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Know Your Cough: A New Index to Assess Effects of Cough Severity on Patient’s Health and Overall Symptoms – An Indian Survey Report

Authors:
  • Dr Varsha's Health Solutions
Ashok et al., Prim Health Care 2017, 7:3
DOI: 10.4172/2167-1079.1000277
Volume 7 • Issue 3 • 1000277
Prim Health Care, an open access journal
ISSN: 2167-1079
OMICS International
Research Article
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ISSN: 2167-1079
Primary Health Care: Open Access
*Corresponding author: Varsha N, Head Medical Affairs, Wockhardt Ltd.,
Wockhardt Towers, BKC, Mumbai 400051, India, Tel: 9821041805; E-mail:
vnarayanan@wockhardt.com
Received August 10, 2017; Accepted August 24, 2017; Published August 31,
2017
Citation: Ashok M, Girish R, Varsha N (2017) Know Your Cough: A New Index to
Assess Effects of Cough Severity on Patient’s Health and Overall Symptoms – An
Indian Survey Report. Prim Health Care 7: 277. doi: 10.4172/2167-1079.1000277
Copyright: © 2017 Ashok M, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
Keywords: Chronic cough; Patient’s health; Respiratory disease
Introduction
e relationship between physiologic measures of cough intensity
and treatment decisions to improve the quality of patient’s life is yet
to be investigated. erefore, there is a need to develop real time
investigation which should be based on the clinical setting, population
examined, and available expertise [1,2].
Generally, the management of cough either acute or chronic is based
on etiology, type of cough and underlying and associated conditions.
e diagnostic evaluation of cough can be challenging for physicians
as it is a nonspecic symptom of respiratory disease including
the inhalation of a foreign body, airway lesions, airway allergies,
environmental pulmonary toxicants, non-asthmatic eosinophilic
bronchitis, respiratory infections and post infectious cough, side eects
of medications, and other otogenic causes with a broad dierential
diagnosis where the pattern of respiratory illness varies with age,
gender and type of population. To enhance patient’s satisfaction, there
must be an eective evaluation and diagnostic approach to treat this
disorder [2,3].
Guidelines to help health care providers for diagnosing and managing
cough have been published globally, Europe and Japan reecting its
magnitude and importance to medical care around the world [2-6]. Various
questionnaire based surveys have also been conducted in dierent regions
to understand the prevalence, pathology and etiology of cough [7-10].
e American Laryngological, Rhinological and Otological Society have
developed and validated a cough severity index (CSI) for chronic cough
related to the upper airway, which is a short, simple instrument consisting
of 10 questions which are scored from 0-4 and assess the cough of the
patient in terms of its eect on disturbing day to day life. It is a universally
standard CSI scale to measure treatment out comes in the clinical setting
to quantify patient’s symptoms of chronic cough of upper airway origin.
However, the questions are very specic and are not all-inclusive when it
comes to the general chronic cough population [11].
e present study is a survey report among Indian urban and
semi-urban population coming to FPs which is a heterogenous mix in
terms of standards of living, climatic and environmental conditions,
nutritional and lifestyle habits as well as education status therefore
can be a representative of the heterogenous world population. is
study is based on two questionnaires; established CSI and another 8
point general know your cough (KYC) questionnaire designed by the
authors. e aspect of addressing ‘Quality of Life’ in cough management
is of importance for improving patient outcomes worldwide and the
questionnaires and scores are designed to serve any population. We
have made eorts to provide a clinically relevant and data driven
approach based on real time studies which can be considered in future
to help physicians for planning patient management for cough.
Materials and Methods
Participants’ enrollment
A total of 23, 157 patients above age of 18 years were enrolled. e
data collection was completed in 3 months (April 2017 to July 2017).
e participants were randomly selected from general population from
all the zones of India. All participants’ information; demographic and
personal, was entered into a database with the participant’s diagnosis.
While recruitment, they all were examined for their previous
history of cough (if any).
Study procedures
A survey named Know Your Cough (KYC) survey was conducted
with over 2209 general physicians (GPs) in India.
e patients recorded their responses in the two questionnaires:
an 8-point general KYC questionnaires – to understand general trends
in cough epidemiology (Appendix 1) and ten point CSI questionnaire
recommended by the American Laryngological, Rhinological and
Otological society [11].
