Picture credit: iStock

Nurses can play an important role in monitoring patients, educating them about the causes of chronic cough – defined as lasting longer than eight weeks – and ensuring timely referral for investigation.

What causes chronic cough and who is at risk?

Chronic cough can affect anyone and its causes can be multifactorial, says Asthma and Lung UK respiratory nurse specialist and advanced nurse practitioner Claire Fisher.

Chronic cough is not itself a diagnosis, rather a symptom of something that must always be investigated, says Ms Fisher.

‘Anyone with a cough of more than three weeks should have a chest X-ray. But don’t presume coughing is due to a pre-existing condition – people can have more than one cause for their cough,’ she says.

Chronic cough and incontinence: specialist nurse support

Manchester chronic cough service clinical nurse specialist in chronic cough Sarah Hennessey has been pivotal in developing the service since she joined Manchester University NHS Foundation Trust in 2018.

Ms Hennessey recognised that urinary incontinence was a significant issue for people with chronic cough, affecting about one third of patients attending the service.

Signposted to local services

Patients’ continence is now routinely assessed during their initial consultation. Those who report incontinence are referred to the clinical nurse specialist for advice and support, and signposted to local continence services for further management and assessment.

Ms Hennessey says the impact of chronic cough on a patient’s life can be overlooked and all nurses can make a big difference.

‘Listen to patients, and be aware of the significant impact a chronic cough can have on their lives, and offer additional support. Patients report this service has been life-changing.’

Picture credit: iStock

Assessing chronic cough: what should nurses look for?

Ms Fisher advises that nurses should look at:

Nurses need to enquire if there are associated symptoms such as wheezing, breathlessness, chest tightness or pain, weight loss or fatigue.

They should look at the patient’s medical history, including any pre-existing respiratory conditions or allergies, and relevant family history.

Nurses should examine the patient’s social history for exposure to irritants, whether through their occupation or hobbies, smoking habits, diet or alcohol intake. Any of which could be linked to their chronic cough, says Ms Fisher.

She recommends patients keep a symptom diary to help identify what could be causing or exacerbating their cough.

What can nurses advise for treatment of a chronic cough?

Treating a chronic cough is about identifying the underlying cause or causes, says Ms Fisher.

‘Sometimes this can involve lifestyle changes, such as avoiding what is triggering the cough, for example, stopping smoking, or changes to diet for patients who have GORD.’

With many chronic lung conditions, a personalised management plan can help patients recognise worsening symptoms. And access to respiratory physiotherapy services can help with mucus clearance and breathing techniques, she says.

What is cough hypersensitivity?

Patients can become oversensitive to a cough and experience dysregulation of the cough response, says independent respiratory consultant nurse Jane Scullion. Exposure to something as simple as perfume, talking or laughing can trigger coughing, she says.

The BTS says cough hypersensitivity is a frequently overlooked but treatable trait and requires specific treatment including antitussives (cough suppressants) and non-pharmacological approaches.

Referral to a physiotherapist or language therapist can work well, adds Ms Scullion.

What complications of chronic cough should nurses be alert to?

‘Chronic cough can strain the chest and abdomen muscles, lead to urinary incontinence, and in severe cases people may pass out. It can also lead to stress, anxiety and people feeling isolated,’ says Ms Fisher.

Loss of consciousness during episodes of cough is known as cough syncope and patients with this complication should be advised not to drive and, if they are drivers, to inform the Driver Vehicle Licensing Authority of their condition, the BTS recommends.

Patients experiencing urinary incontinence should be referred to their local multidisciplinary incontinence service for further specialist input and support, the society advises.

Rib fractures from the strain of coughing, nerve pain, sore throats, and problems with aspiration if coughing when eating, are all potential complications, says Ms Scullion.

When and to which services should I refer patients?

Patients with any red-flag symptoms should be referred to the emergency department, or, if not immediately life-threatening, urgently to a specialist respiratory team, says Ms Fisher.

Any patients with coughs that continue despite treatment, or when the diagnosis is unclear, should be referred on, says Ms Scullion.

Patients with red-flag symptoms should be referred to a specialist respiratory team

Picture credit: iStock

Patients should be referred according to the presentation, the BTS says. For example, this could be to a respiratory clinic, or to an ear, nose and throat service if there are predominant upper airway symptoms, such as nasal obstruction and discharge and voice change.

The BTS advises that patients be referred if there is suspected underlying disease such as bronchiectasis, interstitial lung disease, tuberculosis, and heart failure.

‘It’s essential to get to the root cause of what is causing the chronic cough, to prevent any complications and improve patients’ quality of life and well-being,’ says Ms Fisher. ‘And if necessary, it is vital for nurses to seek expert advice for diagnosis and management of patients’ chronic cough.’

Further information

BMJ Thorax (2023) British Thoracic Society Clinical Statement on chronic cough in adults thorax.bmj.com/content/78/Suppl_6/s3

Asthma + Lung UK asthmaandlung.org.uk

Primary Care Respiratory Society pcrs-uk.org