Cough and the Common Cold

ACCP Evidence-Based Clinical Practice Guidelines

Melvin R. Pratter, MD, FCCP

Objective: To review the literature on cough and the common cold.

Methods: MEDLINE was searched through May 2004 for studies published in the English
language since 1980 on human subjects using the medical subject heading terms “cough” and
“common cold.” Selected case series and prospective descriptive clinical trials were reviewed.
Additional references from these studies that were pertinent to the topic were also reviewed.
Results: Based on extrapolation from epidemiologic data, the common cold is believed to be the
single most common cause of acute cough. The most likely mechanism is the direct irritation of
upper airway structures. It is also clear that viral infections of the upper respiratory tract that
produce the common cold syndrome frequently produce a rhinosinusitis. In the setting of a cold,
the presence of abnormalities seen on sinus roentgenograms or sinus CT scans are frequently due
to the viral infection and are not diagnostic of bacterial sinus infection.
Conclusion: Cough due to the common cold is probably the most common cause of acute cough.
In a significant subset of patients with “postinfectious” cough, the etiology is probably an
inflammatory response triggered by a viral upper respiratory infection (ie, the common cold). The
resultant subacute or chronic cough can be considered to be due to an upper airway cough
syndrome, previously referred to as postnasal drip syndrome. This process can be self-perpetu-
ating unless interrupted with active treatment. (CHEST 2006; 129:72S–74S)

Key words: acute cough; common cold; rhinosinusitis; upper respiratory tract infection

Abbreviations: A/D ⫽ antihistamine/decongestant; PND ⫽ postnasal drip; URTI ⫽ upper respiratory tract infection

I nsearched
preparing this section, MEDLINE was
through May 2004 for studies published
rhinoviruses, coronaviruses, parainfluenza viruses,
respiratory syncytial virus, adenoviruses, and entero-
in the English language since 1980 on human sub- viruses. The histologic effects of infection vary from
jects using the medical subject heading terms epithelial destruction to the absence of histologic
“cough” and “common cold.” Selected case series changes, but all can cause vasodilation and hyperse-
and prospective descriptive clinical trials were re- cretion; the clinical syndrome of nasal congestion,
viewed. Additional references from these studies nasal discharge, postnasal drip (PND), throat clear-
that were pertinent to the topic were also reviewed. ing, sneezing, and cough is common to all of these
The common cold is one of the most common infections. Although there is no prospective study of
infectious diseases of humankind.1 Adults in the the causes of acute cough, it has long been consid-
United States experience two to four colds per year. ered that the common cold is the single most
At least 200 identified viruses are capable of causing common cause of acute cough (ie, cough ⬍ 3 weeks
the common cold2; it is thus more aptly termed the in duration).
common cold syndrome. Implicated viruses include The mechanisms by which the viral infection of
the common cold engenders cough is unclear. A
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians ([Link]. randomized double-blind placebo-controlled study
org/misc/[Link]). of cough and the common cold3 has demonstrated
Correspondence to: Melvin R. Pratter, MD, FCCP, Robert Wood statistically significant associations among cough,
Johnson School of Medicine at Camden, Suite 312, 3 Cooper
Plaza, Camden, NJ 08103; e-mail: Pratter-Melvin@ throat clearing, and PND. Cough also improved in
[Link] parallel with decreases in throat clearing and PND.

