RESPIRATORY DISEASES

Chronic Dry Cough in Allergic Respiratory

Diseases: Diagnostic and Management Approach
Pralhad P. Prabhudesai

Abstract
Cough is considered as a single most common complaint for which patients globally seek medical attention. A multitude of
allergic etiologies contribute to the development of chronic cough in adults, which makes the diagnosis and treatment quite
challenging. Allergic cough is a distinct entity where there is no respiratory obstruction and there is presence of a family history,
past history and/or concomitant allergic conditions. Sensitivity to allergens is readily demonstrable by skin testing. It is also
characterized by a therapeutic response to epinephrine and a periodic nature. The intention of this article is to highlight the
common causes of chronic dry cough associated with allergic diseases, to differentiate allergic cough from various other causes
of chronic cough associated with asthma syndromes (which include related airway disorders like ‘classic’ asthma [cough-variant
asthma], nonasthmatic eosinophilic bronchitis and atopic cough) and to discuss its management strategies.
Keywords: Chronic cough, allergic cough, occupational and environmental causes, mechanisms, management options

Chronic Cough: A Worldwide Problem Rib fractures, pneumothorax, pneumomediastinum

Cough is a forceful expiration against closed glottis.
This maneuver prevents the entry of harmful
substances into the lungs and movement of secretions
and other airway constituents upward from mouth.1,2
Coughing, apart from being a physiological barrier
against irritant substances that reach the respiratory
tract, is also a symptom of diseases of both respiratory
and nonrespiratory origin.1 Cough is considered as
the single most common complaint globally for which
patients seek medical attention.3 An individual’s
lifestyle, quality-of-life and sense of well-being can be
significantly affected by the presence of cough.1,2
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). Cough
lasting longer than this duration can be precluded as
being post-infectious cough. The estimated prevalence
of chronic cough is between 11 and 20%.3,4 This
type of cough is observed commonly in females and
in obese individuals.5 Chronic cough is the fifth
most common symptom reported by patients who
visit the outpatient clinics.2 Morbidities associated
with chronic cough include lack of sleep, exhaustion,
urinary incontinence and syncope. There can also be
socioeconomic encumbrances due to work absenteeism.
Consulting Chest Physician
Lilavati Hospital, Mumbai, Maharashtra
E-mail: aumclinic@hotmail.com
and subcutaneous emphysema are some serious side
effects associated with chronic cough.2
Link between Cough and Allergy: What
Evidences Say?
Chronic Cough and Allergy
Chronic cough has been linked to the presence of
asthma and allergic rhinitis.6 Cough can occur as a
symptom of allergic diseases such as seasonal allergic
rhinitis, which is an inflammatory condition of the
nasal mucous membranes. This type of cough is
usually associated with rhinorrhea, nasal stuffiness/
congestion, nasal itching and sneezing.7 Occupational
and environmental factors such as cigarette smoking
and pollutants are known aggravating factors or
triggers for cough and these may also exacerbate cough
that was initially caused by other mechanisms.8,9
Presence of high levels of particulates has been linked
to productive or chronic nocturnal dry cough in adults
and school children. People, especially children living
in localities which are close to areas of heavy traffic
have been known to suffer from increased respiratory
symptoms including cough and increased symptoms
from respiratory viral infections.9
Causes of Allergic Cough
The most common causes of chronic cough in non-
smoking adults (who have not received treatment with
angiotensin-converting enzyme inhibitors and have

Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014 1085
RESPIRATORY DISEASES

normal chest radiogram) include upper airway cough Upper Airway Cough Syndrome
syndrome, gastroesophageal reflux disease and asthma Upper airway cough syndrome is a common condition
syndromes. In this review, we will be discussing in that occurs in 20-40% (up to 87%) of patients who
detail about the association of cough with asthma present with cough. This syndrome incorporates many
syndromes and allergic diseases. diagnoses in the upper respiratory tract, including
Asthma syndromes represent a collection of related allergic rhinitis, nonallergic rhinitis, post-infectious
airway disorders including: (post-viral) cough, sinusitis and anatomic abnormalities
ÂÂ ‘Classic’ asthma, the so-called cough-variant of the nose and sinuses. All these conditions are linked
asthma to retention of mucosal secretions that drain into the
posterior pharynx.12
ÂÂ Nonasthmatic eosinophilic bronchitis
ÂÂ Atopic cough.10 Cough-variant Asthma

