Chronic Cough Among Primary Care Doctors: Unmet Needs

Chronic cough is a complex clinical entity affecting 5–10% of the adult population. It is one of the most common reasons for consultation in Primary Care, is more prevalent in women, and has a significant impact on quality of life.^1–3

In some patients, chronic cough is a disease in its own right and not merely a symptom of other conditions; it represents a problem of neural dysregulation giving rise to cough hypersensitivity syndrome, characterized by a hyper-response to apparently innocuous stimuli acting on the airway.^4,5 Although some patients with chronic cough may benefit from avoiding triggers or treating comorbidities, in 30–40% of cases no underlying disease is identified, or the cough persists despite appropriate treatment.⁶ The term unexplained chronic cough refers to cases in which the etiology remains unknown after exhaustive investigation, while refractory chronic cough denotes cough that does not respond to treatment even after the cause has been identified.^1,3–5 Chronic cough poses a diagnostic challenge in which repeated or inappropriate tests are frequently performed, alongside empirical treatments of limited effectiveness or with safety and tolerability concerns.^1,4,5

The Primary Care physician plays a fundamental role in the diagnosis and management of chronic cough, as they are typically the patient's first point of contact with the healthcare system.^3,4,7 Despite being a frequent reason for consultation, there is considerable variability in how chronic cough is approached, not only in Primary Care but also among professionals in other relevant specialties.^8,9 Knowledge of chronic cough and adherence to clinical guidelines for its management appears to be lower than advisable; the resources available at the Primary Care level are not uniform; moreover, self-confidence in managing cough and the referral of patients to specialist consultations varies among Primary Care professionals.^1,7–10

The management of chronic cough should be shared and multidisciplinary. To this end, it is necessary to establish protocols that harmonize diagnostic, referral, and treatment criteria. Although there is no consensus on the initial approach to the patient with chronic cough in Primary Care and discrepancies exist between clinical guidelines, many patients can be diagnosed and treated by the family physician,^1,2,4,6 sometimes with limitations due to a lack of access to tests or variability in diagnostic skills. It is recommended to begin the evaluation with a clinical history, physical examination, and complementary tests that allow alarm signs to be recognized, treatable diseases to be excluded, and common aggravating factors to be identified, such as smoking or certain widely used medications such as ACE inhibitors.^4,6,7 Tests available at Primary Care centers, such as chest X-ray, spirometry with bronchodilator testing, and a full blood count for peripheral eosinophil measurement, allow a diagnosis to be reached in a significant number of patients.^2,6,10–12 The assessment of cough severity and its impact on quality of life should not be overlooked, anticipating its deterioration, which can be objectively measured using various questionnaires.^2,7,12

Discontinuing ACE inhibitor therapy and smoking cessation are the first step in the therapeutic approach. Asthma and COPD should be managed in accordance with clinical guidelines. The latest recommendations emphasize the importance of avoiding empirical treatments in the absence of objective evidence of disease. The causal relationship is well established for smoking, airway diseases, and ACE inhibitors, but not for other conditions classically considered responsible for chronic cough, such as gastro-esophageal reflux or upper airway syndrome, meaning that some treatments may prove ineffective.^6,11 The presence of heartburn is the best predictor of response to proton pump inhibitor therapy, though discontinuation is advised after one month if it proves ineffective.^6,11 In patients with post-nasal drip, a therapeutic trial with nasal saline irrigation and nasal corticosteroids over six weeks could be considered, although the evidence is limited.⁶

Referral to Specialist Care is recommended when alarm signs are present, when a diagnosis cannot be reached, to confirm a suspected diagnosis when the necessary tests are unavailable, or when treatment is not available in Primary Care. Referral is also indicated in cases of refractory chronic cough or when cough hypersensitivity syndrome is suspected.^2,6,11 Delays in accessing specialist consultations due to waiting lists, distance, or lack of transport to referral centers, together with heterogeneous management among professionals, are common barriers faced by both patients and Primary Care physicians.

A multidisciplinary approach to chronic cough reduces the overdiagnosis of idiopathic cough and improves treatment outcomes. In this way it becomes possible to identify patients in whom comorbidity-focused treatment has failed and who might benefit from a different therapeutic approach. Central neuromodulators, such as gabapentin and pregabalin, can improve the frequency and severity of chronic cough, though with limitations related to their side effects.^3,5 Recent data support the use of P2X3 receptor antagonists such as gefapixant^3,5; the excessive cost for some patients remains the main drawback. Behavioral therapies, speech and language therapy, and physiotherapy may be useful in certain cases,^3,6,10,11 albeit subject to similar limitations regarding the delays and access issues mentioned above.

Research into neuromodulation and the search for specific biomarkers enabling treatment to be personalized according to clinical profile will, in the future, help optimize outcomes and minimize adverse effects. In the meantime, we must work on training professionals and developing shared referral and treatment strategies across different specialties.

In conclusion, cough is a common health problem with a significant impact on patients’ quality of life, one that could benefit from the design of multidisciplinary care pathways in which Primary Care should serve as a key step, as it typically represents the patient's first point of contact with the healthcare system.

Artificial intelligence involvement

The authors did not use AI Technologies in the creation of this manuscript.

Funding

None.

Authors’ contributions

MTGS and SMG designed and wrote the manuscript; KN revised the article. All authors approved the final version.

Conflicts of interest

The authors declare that they have no conflicts of interest.