72S Diagnosis and Management of Cough: ACCP Guidelines

In this study, treatment with an antihistamine/decon- shown to abbreviate symptoms of the common cold
gestant (A/D) preparation containing sustained-re- including cough,2,13 two other studies13,14 and a
lease pseudoephedrine and a first-generation antihis- metaanalysis15 have disputed this conclusion. While
tamine (brompheniramine) led to more rapid topical anticholinergic therapy has been shown pro-
improvement in all three symptoms when compared spectively to decrease rhinorrhea and sneezing,16 this
to placebo. The implication of this study is that the study did not evaluate cough as a symptom. Inter-
primary mechanism responsible for the cough was feron therapy has potential adverse side effects and
the associated virus-induced PND. Alternatively, it is useful only if used prophylactically.17 Specific
has been proposed that a viral upper respiratory tract antiviral therapies for the common cold have shown
infection (URTI) produces inflammatory mediators some promise, but their efficacy is limited by the
that result in an increase in the sensitivity of the myriad of potential viral causes of the common cold
afferent sensory nerves in the upper airway. In a and also by side effects.17,18
prospective study4 on healthy volunteers, it was It is important to appreciate that a diagnosis of
shown that the cough sensitivity to inhaled capsaicin acute bacterial sinusitis cannot be made accurately in
was increased when the volunteers were studied the face of an acute viral infection. The separation
during the acute phase of a viral URTI. A similar between sinusitis and rhinitis has some clinical util-
increase in cough sensitivity associated with URTI ity, but in the setting of the common cold it has been
has also been found when using inhaled citric acid5 clearly demonstrated that the viral infection involves
or nebulized distilled water6 to induce cough. More- all nasal and sinus mucosal surfaces, and that the
over, Madison and Irwin5 have proposed that this term viral rhinosinusitis is more accurate.19,20 In a
increase in cough sensitivity during URTI may be key study20 looking at CT scans of the sinuses of
due to an increased sensitivity of the rapidly adapting patients with recent-onset colds, abnormalities of the
sensory receptors in the airway. The rapidly adapting maxillary sinuses were present in 87% of patients.
sensory receptors are particularly sensitive to me- No patient received antibiotic treatment, and 79% of
chanical stimulation,7,8 and therefore it should be those scanned again at days 13 to 20 had resolution
possible to induce cough with an adequate mechan- or marked improvement in imaging abnormalities
ical stimulus to the upper airway. Recent studies even when air-fluid levels had initially been ob-
have demonstrated that while healthy subjects do not served. While sinus inflammation caused by viral
cough significantly in response to airway vibration, in infection may in some patients be a precursor to
those having a viral URTI, airway stimulation in- bacterial sinusitis, the roentgenographic evaluation
duces a significantly increased cough response. of the sinuses and the presence of abnormalities have
Whatever the actual mechanisms of viral URTI- no clinical specificity for bacterial infection within
induced cough, the study cited above5 demonstrated the first week of onset of the common cold.19 The
that an older, first-generation A/D preparation can specificity for a bacterial process increases with an
be effective in reducing the cough. In contrast, increasing interval from the onset of the original
studies9 –11 have shown that newer generation “non- rhinosinusitis. Therefore, clinical judgment is often
sedating” antihistamines are relatively ineffective in required to decide when to institute antibiotic therapy.
the treatment of the common cold. In a randomized, One of the most important facts to emerge from
double-blind, placebo-controlled trial12 of an exper- the prospective study of cough and the common cold
imentally induced rhinovirus common cold, the non- cited above is that the placebo group allowed for a
steroidal antiinflammatory drug naproxen decreased close look at the natural history of cough in untreated
cough (as well as headache, malaise, and myalgia), common colds. On day 14, the last day of the study,
supporting the contribution of inflammation to the while cough and upper airway symptoms were im-
pathogenesis of cough in the common cold. proving, approximately 25% of patients continued to
As with the treatment of chronic upper airway have symptoms of cough, PND, and throat clearing.
cough syndrome, there are several available options This correlates well with the finding in the CT scan
for the treatment of the symptoms of the common study of sinus changes in the common cold, in which
cold in addition to A/D. Topical ␣-adrenergic ther- 21% of patients had significant persistent anatomic
apy can be used in the short term, although no abnormalities at day 13 to 20. These data, combined
prospective data showing its efficacy are available. with the studies on the diagnosis and treatment of
However, the possible development of rhinitis me- chronic cough, support the concept that a large
dicamentosa makes its prolonged use inadvisable. subset of patients with postinfectious cough has an
Because of conflicting data, it is not clear whether inflammatory response triggered by an upper respi-
zinc-containing compounds are beneficial in treating ratory infection, which causes chronic cough due to
cough due to the common cold. For example, while upper airway cough syndrome and which can be
zinc-containing lozenges have been prospectively self-perpetuating unless interrupted with active