Questionnaire’s characteristics
e 8-point general KYC questionnaire: It was designed as per
the specic questions. e questions were divided in ve categories: a)
patient history, b) cough characteristics, c) symptoms accompanying
with cough, d) co-existing conditions and e) medical trends for
administering drugs. e percentage response rate of patients for every
question was recorded.
Know Your Cough: A New Index to Assess Effects of Cough Severity on
Patients Health and Overall Symptoms – An Indian Survey Report
Ashok M1, Girish R2 and Varsha N3*
1Hinduja Hospital Mumbai, India
2Consultant ENT Physician, Indraprastha Apollo Hospital, New Delhi, India
3Wockhardt Ltd., Wockhardt Towers, BKC, Mumbai 400051, India
Abstract
Cough intensity is an important determinant of global cough severity. Acute cough usually resolves in less than
2-3 weeks while if prolonged, it is considered chronic cough (lasting longer than 8 weeks). The classifying of cough
based on ‘severity’ and its impact on the daily life of the patient is an important gap in the management. In most of
the clinical studies conducted so far, there is generally a lack of specic and sensitive data of individual symptoms for
cough evaluation.
Citation: Ashok M, Girish R, Varsha N (2017) Know Your Cough: A New Index to Assess Effects of Cough Severity on Patient’s Health and Overall
Symptoms – An Indian Survey Report. Prim Health Care 7: 277. doi: 10.4172/2167-1079.1000277
Page 2 of 4
Volume 7 • Issue 3 • 1000277
Prim Health Care, an open access journal
ISSN: 2167-1079
e 10-point CSI questionnaire: e questionnaire had 10
questions which were based on the common symptoms relating to
chronic cough associated with upper airway pathology. e questions
airway pathology. e questions were designed as per the day to day
situations being faced by cough patients during the study period. Every
question had to be answered based on 5 point Likert scale (i.e., 0=never;
1=almost never; 2=sometimes; 3=almost always; 4=always). e
patients were asked to circle the response that indicated how frequently
they experience the same symptoms. From the mean and standard
deviation results, anyone with a score of 2 standard deviations (SD)
above the mean (i.e., >3.23) was considered signicantly or severely
symptomatic for cough.
Based on the above ndings from both the questionnaires, nal
CSI was calculated and shared with the treating GP along with the
patient responses, for physician’s consideration in planning patient
management.
Results
KYC results
e percentage response rate of patients was calculated for all the
questions.
Patient history: Overall, 85% (n=19683/23157) of the patients
responded “Yes” for the presence of cough while starting the study,
out of which 77.5% (n=15254/19683) showed symptoms of acute
cough of the OPD patients who were not having cough currently, 85%
(n=2953/3474) had some past history of cough in preceding 3 months.
Figure 1 represents the percentage of patients and their duration of
cough; 3 months before the study and at the study commencement.
Cough characteristics (time of worsening and cough type):
Patients were asked for the time at which they feel their cough was
worst, the percentage response rates were recorded for morning,
aernoon, evening and night. Majority (39%) of the patients complained
worsening condition during night time. For cough type, 66% felt that
their cough was dry without phlegm and 34% complained of phlegm
that needed to be spit (Figure 2).
Symptoms accompanying cough: e symptoms such as nasal
symptoms, sore throat, fever and ear pain present with cough were
also examined. Percentage response rates against all symptoms were
recorded. Sore throat was found associated (34%) in many of the patients.
e patients (77%) complained of some degree of breathlessness like
‘run out of air’ aer coughing, 80% felt cough aected their voice and
77% also pointed that cough restricted their physical activity.
Common coexisting conditions with cough: Patients were
evaluated for co- morbid conditions of which smoking (27%) was
found to be the major risk factor. Diabetes (14%), hypertension (17%)
and airway allergies/asthma (18%) were also associated co morbidities
in patients.
Medical trends: On evaluation of medical trends followed; patients
undergoing self-medication or taking prescribed medications, it
was found that only 45% of patients were actually taking medicines
prescribed by doctors and 17% were those who were on self-medication.
Rest were either not taking or were dependent on local chemists
recommendations.
CSI scores: e CSI scale results were evaluated on 0-4 scales.
