Cough

Last updated 31 May 2026 · Respiratory

📋 Key Information Summary

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Acute cough (<3 weeks) is most commonly due to upper respiratory tract infection (URTI), acute bronchitis, or pertussis; the majority are self-limiting and do not require antibiotics.
Subacute cough (3–8 weeks) most often follows a post-infectious aetiology; consider Bordetella pertussis in unvaccinated or waning-immunity adults — pertussis PCR on nasopharyngeal swab is the investigation of choice.
Chronic cough (>8 weeks) in non-smokers with a normal chest X-ray is most frequently caused by upper airway cough syndrome (UACS), asthma, gastro-oesophageal reflux disease (GORD), or a combination thereof.
Upper airway cough syndrome (UACS) — treat with first-generation antihistamines (e.g. dexchlorpheniramine) or intranasal corticosteroids (e.g. fluticasone propionate); trial therapy is both diagnostic and therapeutic.
GORD-related cough may present without classic heartburn; empirical PPI therapy (e.g. esomeprazole 40 mg daily) for ≥8 weeks is a reasonable diagnostic trial.
Haemoptysis always warrants investigation — massive haemoptysis (>200 mL/24 h or haemodynamic instability) is a medical emergency requiring resuscitation, bronchial artery embolisation, and urgent respiratory/thoracic surgical consultation.
Chest X-ray (CXR) is the first-line investigation for any patient with haemoptysis, chronic cough, red-flag features, or cough lasting >8 weeks.
ACE inhibitor-induced cough affects 5–35% of patients; switch to an ARB (e.g. irbesartan, losartan) — cough resolves within 1–4 weeks of cessation.
Cough in children — aetiology is age-dependent: neonates (congenital anomalies, aspiration), infants (viral bronchiolitis, pertussis), preschool (viral URTI, asthma), school-age (asthma, UACS, psychogenic).
Pertussis remains endemic in Australia; the paroxysmal "whooping" cough phase lasts 1–10 weeks; notify to the State/Territory health department and treat with macrolides (azithromycin) within 21 days of onset to reduce transmission.
Red-flag features requiring urgent investigation: haemoptysis, weight loss, night sweats, new cough in a smoker >45 years, dysphagia, hoarseness, stridor, or systemic symptoms suggestive of malignancy or TB.
Aboriginal and Torres Strait Islander Australians have higher rates of chronic suppurative lung disease, bronchiectasis, pertussis, and rheumatic heart disease — all of which present with chronic cough and require a lower threshold for investigation.

Introduction & Australian Epidemiology

Cough is the most common symptom prompting presentation to Australian general practice, accounting for an estimated 3–4 million consultations annually. It serves as a vital protective reflex — clearing secretions and foreign material from the airways — but when persistent, it significantly impairs quality of life, disrupts sleep, and causes social embarrassment.

The diagnostic approach to cough is guided by its duration: acute (<3 weeks), subacute (3–8 weeks), and chronic (>8 weeks). In Australian primary care, acute cough overwhelmingly results from viral upper respiratory tract infections (URTIs). Chronic cough affects approximately 10–12% of the adult population and, in non-smokers with a normal chest radiograph, is most frequently attributable to upper airway cough syndrome (UACS), asthma, and gastro-oesophageal reflux disease (GORD) — often in combination.

Australia's diverse population and geography present unique epidemiological considerations. Pertussis remains endemic with cyclical peaks every 3–5 years; the 2009–2012 and 2015–2017 outbreaks resulted in >40,000 notifications nationally. Aboriginal and Torres Strait Islander Australians experience disproportionately higher rates of chronic suppurative lung disease, bronchiectasis, rheumatic fever-related mitral valve disease, and tuberculosis — all important causes of chronic cough. Rural and remote communities face additional barriers including limited access to spirometry, specialist respiratory services, and CT imaging.

This article provides a structured, evidence-based diagnostic framework for cough in Australian practice, covering the diagnostic model, GORD-related and upper airway cough syndrome, haemoptysis, and cough in children.