[Link] CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 73S

treatment. For discussion and recommendations re- health-related quality of life in patients complaining of
garding over the counter cough medications for chronic cough. Chest 2004; 125:482– 488
5 Madison JM, Irwin RS. Pharmacotherapy of chronic cough in
cough due to the common cold, see the Cough
adults. Expert Opin Pharmacother 2003; 4:1039 –1048
Suppressant and Pharmacologic Protussive Therapy 6 Schaefer OP, Irwin RS. Unsuspected bacterial suppurative
section (pp 238S–249S). disease of the airways presenting as chronic cough. Am J Med
2003; 114:602– 606
7 Irwin RS. Ex-smoker with productive cough, weight loss, and
Summary of Recommendations draining lesion. Chest 2002; 122:1837–1839
1. Patients with acute cough (as well as 8 Irwin RS, Madison JM. Diagnosis and treatment of chronic
cough due to gastro-esophageal reflux disease and postnasal
PND and throat clearing) associated with
drip syndrome. Pulm Pharmacol Ther 2002; 15:261–266
the common cold can be treated with a 9 Gaffey MJ, Kaiser DL, Hayden FG. Ineffectiveness of oral
first-generation A/D preparation (bromphe- terfenadine in natural colds: evidence against histamine as a
niramine and sustained-release pseudo- mediator of common cold symptoms. Pediatr Infect Dis J
ephedrine). Naproxen can also be adminis- 1988; 7:223–228
tered to help decrease cough in this setting. 10 Berkowitz RB, Tinkelman DG. Evaluation of oral terfenadine
Level of evidence, fair; benefit, substantial; for treatment of the common cold. Ann Allergy 1991; 67:593–
597
grade of recommendation, A 11 Berkowitz RB, Connell JT, Dietz AJ, et al. The effectiveness
2. In patients with the common cold, of the nonsedating antihistamine loratadine plus pseudo-
newer generation nonsedating antihista- ephedrine in the symptomatic management of the common
mines are ineffective for reducing cough cold. Ann Allergy 1989; 63:336 –339
and should not be used. Level of evidence, 12 Sperber SJ, Hendley JO, Hayden FG, et al. Effects of
naproxen on experimental rhinovirus colds: a randomized,
fair; benefit, none; grade of recommendation, D double-blind, controlled trial. Ann Intern Med 1992; 117:
3. In patients with cough and acute URTI, 37– 41
because symptoms, signs, and even sinus- 13 Prasad AS, Fitzgerald JT, Bao B, et al. Duration of symptoms
imaging abnormalities may be indistin- and plasma cytokine levels in patients with the common cold
guishable from acute bacterial sinusitis, the treated with zinc acetate: a randomized, double-blind, place-
bo-controlled trial. Ann Intern Med 2000; 133:245–252
diagnosis of bacterial sinusitis should not be 14 Macknin ML, Piedmonte M, Calendine C, et al. Zinc glu-
made during the first week of symptoms. conate lozenges for treating the common cold in children: a
(Clinical judgment is required to decide randomized controlled trial. JAMA 1998; 279:1962–1967
whether to institute antibiotic therapy.) 15 Jackson JL, Peterson C, Lesho E. A meta-analysis of zinc salts
Level of evidence, fair; benefit, none; grade of lozenges and the common cold. Arch Intern Med 1997;
157:2373–2376
recommendation, D 16 Hayden FG, Diamond L, Wood PB, et al. Effectiveness and
safety of intranasal ipratropium bromide in common colds: a
randomized, double-blind, placebo-controlled trial. Ann In-
tern Med 1996; 125:89 –97
17 Jefferson TO, Tyrrell D. Antivirals for the common cold.
Cochrane Database Syst Rev (database online). Issue 3, 2001
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74S Diagnosis and Management of Cough: ACCP Guidelines