Figure 3 shows the scores evaluated. Each QOL parameter above was
aecting 75-80% patients.
Severity index: e nal severity index was calculated, considering
CSIs>3.2=2 SD above the mean; signicant cough severity was found in
8% (n=1853) patient population (Figure 4).
Discussion
e KYC survey is an initiative taken to prepare an index for
the patients in India to evaluate cough severity so that to propose an
ecient and well planned cough management system to GPs. In India,
however, only some community-based studies with as many factors
associated with cough have been investigated previously to study the
prevalence and determinants of caregivers’ practice for treating cough
[9,10,12-14]. As per the latest survey (2016) conducted by Apte et al.
in 880 urban cities and townsof India, cough was found to be the
second most common symptom reported in primary care practice in
India[10].
e KYC index was designed taking in to consideration the general
problems reported in the patients with cough. CSI was considered
as a key parameter to understand the trends in cough epidemiology.
CSI gives a clear picture of severity of cough; if it is acute or chronic.
Figure 1: Algorithm presenting (q1, 2 and 3) of kyc index-patient history
(percentage of patients and their duration of suffering; 3 months before the
study and at study commencement).
Figure 2: Patients Response (%age) for KYC Index- Worsening at cough
timings (Q4), Cough type (Q5), Symptoms associated with cough (Q6), Co-
existing conditions with cough (Q7) and Medical trends of administration of
drugs (Q8).
Citation: Ashok M, Girish R, Varsha N (2017) Know Your Cough: A New Index to Assess Effects of Cough Severity on Patient’s Health and Overall
Symptoms – An Indian Survey Report. Prim Health Care 7: 277. doi: 10.4172/2167-1079.1000277
Page 3 of 4
Volume 7 • Issue 3 • 1000277
Prim Health Care, an open access journal
ISSN: 2167-1079
e index was specically categorized for the questions including all
the important factors which were supported by the relevant literature
and studies conducted in past. e present KYC survey included a
large sample size for patients and GPs which was estimated utilizing
the available information on the prevalence of cough in India which is
3.49% among the adults >35 years of age [13]. erefore, we included all
the adult patients without any gender, race or ethnicity bias.
Mahesh et al. in their study conducted at Mysore, India have
shown that the prevalence of chronic cough and chronic phlegm, are
the important indicators of respiratory morbidity and mortality, the
study showed that the prevalence of chronic cough in the population
studied was 2.5% and the prevalence of chronic phlegm was 1.2% [9].
Few pediatric studies have reported that nocturnal cough is a major
risk factor for asthma and rhinitis [15,16]. We reported that dry cough
was more prominent in the adult patients and they mostly complained
worsening of cough in night when they lie down.
Cough is oen accompanied with cold and soreness in throat.
Other symptoms like nasal secretions, fever and ear pain also coexist
in many patients. A report on a questionnaire based survey for
physicians in Mumbai, India for the prevalence and management of
dry cough reported the associated symptoms ‘frequently’ were sore
throat (73.0% physicians), sleep disturbance (51.4% physicians),
fever (49.8% physicians), and nausea and vomiting (9.0% physicians).
As per physicians, 19.6% of their patients had allergy/asthma and
19% physicians reported coronary artery diseases are the co-morbid
conditions associated with cough [14]. We reported that besides above
symptoms, almost 50-60% patients had co-morbid cardiovascular
disease (CVD) risks with cough. Our survey report showed that many
patients also felt some degree of breathlessness like ‘run out of air’ aer
coughing, reduced physical activity and aected voice aer coughing.
For the various risk factors considered in questionnaire,
environmental tobacco smoke is found to be the major risk factor.
Jaakkola et al., quoted in their studies that smoking is the leading
cause of cough especially in the women and children [17]. Jindal and
his coworkers in their multicentre study on epidemiology of chronic
obstructive pulmonary disease, reported that there is a signicant
relationship with tobacco smoking and environmental tobacco smoke
exposure with all kind of respiratory disorders [12]. In our study, we
reported 27% of patients had a smoking history.
