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Cough in adults (subacute and chronic)

Red flags

Consider immediate referral for patients with the following in association with a subacute/chronic cough

  • Progressive dyspnoea
  • Moderate haemoptysis
  • Pleural effusion
  • Consolidation
  • CXR findings suggesting malignancy

The following features may lead to more urgent categorisation

  • Weight loss
  • Progressive cough with no cause after investigation
  • Clubbing

Definitions

  • Subacute cough is a cough present for 3 to 8 weeks
  • Chronic cough has been present for over 8 weeks.

There are many causes of persistent cough. These can be categorised into:

  • Respiratory (Infective, non-asthmatic eosinophilic bronchitis, related to chronic lung disease (COPD, Bronchiectasis, restrictive LD, occupational LD, asthma), cancer, related to pleural disease, foreign body, allergic)
  • ENT (due to tonsillar /adenoidal infection, sinusitis/ rhinitis –PN drip, laryngeal/tracheal)
  • Gastrointestinal (GORD, tracheo-oesophageal fistula)
  • Cardiac (heart failure)
  • Drug related (ACEI, aspirin, beta blockers)
  • Thromboembolic (pulmonary embolism/infarction)
  • Neurological/neuromuscular (degenerative (MS, MND, nerve palsies, Stroke related)
  • Psychogenic

Acute cough (less than 3 weeks) does not usually require investigation unless there is persistent fever, haemoptysis, chest pain weight loss. It should be possible to arrive at a diagnosis in most cases by careful history and examination with directed investigations. If considering referral try to arrive at a probable diagnosis as this will determine which specialty to refer to.

Other important information for referring practitioners

It is important to arrive at a probable diagnosis as this will determine the specialty of referral.

A comprehensive history is very important.

  • Look for evidence of progression
  • Nature of cough
    • Laryngeal/tracheal
    • Associated hoarse voice or dysphagia
    • Productive or dry
    • Wheezy or harsh/barking
  • Triggers
  • Diurnal variation
  • Drug factors
  • Allergies
  • Pets
  • FH
  • Infective contact
  • Occupational factors

Basic investigations include

  • FBC, ESR, CRP,
  • Sputum microscopy and culture
  • Spirometry (pre and post bronchodilator) and
  • CXR.

If the patient is not unwell and there are no red flags, a logical therapeutic trial (only use 1 trial medication at a time) could be considered in the following circumstances

  • Possible GORD consider trial of PPI
  • Possible upper airways cough syndrome trial nasal steroid preparations
  • Possible laryngeal hypersensitivity or post pertussis consider trial of Nedocromil sodium
  • Possible ACEI cough, change to ARB
  • Possible bronchospasm related to beta blocker consider alternative drugs
  • Possible bronchospasm consider trial of beta agonists or inhaled corticosteroids (ICS)

If these do not suggest a diagnosis to allow more directed investigation, consider

  • HRCT chest or sinuses
  • Gastroscopy

Referral requirements

A referral may be rejected without the following information.

Essential referral informaiton

  • Reason for referral
  • Symptoms
    • Duration and severity
      • Associated with syncope, incontinence, SOB
      • If productive, describe sputum quantity and colour/consistency
      • Any diurnal variation in severity (e.g nocturnal or positional)
      • Triggers e.g air temp, food, talking, exercise
        • Swallowing difficulties
      • Voice change
  • Relevant examination findings
    • Tracheal deviation, check thyroid
    • Any local LN enlargement
    • Check for central cyanosis and clubbing
    • Examine ENT (PN drip etc)
    • Check uniform lung expansion and any percussive changes
    • Auscultatory abnormalities
  • Other relevant medical conditions ( respiratory or otherwise)
  • Medications
    • Include full medication list and allergies
    • List any therapeutic trials
  • Smoking and occupational history if relevant
  • FH or possible infectious contact source
  • Investigations
    • FBC, E/LFT, ESR
    • Sputum microscopy C&S
    • Sputum cytology if cancer suspected
    • CXR
    • Spirometry pre and post bronchodilator

Additional referral information (useful for processing the referral)

  • CT chest if done
  • ECG
  • TB staining/culture
  • Previous gastroscopy findings
  • Specialist letter if seen for this condition previously
  • Serum ACE level
  • Allergy testing results

Out of catchment!

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can’t order, or the patient can’t afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
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