29 Apr Occupational and Environmental Contributions to Chronic Cough in Adults
In response to occupational and environmental exposures, cough can be an isolated symptom reflecting exposure to an irritant with little physiological consequence, or it can be a manifestation of more significant disease. This document reviews occupational and environmental contributions to chronic cough in adults, focusing on aspects not previously covered in the 2006 ACCP Cough Guideline or our more recent systematic review, and suggests an approach to investigation of these factors when suspected.
A summary of suggestions are as follows:
- For every adult patient with chronic cough, we suggest that occupational and environmental causes be routinely elicited in the history.
- The duration, severity, and temporal relationship of the exposure to the onset or exacerbation of the patient’s cough should be noted.
- Smoking history and atopic history should be elicited.
- Material Safety Data Sheets and/or occupational hygiene reviews of the workplace may be helpful in the overall assessment of symptoms including cough.
- The time period between last exposure and medical evaluation should be noted because results of objective testing may be influenced by this (Ungraded, Consensus Based Statement)
- For adult patients with chronic cough, if the history is suggestive of an occupational or environmental association, we suggest that it be confirmed when possible by objective testing, in order to maximize favourable patient outcomes and determine the incidence of occupational and environmental causes of chronic cough. This may include pulmonary function testing and rhinolaryngoscopy (Ungraded, Consensus Based Statement).
- For adult patients with chronic cough with an occupational or environmental exposure history, we suggest that appropriate objective tests should be performed to elucidate potential mechanistic associations between cough and the suspected exposure. These include the following:
- Mannitol challenge for cough associated with work-related asthma/eosinophilic bronchitis
- Sputum/induced sputum cytology for eosinophilia
- Before and after exposure tests to demonstrate potential causality (eg, perform both at the end of a regular working week and, if positive, repeat at the end of a period off work such as the end of vacation, to document any work-related changes)
- Immunologic tests for hypersensitivity guided by specific exposure history including:
- Skin tests
- Specific serum IgE antibodies
- Specific serum IgG antibodies for suspected hypersensitivity pneumonitis
- Beryllium lymphocyte proliferation tests for chronic beryllium disease (Ungraded, Consensus Based Statement)
- For adult patients with chronic cough and a high suspicion of cough due to environmental and/or occupational exposures, we suggest that these patients be managed according to evidence-based guidelines for these exposures and/or be referred to specialists with expertise in environmental and occupational disease (Ungraded, Consensus Based Statement).
Tarlo, Susan M. Adams, Todd M. et al. Occupational and Environmental Contributions to Chronic Cough in Adults CHEST, Volume 150 , Issue 4 , 894 – 907 doi.org/10.1016/j.chest.2016.07.029