Besides smoking, diabetes, hypertension and asthma or other airway
allergies could also be associated with cough. A recent survey based
analysis to understand the management of dry cough among primary
care physicians in Indian clinical setting; 33% physicians suggested that
hypertension is the most common comorbid condition associated with
cough followed by diabetes (28% physicians) [14]. Cough is the initial
worsening sign that may be associated with wheezing and shortness
of breath in the asthmatic patients. erefore airway allergies should
always be kept in mind as a possibility for chronic cough.
Another important factor which is usually overlooked in many
studies; self or prescribed medication was also considered. As this
Figure 3: CSI scores: Percentage response rates against scores.
Figure 4: Cough severity index (CSI): Proportion of patients with severe cough.
Citation: Ashok M, Girish R, Varsha N (2017) Know Your Cough: A New Index to Assess Effects of Cough Severity on Patient’s Health and Overall
Symptoms – An Indian Survey Report. Prim Health Care 7: 277. doi: 10.4172/2167-1079.1000277
Page 4 of 4
Volume 7 • Issue 3 • 1000277
Prim Health Care, an open access journal
ISSN: 2167-1079
survey was done in the patients who had come for doctor’s consultation,
the proportion of self-medication (17%) or direct buying from chemist
(25%) may be lower. is component should be considered important;
it has seen to be high in surveys done directly with general adult
population. WHO in one of its survey conducted on non-prescribed
use of antibiotics for children in an urban community in Mongolia
reported that fewer than half of the respondents (n=210/503) had given
antibiotics to the index child without a prescription for symptoms of
upper respiratory tract infection such as cough (84%), fever (66%)
or nasal (65%) and throat symptoms (60%). e main source of
non-prescribed antibiotics were pharmacies (86%) [18]. Although,
respiratory tract infections are the most common label associated with
cough, still the practice of administering drugs without prescription or
without diagnosis is being followed. In another Indian survey, it was
reported that 68.7% of cough patients were treated without any specic
underlying diagnosis [10]. erefore, there is a need to educate GPs in
India on cough management.
e strengths of our study were its large sample size, good study
design, and good sampling strategy. Further, we have focused on all
the factors which can help physicians for the management of cough to
substantially improve patient’s QoL.
Ciccone et al. had studied and recommended assigning care
managers, besides GPs and family physicians (FPs), in the oces of GP
/FP along with the support of dedicated soware for data collection and
care management decision to improve patient health outcomes [19].
Data of our study has highlighted some interesting results. However, the
available information is based only on questionnaire lled by patients;
the questionnaire obtained from physicians as well could have served
a better purpose. Also, we have not validated the questionnaire on
any statistical tests. ough, the index is not providing any diagnostic
support to treat cough but it is a guiding tool for the physicians to opine
on which symptoms indicate the type of severity (i.e., acute or chronic).
is can help largely in opting for the treatment approach.
Based on these study results, we further recommend research
which should include assessing treatment outcomes of patients in
whom QOL parameters were considered in management decisions so
that to identify and validate which factors and which order can work
together to explain chronic cough.
Conclusion
e KYC survey has provided some important conclusions which
are though not diagnostic but can be used by clinicians to evaluate the
treatment. KYC covers a broad range of quantiable eects of cough
on patient’s health and overall symptom severity, while simultaneously
address clinical practicality.
Acknowledgement
We acknowledge the contribution of Mr. Rajiv Kapoor (Business Unit Head
Wockhardt (Orion)), Mr. Shailendra Tripathi (Marketing Head Wockhardt (Orion))
and Mr. Sharad Aggarwal (Group Product Manager Wockhardt (Orion)) in
logistical execution of the survey and Knowledge Isotopes Pvt. Ltd. (http://www.
knowledgeisotopes.com) contribution in medical writing and drafting.