Cough Diagnostic Model (Acute vs Chronic)

Classification by Duration

Category	Duration	Common Causes	Key Differentials
Acute	<3 weeks	Viral URTI (rhinovirus, RSV, influenza, SARS-CoV-2), acute bronchitis, pertussis	Pneumonia, pulmonary embolism, foreign body
Subacute	3–8 weeks	Post-infectious cough, pertussis, Mycoplasma pneumoniae	New-onset asthma, UACS, early malignancy
Chronic	>8 weeks	UACS, asthma, GORD, non-asthmatic eosinophilic bronchitis (NAEB), ACE inhibitor	Lung cancer, bronchiectasis, TB, ILD, chronic aspiration

Acute Cough Algorithm

Identify red flags

Respiratory distress, haemodynamic instability, haemoptysis, pleuritic chest pain, high fever (>38.5°C), signs of consolidation, or immunocompromise — proceed to urgent CXR and consider CT pulmonary angiography (CTPA) if PE suspected.

Assess for pneumonia

Fever ≥38°C, tachypnoea, focal crackles/bronchial breathing, CRP >50 mg/L. Use the CRB-65 score for community-acquired pneumonia (CAP) severity stratification.

Consider pertussis

Paroxysmal cough, inspiratory whoop, post-tussive vomiting, cough >2 weeks without other cause. Obtain nasopharyngeal swab for B. pertussis PCR and notify public health.

Manage self-limiting URTI / acute bronchitis

Reassure, symptom management (honey for >1 year of age, saline nasal irrigation, paracetamol/ibuprofen). Antibiotics are NOT routinely indicated for acute bronchitis in immunocompetent adults — advise 5–10% may still be coughing at 3 weeks.

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Antibiotic stewardship: Acute bronchitis in immunocompetent adults should not be treated with antibiotics. A Cochrane review (2017) demonstrated minimal benefit (0.5 day shorter cough) with significant adverse effects. Reserve antibiotics for confirmed bacterial pneumonia, pertussis, or patients with significant comorbidities (e.g. COPD exacerbation, immunosuppression).

Chronic Cough — The Anatomical Diagnostic Protocol

The systematic evaluation of chronic cough (often termed the "anatomical diagnostic protocol") proceeds through identifiable causes before considering refractory or unexplained cough. The three most common aetiologies in adults are UACS, asthma, and GORD — which coexist in up to 62% of cases.

History & examination

Medication review (ACE inhibitors, ARBs rarely), smoking status, occupational exposures, atopic history, nasal symptoms, heartburn, sputum character, weight loss, and travel history. Examine ears (Arnold nerve reflex), oropharynx (cobblestoning), chest, and cardiac status.

Chest X-ray

Mandatory for all chronic cough presentations. Identifies malignancy, parenchymal disease, bronchiectasis patterns, cardiomegaly, and pleural effusion.

Remove offending agents

Discontinue ACE inhibitor → switch to ARB. Allow 4 weeks for resolution. Encourage smoking cessation (refer to Quitline 13 7848 or QuitCoach).

Empirical sequential trials

Treat UACS → asthma → GORD sequentially (each ≥2–4 weeks). Response to therapy is both diagnostic and therapeutic. If cough resolves at any step, diagnosis is confirmed.

Further investigations

Spirometry with bronchodilator reversibility, FeNO (>40 ppb suggestive of eosinophilic airway inflammation), HRCT chest (bronchiectasis, ILD), 24-hour oesophageal pH/impedance monitoring, bronchoscopy if suspicion of endobronchial lesion or foreign body.

Pertussis — A Key Cause of Subacute Cough

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Pertussis is a notifiable disease in all Australian States and Territories. Laboratory-confirmed and clinically suspected cases must be notified to the relevant public health unit. Notifications have risen since 2024, with waning vaccine immunity in adolescents and adults contributing to ongoing transmission to vulnerable neonates.

Clinical Phases of Pertussis

Catarrhal phase (1–2 weeks): coryza, mild cough, low-grade fever — most infectious
Paroxysmal phase (1–10 weeks): violent coughing fits, inspiratory whoop, post-tussive vomiting, cyanosis
Convalescent phase (weeks–months): gradual resolution of paroxysms, recurrent cough with subsequent URTIs

Diagnosis & Treatment

PCR: nasopharyngeal swab or aspirate — highest sensitivity in first 3 weeks
Serology: anti-pertussis toxin IgG — useful after 2 weeks of cough
Treatment (within 21 days of onset): Azithromycin 500 mg Day 1, then 250 mg Days 2–5 (adults); reduces transmission but does not alter clinical course once paroxysmal phase established
Post-exposure prophylaxis: same azithromycin regimen for household/close contacts

