secondary care referral to respiratory medicine [Mathur, 2019a].
  • The ERS guideline recommends trials of low-dose morphine, gabapentin, or pregabalin and cough control therapy for people with chronic refractory cough [Morice, 2020].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Proton pump inhibitors

For detailed information on prescribing a proton pump inhibitor, see the section on Proton pump inhibitors in the CKS topic on Dyspepsia - proven GORD.

Nasal corticosteroids

For detailed information on prescribing a nasal corticosteroid, see the section on Intranasal corticosteroid treatment in the CKS topic on Corticosteroids - topical (skin), nose, and eyes.

Beta-2 agonists

For detailed information on prescribing a beta2 agonist, see the section on Beta-2 agonists in the CKS topic on Asthma.

Inhaled corticosteroids

For detailed information on prescribing an inhaled corticosteroid, see the CKS topic on Asthma.

Supporting evidence

This CKS topic is largely based on the American College of Chest Physicians (CHEST) guidelines Classification of cough as a symptom in adults and management algorithms: CHEST guideline and expert panel report [Irwin, 2018], Somatic cough syndrome (previously referred to as psychogenic cough) and tic cough (previously referred to as habit cough) in adults and children: CHEST guideline and expert panel report [Vertigan, 2015], Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnatal drip syndrome) [Pratter, 2006a], and Occupational and environmental contributions to chronic cough in adults: chest expert panel report [Tarlo, 2016];  European Respiratory Society (ERS) ERS guidelines on the diagnosis and treatment of chronic cough in adults and children [Morice, 2020]; British Thoracic Society Clinical Statement on chronic cough in adults [BTS, 2023]; the National Institute for Health and Care Excellence (NICE) guidelines Cough (acute): antimicrobial prescribing [NICE, 2022]; National Institute for Health and Care Excellence (NICE) guidelines Pneumonia in adults: diagnosis and management [NICE, 2023a]; National Institute for Health and Care Excellence (NICE) guidelines Idiopathic pulmonary fibrosis [NICE, 2024b], National Institute for Health and Care Excellence (NICE) guidelines Asthma: diagnosis, monitoring and chronic asthma management [NICE, 2024a]; Chronic cough management: Practical guidelines and PICO-based evidence for screening and investigation [Kanjanawasee, 2024] and expert opinion in narrative reviews Methods of cough assessment and objectivisation [Jakusova, 2023], Chronic cough [Kruger, 2022], Chronic cough: a practical approach to assessment and management [Mathur, 2019a]. The rationale for individual recommendations is outlined in the relevant basis for recommendation sections of the topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on primary care management of cough.

Search dates

April 2020 - April 2025

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 6th April 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases.

S3    S1 OR S2 
S2    AB ( cough or coughs or coughing ) OR TI ( cough or coughs or coughing ) 
S1    (MH "Cough") 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

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