Both upper and lower respiratory causes of cough such In referral populations of adult nonsmokers, cough-
as allergic rhinitis, asthma, allergic bronchopulmonary variant asthma accounts for about 24-29% of diagnoses
mycoses can be triggered by exposure to allergens such for chronic cough. Chronic and/or recurrent respiratory
as dust mite, animal or cockroach allergens, fungi and symptoms associated with reversible airflow obstruction
pollen at indoor or outdoor environments (see Table 1).9 and airway inflammation are the characteristic features
of asthma. Stimulation of airway sensory nerves by
Cough and Allergic Diseases inflammation is thought to be responsible for the
occurrence of cough in these patients. Heightened
Allergic cough has certain characteristics that are
cough sensitivity has been observed in patients with
common to all allergic diseases such as:11
both asthma and chronic obstructive pulmonary
ÂÂ Presence of a family history of allergy disease.12 In contrast, allergic cough is not associated
ÂÂ History of past and/or concomitant allergic with any airflow obstruction.11
conditions (such as urticaria, eczema)
Eosinophilic Bronchitis
ÂÂ Sensitivity to allergens that can be elicited by skin
testing Chronic cough is also an important entity in patients
ÂÂ Therapeutic response to epinephrine with eosinophilic bronchitis and the condition has two
important similarities with asthma:
ÂÂ Periodic nature of the allergic condition.
ÂÂ Presence of an eosinophilic airway infiltrate
Cough is essentially produced on exposure to allergens
and relieved on removing them. The sensitivity can ÂÂ Response to corticosteroids.
be decreased by immunizing with the ‘concerned’ There is no evidence of variable airflow obstruction or
allergen, if the allergen is an inhalant. Important bronchial hyper-reactivity in patients with eosinophilic
characteristic features of common allergic diseases have bronchitis but there is evidence of basement membrane
been described as follows.11 thickening and elevated levels of exhaled nitric oxide
that is reflective of airway eosinophilia. Patients with
eosinophilic bronchitis, by definition, have sputum
Table 1. Occupational and Environmental Causes of eosinophilia >3%.12
Allergic Cough
Atopic Cough
Occupational factors Environmental factors
This type of cough has clinical features of chronic
Occupational rhinitis Exposure to dust mite, animal or
cockroach allergens, fungi and nonproductive cough, sputum eosinophilia and
pollen lacks bronchial hyper-responsiveness. In contrast to
Occupational asthma Exposure to cigarette smoking or eosinophilic bronchitis, atopic cough has eosinophilia
other respiratory irritants only in the upper airway and the condition usually
Occupational Exposure to indoor particulate
does not respond to inhaled corticosteroids.12
eosinophilic bronchitis pollution from biomass combustion The Japanese Cough Research Society criteria for
Hard metal disease Exposure to air pollutants such as recognizing atopic cough include.10
nitrogen oxides from gas cooking ÂÂ Nonproductive cough lasting for >8 weeks without
stoves or outdoor traffic
wheezing or dyspnea.

1086 Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014

ÂÂ Presence of one or more findings indicative of
an atopic constitution, including a past history
and/or complications of allergic diseases excluding
asthma.
ÂÂ No bronchial reversibility (defined as less than a
10% increase in forced expiratory volume in 1 sec
(FEV1) after inhalation of 300 μg salbutamol sulfate
ÂÂ Normal bronchial responsiveness.
ÂÂ Increased cough reflex.
ÂÂ Cough-resistant to bronchodilator therapy.
ÂÂ No abnormal findings indicative of cough etiology
on chest X-ray.
ÂÂ Normal FEV1 (≥80% of predicted value) and normal
forced vital capacity (FVC) and FEV1/FVC ratio.
Characteristics of Allergic Cough
Allergic cough is characterized by a loud barking
sound with intensity and force that is similar to
sneezing in hay fever. This type of cough is paroxysmal
and nonproductive in nature, and may last from a
few minutes to hours or days.11 In contrast, cough
associated with cough-variant asthma is dry and
nocturnal in nature while atopic cough is isolated in
nature with cough hypersensitivity and normal airway
responsiveness. Eosinophilic bronchitis, on the other
hand, is characterized by a troublesome cough that is
devoid of asthma symptoms and hyper-responsiveness.8
Pathophysiological events, following allergen exposure
are generally biphasic.6
ÂÂ The early phase is mediated by mast cell-derived
mediators.
ÂÂ The late phase response that occurs from 4 to 12
hours after exposure and persists up to 24 hours,
involves increased recruitment and activation of
inflammatory cells such as T cells, neutrophils,
macrophages and eosinophils.
Evaluation and Diagnosis
Evaluation and History Taking
The trigger for chronic cough can be gleaned from a
detailed history of the patient. The evaluation should
include a number of key components. The British
Thoracic Society Cough Guidelines recommendations
for evaluating a patient with chronic cough include:5
ÂÂ A detailed history (including a thorough
occupational history) should be taken in all patients.
ÂÂ Physical examination should be performed with
focus on the afferent sites of the vagus nerve most
commonly associated with irritation leading is
chronic cough.
RESPIRATORY DISEASES
ÂÂ An assessment of health status and cough severity
should be done.
ÂÂ Chest radiograph and spirometry which are
considered as mandatory should be advised.
ÂÂ Bronchial provocation testing should be performed
in patients with chronic cough without a clinically
obvious etiology and normal spirometry.
ÂÂ Bronchoscopy should be performed in all patients
with chronic cough and suspected foreign body
inhalation.
ÂÂ High resolution computed tomography may be
helpful in patients with chronic cough in whom
other more targeted investigations are normal.
ÂÂ Optimal management strategies should be chosen
based on the most likely aggravator(s) by using a
combination of diagnostic testing and treatment
trials.
ÂÂ Effects of treatment should be quantified.
Diagnosis
With respect to allergic cough, the radiographic as
well as physical examination of the chest and sputum
analysis may be within normal limits. Patients with
allergic cough may not look or feel sick, but may
complain of an itchy, scratchy or rubbing sensation
deep in the throat, leading to an irritation which can
reflexly cause coughing spells.11
Differential Diagnosis of Common Allergic
Respiratory Conditions Causing Cough
Although allergic cough may resemble asthmatic
cough, it can be differentiated by a normal chest
examination and the lack of sibilant and sonorous rales
and prolonged expiration that is observed in asthmatic
cough.
Additionally, patients with asthmatic cough have
dyspnea and complaints of pressure over the sternum,
whereas in patients with allergic cough there is no
obstruction to respiration and other complaints.11
A negative result of methacholine challenge may rule
out asthma as a cause of chronic cough.3 Differentiating
features of the asthma syndromes have been presented
in Table 2.8,11
Managing Chronic Dry Cough in Patients
with Allergic Respiratory Diseases
For cough associated with allergic conditions such as
allergic rhinitis, in addition to avoidance of the offending
allergen, oral antihistamines such as loratadine,
Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014 1087
RESPIRATORY DISEASES