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Azithromycin

Zithromax® · APO-Azithromycin · Macrolide

Adult dose 500 mg PO Day 1, then 250 mg PO Days 2–5 (or 500 mg PO daily × 3 days)

Paediatric dose 10 mg/kg PO Day 1, then 5 mg/kg PO Days 2–5 (max 500 mg Day 1)

Route Oral (IV for severe infection)

Duration 5 days (pertussis prophylaxis/treatment)

Renal adjustment No adjustment required (eGFR >10 mL/min)

Hepatic adjustment Use with caution in severe hepatic impairment

PBS status ✔ PBS General Benefit

GORD-Related & Upper Airway Cough Syndrome

Upper Airway Cough Syndrome (UACS)

UACS (formerly "post-nasal drip syndrome") is the single most common cause of chronic cough, responsible for up to 40% of cases when measured by response to empirical therapy. It encompasses a heterogeneous group of conditions including allergic rhinitis, vasomotor rhinitis, chronic sinusitis, and non-allergic rhinitis with eosinophilia (NARES). The mechanism involves pharyngeal/laryngeal irritation from secretions and/or direct stimulation of upper airway cough receptors.

Clinical Features

Sensation of "something dripping" down the back of the throat
Nasal congestion, rhinorrhoea, frequent throat clearing
Cobblestoning of the posterior pharynx on examination
Mucoid or mucopurulent post-nasal discharge
Worse in the morning or with positional changes

Management

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Intranasal Fluticasone Propionate

Flixonase® · Flomist® · Intranasal corticosteroid

Adult dose 100 mcg per nostril once daily (200 mcg daily total)

Paediatric dose 50 mcg per nostril once daily (≥4 years); 1 spray per nostril daily (2–4 years)

Duration Minimum 4 weeks trial; continue for 3 months if effective

PBS status ✔ PBS General Benefit

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Ipratropium Bromide (Intranasal)

Atrovent® Nasal · Anticholinergic

Adult dose 42 mcg (2 sprays) per nostril BDS–TDS for vasomotor rhinitis

Duration Ongoing as needed

PBS status ⚠️ PBS Authority Required

For suspected chronic sinusitis, consider addition of saline nasal irrigation (NeilMed® or equivalent), a short course of intranasal decongestant (xylometazoline ≤5 days), and antibiotic therapy (amoxicillin-clavulanate 875/125 mg PO BD for 21 days) if mucopurulent discharge or CT-confirmed sinusitis.

GORD-Related Chronic Cough

GORD is the third most common cause of chronic cough, implicated in 20–40% of cases. Importantly, up to 75% of patients with GORD-related cough do not report typical heartburn or regurgitation ("silent reflux"). The mechanism involves vagally-mediated oesophagobronchial reflex, micro-aspiration of gastric contents, and laryngeal irritation.

Diagnostic Approach

Empirical PPI trial

Esomeprazole 40 mg PO daily (30 min before breakfast) for 8 weeks. Twice-daily PPI (BD dosing) may be more effective. This is both diagnostic and therapeutic.

Lifestyle measures

Weight loss if overweight/obese, elevate head of bed, avoid eating within 3 hours of lying down, reduce alcohol, caffeine, chocolate, and fatty foods.

24-hour oesophageal pH/impedance monitoring

Gold standard for confirming acid and non-acid reflux. Off PPI for 7 days prior (or on-PPI if testing for refractoriness). Referral to gastroenterology.

Consider fundoplication

Surgical anti-reflux procedure only when objective reflux confirmed and cough refractory to maximal medical therapy. Referral to upper GI surgeon.

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Esomeprazole

Nexium® · SOMAC equivalent · Proton pump inhibitor

Adult dose 40 mg PO once daily (before breakfast) for GORD-related cough; 20 mg PO daily for maintenance

Paediatric dose 1 mg/kg/day PO (1–11 years); 20–40 mg/day PO (12–17 years)

Duration 8–12 weeks initial trial; long-term if relapse

Renal adjustment No adjustment required

Hepatic adjustment Max 20 mg in severe hepatic impairment

PBS status ✔ PBS General Benefit

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Dexchlorpheniramine

Polaramine® · First-generation antihistamine

Adult dose 2 mg PO TDS–QID for UACS

Paediatric dose 0.1 mg/kg/dose PO TDS (≥2 years)

Duration Minimum 2–4 weeks trial

Note First-generation antihistamines preferred for UACS due to anticholinergic drying effect; warn of sedation

PBS status ✔ PBS General Benefit

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Overlap aetiology: Up to 62% of patients with chronic cough have two or more coexisting causes (UACS + asthma + GORD). If empirical trials for individual causes do not resolve cough, consider combined therapy or escalate to specialist assessment with HRCT, bronchoscopy, and reflux monitoring.