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Citation: Ashok M, Girish R, Varsha N (2017) Know Your Cough: A New Index
to Assess Effects of Cough Severity on Patient’s Health and Overall Symptoms
– An Indian Survey Report. Prim Health Care 7: 277. doi: 10.4172/2167-
1079.1000277
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Cough is a common symptom reported in PC. We aimed to determine the prevalence of cough and its associated diagnoses as reported by primary care physicians (PCPs) across all age groups in the POSEIDON study in India. Methods: 13,225 general practitioners (GPs), general physicians (GenPs) and pediatricians (Ps) from 880 urban cities and towns were randomly selected and invited to participate in this 1-day point prevalence study. Clean data was entered in Epi-Info software. Simple descriptive analysis was performed. Results: 7400 PCPs (60.6% GPs, 20.8% GenPs, 18.8% Ps) consented and provided clean data of 204,912 patients. Fever (35.5%) and cough (30%) were the most common symptoms reported. ----28.1%, 25.5% and 41.6% of patients seen by GPs, GenPs and Ps respectively were reported to have cough as a presenting symptom with males showing a higher prevalence [OR 1.2, CI (1.17, 1,23) p<0.0001]. Among reported cases of cough, a conclusive diagnosis was made in only 30.7%, 36.1% and 29.4% by GPs, GenPs and Ps respectively. Diagnoses made in these cases were Upper respiratory Tract Infections (12.2%), Lower Respiratory Tract Infections (8.1%), Asthma (7.4%), COPD (4%), Tuberculosis (2.5%) and Congestive Cardiac Failure (0.5%). Conclusion: Cough was the second most common symptom reported in PC practice in India. Although respiratory tract infections were the most common label associated with cough, 68.7% of cough patients were treated without any specific underlying diagnosis. PCPs in India need to be educated on cough management.
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Purpose: The aim of the survey was to understand the prevailing practice pattern for the management of dry cough among primary care physicians in Indian clinical setting. Material and methods: This single visit, cross-sectional, non-interventional, interview based physician survey was conducted over a period of 3 months where 500 registered physicians with at least 6 months of clinical practice and willing to participate in the survey were interviewed in their clinic or hospital from June to August 2015. They were asked to complete a structured questionnaire, consisting of 28 questions, regarding their routine clinical practice ranging from patient demographics to etiology to treatment modalities for management of dry cough. Results: Approximately 40% physicians reported that 11-20% of their patients had dry cough predominantly. 57% and 46% physicians reported acute and chronic dry cough in >30% of their patients, respectively. 68% physicians reported that > 21% of their patients with chronic dry cough were smokers and 61-62% physicians reported that 11-30% of their patients had exposure to pollution. As per physicians, 19.6% of their patients had allergy/asthma followed by respiratory tract infections (17.6% patients), smokers cough (11.4%) and gastroesophageal reflux disease (10.4%). 86.4% physicians recommended that the underlying cause of chronic dry cough should be determined prior to initiating the specific therapy and 13.6% recommended that cough should be suppressed to improve quality of life of the patients. Dextromethorphan (ranked 1 by 68% physicians) and codeine (ranked 2 by 47% physicians) were the most recommended antitussives in patients with dry cough. Conclusions: Dry cough causes the significant impairment in patient's daily associated activities. An increased awareness of treatment patterns for the management of dry cough among physicians could significantly improve patient's quality of life.
Article
BACKGROUND: The intensity of cough is an important determinant of cough severity. Few studies have quantified cough intensity in patients with chronic cough with objective measures. We investigated the intensity of voluntary, induced, and spontaneous cough in patients with chronic cough and healthy control subjects. METHODS: Patients with chronic cough and control subjects underwent physiologic assessment of the intensity of maximum voluntary, capsaicin-induced, and spontaneous cough. Assessments included measurement of gastric pressure (Pga) and esophageal pressure (Pes) during cough, peak cough flow (PCF), expiratory muscle strength (twitch gastric pressure [TwPga]), and cough compression phase duration (CPD). Subjective perception of cough intensity was assessed using a visual analog scale (VAS). RESULTS: Pes, Pga, and PCF during maximum voluntary cough were significantly greater in patients with chronic cough compared with control subjects (P = .003-.042). There was no difference in TwPga between patients and control subjects. CPD was increased in female patients compared with control subjects (mean ± SD, 0.50 ± 0.22 s vs 0.28 ± 0.17 s; P = .007). Mean ± SD Pes during spontaneous cough was comparable to induced cough (128 ± 28 cm H2O vs 122 ± 37 cm H2O, P = .686) but less than maximum voluntary cough (170 ± 46 cm H2O, P = .020). Median within-subject correlation coefficients between cough intensity VAS and Pes, Pga, and PCF were r = 0.82 to 0.86. CONCLUSIONS: Maximum voluntary cough intensity was increased in patients with chronic cough compared with control subjects. There was no significant difference in expiratory muscle contractility. Further studies should evaluate the compressive phase of cough in more detail. Physiologic measures of cough intensity correlated strongly with subjective perception of intensity in patients with chronic cough and may be relevant objective outcome measures for clinical studies.