Table 2. Features of Cough Caused by Airway Diseases

Asthma Cough-variant asthma Atopic cough Eosinophilic bronchitis
Symptoms Cough, Cough only Cough only Cough and sputum
breathlessness,
wheeze
Atopy Common Common Common As in general population
Variable airflow obstruction + ± − −
Airway hyper-responsiveness + + − −
Capsaicin cough ± ± − +
hyper-responsiveness
Bronchodilator response + + − −
Corticosteroid response + + + +
Response to H1 antagonist ± ± + NK
Progression to asthma n/a 30% Rare 10%
Sputum eosinophilia (>3%) Frequent Frequent Frequent Always
Submucosal eosinophils ↑ ↑ ↑ ↑
BAL eosinophilia ↑ ↑ ↓ ↑
Mast cells in ASM ↑ ↓ NK ↓
Basement membrane thickness ↑ ↑ NK ↑

ASM = Airway smooth muscle; BAL= Bronchoalveolar lavage; n/a = Not applicable; NK = Not known. + = Often present; ± = Sometimes
present; − = Not present; ↑ = Increased; ↓ = Not increased.

10 mg once a day is recommended. Nasal cromolyn,
corticosteroids and azelastine may also be helpful.
Upper airway cough syndrome can be managed with
a trial of H1 antihistamines and decongestants for a
period of 1-2 weeks. Patients who respond or partially
respond to this treatment are advised to continue on
the same for one more week and nonresponders are
cough-variant asthma can be managed with the use of
inhaled steroids by metered-dose inhaler with spacer
or salbutamol by metered-dose inhaler with spacer as
needed. Improvement of cough is usually noted within
1 week and resolution may take 6-8 weeks. Patients with
this type of cough may require long-term maintenance
therapy with an anti-inflammatory agent. For managing
eosinophilic bronchitis, inhaled budesonide, 400 μg
twice-daily for a period of 1-2 weeks is recommended;
equivalent doses of other inhaled corticosteroids are
also effective. Patients with this condition may require
long-term therapy. Avoidance of aggravants is advised
if the condition is found to be associated with an
environmental irritant such as acrylic resin.3
Value of Antitussive Agents
A trial of antitussive therapy is generally indicated
for patients with chronic dry cough when the cause
of an increased cough reflex is not known or when
the treatment against potential aggravating factors
remains unsatisfactory.13 Most antitussives available
are combinations of dextromethorphan or codeine
with antihistamines, expectorants, decongestants
and/or antipyretics. Codeine is a commonly used,
centrally-acting cough suppressant and its effectiveness
in suppressing artificially-induced, disease-related
and chronic cough has been established from animal
models and in humans. Codeine has analgesic and
sedative effects in addition to its antitussive property,
which may be useful in relieving painful cough. The
American College of Chest Physicians (ACCP) evidence-
based clinical practice guidelines recommend cough
suppressants such as codeine and dextromethorphan
for short-term symptomatic relief of cough in patients
with chronic bronchitis.14
Conclusions
Allergic cough is characterized by the presence of
marked familial history, past history and/or concomitant
allergic conditions, sensitivity to allergens readily
demonstrable by skin testing, therapeutic response to
epinephrine and its periodic nature. Chronic cough
is a common symptom in a multitude of allergic
diseases in adults, which makes the diagnosis and
treatment quite challenging. Differential diagnosis and

1088 Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014

a systematic therapeutic approach might simplify the
management of cough related to allergies. Avoidance
of offending allergen is the first-line of defense to
reduce the possibility of an allergic attack. Various
therapeutic options available for the management
of cough associated with allergic conditions. Use of
antitussive agent such as codeine or dextromethorphan
is suggested for the short-term symptomatic relief of
dry cough.
Key Messages
ÂÂ Chronic cough is a common symptom in a multitude
of allergic diseases in adults, which makes the
diagnosis and treatment quite challenging.
ÂÂ Differential diagnosis and a systematic therapeutic
approach might simplify the management of cough
related to allergies.
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Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014 1089
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