Haemoptysis

Haemoptysis — the expectoration of blood originating from the lower respiratory tract — ranges from blood-streaked sputum to life-threatening haemorrhage. It must be distinguished from epistaxis, haematemesis, and oropharyngeal bleeding. Even minor haemoptysis in a smoker aged ≥45 years warrants urgent investigation to exclude lung malignancy.

Classification

Mild / Incidental

Blood-streaked sputum

Small volume (<20 mL/episode), haemodynamically stable, no respiratory compromise. Often seen post-infection, in mild bronchiectasis, or URTI.

Setting: Outpatient GP — CXR within 2 weeks; refer respiratory if recurrent or smoking >45 yrs

Moderate

Significant haemoptysis

20–200 mL/24 hours. Concern for bronchiectasis, TB, lung abscess, cavitary malignancy, fungal ball, vasculitis (GPA).

Setting: ED assessment — urgent CXR, FBC, coagulation, sputum MC&S, consider HRCT ± bronchoscopy

Severe / Life-threatening

Massive haemoptysis

>200 mL/24 h OR any volume with haemodynamic compromise, respiratory distress, or aspiration risk. Most common causes: bronchiectasis, TB, lung cancer, aspergilloma, PE.

Setting: Resuscitation bay — secure airway, large-bore IV access, cross-match blood, urgent interventional radiology for bronchial artery embolisation; thoracic surgery consult

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Massive haemoptysis is a medical emergency. Mortality exceeds 50% without intervention. Secure the airway (intubate with single-lumen ETT advanced into the non-bleeding lung), establish large-bore IV access, cross-match 4 units pRBC, and activate the interventional radiology and thoracic surgery teams immediately. Position patient with the bleeding lung in the dependent position.

Causes of Haemoptysis

Category	Common Causes	Key Investigations
Infective	Acute/chronic bronchitis, pneumonia, lung abscess, TB (pulmonary), fungal (aspergilloma), bronchiectasis	Sputum MC&S, AFB smear/culture, CXR, CT, Mantoux/IGRA
Neoplastic	Bronchogenic carcinoma (SCC > adenocarcinoma), endobronchial metastases, carcinoid tumour	CT chest, bronchoscopy with biopsy, sputum cytology
Vascular	Pulmonary embolism, mitral stenosis, pulmonary arteriovenous malformations, bronchial artery erosion	CTPA, ECHO, pulmonary angiography
Inflammatory/Autoimmune	Granulomatosis with polyangiitis (GPA), Goodpasture syndrome, anti-GBM disease, SLE	ANCA, anti-GBM antibodies, renal function, urinalysis
Iatrogenic/Other	Anticoagulant therapy, coagulopathy, foreign body, trauma	Coagulation screen, INR, bronchoscopy

Investigations for Haemoptysis

Essential Chest X-ray (PA and lateral) First-line for all haemoptysis presentations. Identifies mass, consolidation, cavity, effusion. MBS item 58503.

Essential Full blood count, coagulation screen (INR/APTT), renal function Quantify blood loss, identify coagulopathy, assess renal function (pulmonary-renal syndromes).

Essential Sputum microscopy, culture & sensitivity Including AFB smear and mycobacterial culture if TB suspected. Available at all Australian public hospital labs.

Available CT chest with contrast (HRCT) Superior to CXR for detecting bronchiectasis, small masses, aspergilloma, and vascular anomalies. MBS item 56300/56303.

Specialist Bronchoscopy (flexible) Localise bleeding source, obtain biopsy, therapeutic intervention. Essential if CT non-diagnostic or suspicion of endobronchial lesion. Requires respiratory medicine referral.

Specialist Bronchial artery embolisation (BAE) First-line treatment for massive haemoptysis. Performed by interventional radiology. Success rate 85–95%; recurrence 10–30%.