Article
Objectives/hypothesis: To develop and validate a cough severity index (CSI) which quantifies patients' symptoms associated with upper airway chronic cough and to provide a tool for treatment outcome measures. Methods: Two hundred patients who had a complaint of chronic cough and/or dyspnea were given a 49- item questionnaire developed through a clinical consensus of the most common symptoms of chronic cough of upper airway origin. The instrument was reduced to 10 questions using statistical methodology. Fifty subsequent patients were given the CSI to measure test-retest reliability at two different moments in time. Twenty healthy controls (HC) were given the instrument to obtain validity. An additional 95 participants provided pre- and posttreatment outcomes using the CSI. Results: Principle Component Analysis (PCA) revealed a single factor with the original 49 questions. A combination of PCA, rank-ordering item-total correlation and communality, as well as clinical consensus further reduced the questionnaire to 10 items. Internal consistency of the CSI was 0.97. Test-retest reliability was r = 0.83. An r = 0.60 for divergent validity between the CSI and the Cough-Specific Quality-of-Life Questionnaire (CQLQ) demonstrated two fairly separate instruments, although both measured cough. Mann-Whitney test was significant between symptomatic patients and healthy controls (P < 0.0004). The results of 20 HC showed a mean of 0.45 (standard deviation = 1.39). Results for treatment outcomes revealed significance with the Wilcoxon test (P < 0.0001) and paired samples t test showed significantly different correlations between pre- and postmeasures. Conclusion: The CSI is a short, simple instrument that can be used in the clinical setting to quantify a patient's symptoms of chronic cough of upper airway origin. It represents a statistically reliable, valid, and clinically relevant instrument that can be used to measure treatment outcomes for chronic cough.
Article
Chronic cough and chronic phlegm are important indicators of respiratory morbidity, accelerated lung function decline, increased hospitalization and mortality. This study was planned to estimate the prevalence of chronic cough and phlegm in the absence of dyspneoa and wheezing and to study its associated factors in a representative population of Mysore district. A cross-sectional survey was planned in a representative population of Mysore taluk. Eight villages were randomly selected based on the list of villages from census 2001. Trained field workers using the Burden of Obstructive Diseases questionnaire carried out a house-to-house survey. A total of 4333 adult subjects were enrolled in the study with 2333 males and 2000 females. The prevalence of chronic cough in the community was 2.5 per cent and that of chronic phlegm was 1.2 per cent. A significant association was observed between chronic cough and age, gender, occupation and smoking and chronic phlegm with age, gender, occupation, indoor animals and smoking. A multivariate analysis confirmed independent association of age, occupation and smoking for chronic cough and age and smoking for chronic phlegm. On sub-group analysis of males, heavy smokers had higher prevalence of chronic cough and chronic phlegm as compared to light smokers and non smokers. The prevalence of chronic cough was 2.5 per cent and chronic phlegm was 1.2 per cent in the general population in Mysore which is lower than that observed in other studies. Heavy smoking was an important preventable risk factor identified in this study and efforts towards smoking cessation are crucial to achieve good respiratory health in the community.
Article
Cough is a common and important respiratory symptom that can produce significant complications for patients and be a diagnostic challenge for physicians. An organized approach to evaluating cough begins with classifying it as acute, subacute, or chronic in duration. Acute cough lasting less than 3 weeks may indicate an acute underlying cardiorespiratory disorder but is most commonly caused by a self-limited viral upper respiratory tract infection (eg, common cold). Subacute cough lasting 3 to 8 weeks commonly has a postinfectious origin; among the causes, Bordetella pertussis infection should be included in the differential diagnosis. Chronic cough lasts longer than 8 weeks. When a patient is a nonsmoker, is not taking an angiotensin-converting enzyme inhibitor, and has a normal or near-normal chest radiograph, chronic cough is most commonly caused by upper airway cough syndrome, asthma, nonasthmatic eosinophilic bronchitis, or gastroesophageal reflux disease alone or in combination.