Available CTPA If pulmonary embolism is suspected (pleuritic pain, DVT risk factors, hypoxia). MBS item 57360.

⚠️

Smokers ≥45 years with haemoptysis: Even a single episode of blood-streaked sputum in a current or ex-smoker aged ≥45 requires urgent CT chest and consideration of bronchoscopy to exclude malignancy. In Australia, the lung cancer screening programme (commencing 2025) targets high-risk individuals — haemoptysis remains a critical "red flag" symptom prompting rapid investigation.

Cough in Children (Age-Related Causes)

Cough in children is one of the most common presenting complaints in Australian paediatric primary care. The aetiology varies significantly with age, and the diagnostic approach differs substantially from adults. Most childhood cough is due to viral URTI and is self-limiting, but chronic cough in children warrants systematic evaluation as it may indicate underlying asthma, protracted bacterial bronchitis (PBB), bronchiectasis, or congenital anomalies.

Age-Related Causes

Age Group	Common Causes	Important Considerations
Neonate (0–28 days)	Congenital anomalies (tracheo-oesophageal fistula, vascular ring, choanal atresia), aspiration, neonatal pertussis, RSV bronchiolitis	Always investigate — neonatal cough is never normal. Consider congenital heart disease with pulmonary oedema.
Infant (1–12 months)	Viral bronchiolitis (RSV, rhinovirus), pertussis (especially <6 months — high morbidity/mortality), aspiration (gastro-oesophageal reflux, swallowing dysfunction)	Pertussis in infants <6 months can be fatal — early macrolide therapy essential. Apnoeic episodes common.
Preschool (1–5 years)	Viral URTI (6–12 episodes/year is normal), asthma, protracted bacterial bronchitis (PBB), foreign body aspiration, adenotonsillar hypertrophy with UACS	PBB is the most common cause of chronic wet cough in preschoolers — responds to 2–4 weeks of oral antibiotics (amoxicillin). Foreign body: acute onset choking/gagging + unilateral wheeze/absent breath sounds.
School-age (5–12 years)	Asthma, UACS (allergic rhinitis), PBB, bronchiectasis, psychogenic/habit cough, pertussis (waning vaccine immunity)	Psychogenic/habit cough: characteristically absent during sleep, barking/honking quality, often preceded by a viral trigger.
Adolescent (12–18 years)	Asthma, UACS, smoking-related cough, pertussis, anxiety-related, e-cigarette/vaping-associated lung injury (EVALI)	E-cigarette and vaping use is rising rapidly among Australian adolescents — enquire about in all teenage cough presentations.

Red Flags in Paediatric Cough

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Urgent investigation is required if any of the following are present:

Neonatal onset cough (consider congenital anomaly)
Chronic moist/wet productive cough (>4 weeks) — suspect PBB or bronchiectasis
Haemoptysis (any volume)
Failure to thrive, recurrent pneumonia, digital clubbing
Associated stridor, biphasic stridor, or feeding difficulties
Cough persisting >8 weeks without clear aetiology
Foreign body aspiration history (acute onset choking episode)
Immunocompromised child

Protracted Bacterial Bronchitis (PBB)

PBB is the most common cause of chronic wet cough in Australian children and is increasingly recognised as a precursor to bronchiectasis if inadequately treated. Diagnostic criteria (per CHEST/ERS guidelines):

Chronic (>4 weeks) wet/productive cough
Absence of signs suggestive of alternative causes
Cough resolves with 2–4 weeks of appropriate oral antibiotics

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Amoxicillin

Amoxil® · Trimox® · Aminopenicillin

Paediatric dose (PBB) 30–50 mg/kg/day PO divided TDS (max 500 mg TDS) for 2–4 weeks

Route Oral

Duration 2–4 weeks; extend to 6 weeks if partial response

PBS status ✔ PBS General Benefit

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Amoxicillin-Clavulanate

Augmentin® · Augmentin Duo® · Beta-lactam/beta-lactamase inhibitor

Paediatric dose (PBB — second-line) 22.5 mg/kg/day (as amoxicillin component) PO divided BD for 2–4 weeks

Route Oral

Note Use if no response to amoxicillin alone; covers beta-lactamase producing H. influenzae and Moraxella

PBS status ✔ PBS General Benefit

Bronchiolitis Management (Infants)

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Supportive care is the mainstay of bronchiolitis management. Neither bronchodilators nor corticosteroids are recommended for bronchiolitis in Australian paediatric guidelines (RCH Melbourne, CHQ Queensland). Hypertonic saline nebulisation (3%) may reduce length of stay in hospitalised infants. Consider nasogastric feeding if unable to maintain oral intake; supplemental oxygen if SpO₂ <90% persistently.

Paediatric Investigations for Chronic Cough

Essential Chest X-ray (PA) First-line investigation for any chronic cough in children. Looks for hyperinflation, focal changes, bronchial wall thickening, foreign body. MBS item 58503.

Available Spirometry (≥5–6 years) Assess for obstructive pattern (asthma) with bronchodilator reversibility. Requires cooperative child. MBS item 11300.

Available Sputum culture Useful in wet cough; obtained by hypertonic saline induction or early-morning gastric aspirate in young children. Guides antibiotic therapy in PBB/bronchiectasis.

Specialist Flexible bronchoscopy with bronchoalveolar lavage (BAL) For recurrent/chronic cough not responding to standard therapy. Identifies foreign body, anatomical anomalies, BAL cell differential (neutrophilic = PBB/bronchiectasis). Requires paediatric respiratory medicine referral.

Specialist HRCT chest Gold standard for bronchiectasis diagnosis. Low-dose paediatric protocols available at major tertiary centres. Consider if PBB recurs ≥3 times/year or cough persists >4 weeks despite appropriate antibiotics.

Available Pertussis PCR (nasopharyngeal swab) Essential for any infant <12 months with paroxysmal cough, and all subacute/chronic cough with whoop or post-tussive vomiting. Highest sensitivity within first 3 weeks.

Investigations

Summary of Key Investigations

Investigation	Indication	MBS Item	Availability
Chest X-ray	All chronic cough, haemoptysis, red flags, subacute cough with systemic symptoms	58503	All Australian facilities including rural
Spirometry + bronchodilator reversibility	Suspected asthma, COPD, or airflow obstruction	11300	Most GP practices; respiratory labs
Fractional exhaled nitric oxide (FeNO)	Suspected eosinophilic airway inflammation / cough-variant asthma	11306	Respiratory function laboratories; selected GP practices
CT chest (HRCT)	Bronchiectasis, ILD, mass lesion, structural anomaly	56300/56303	Metropolitan and large regional centres
CTPA	Suspected pulmonary embolism	57360	Metropolitan and large regional centres; emergency transfer if remote
Pertussis PCR	Subacute/chronic cough with paroxysmal features, post-tussive vomiting, whoop	69316	State public health laboratories; all NATA-accredited labs
Sputum MC&S + AFB	Productive cough, suspected TB, bronchiectasis, lung abscess	69300/69303	All Australian pathology services
24-hour oesophageal pH/impedance	Suspected GORD-related cough refractory to PPI trial	32116	Gastroenterology specialist centres
Flexible bronchoscopy	Non-resolving cough, suspected endobronchial lesion, foreign body, haemoptysis source localisation	18350/18353	Major hospitals; respiratory medicine specialist

Special Populations

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Pregnancy

Cough management: Honey and saline gargles are first-line. Avoid codeine (Category C — neonatal respiratory depression). Dextromethorphan is Category A but use sparingly.

Antihistamines: Chlorpheniramine (Category A) and loratadine (Category B1) are preferred for UACS.

PPIs: Pantoprazole (Category B3) is the preferred PPI in pregnancy for GORD-related cough. Esomeprazole is Category B3.

Pertussis: Azithromycin is Category B1. Administer to pregnant women with confirmed/suspected pertussis — benefits of reducing transmission to neonate outweigh theoretical risks. Pertussis vaccination (Boostrix®) is funded in the third trimester (20–32 weeks) under the NIP.

Haemoptysis: Immediate investigation is mandatory — pregnancy does not delay CXR or CT (shield abdomen if possible). VTE risk is increased — consider PE as a cause.

Note: All investigations should proceed if clinically indicated — pregnancy should not delay investigation of haemoptysis or red-flag symptoms.

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Paediatrics

Cough and cold preparations: Contraindicated <6 years (TGA warning 2012). Do not use OTC cough suppressants, antihistamines, or decongestants in young children.

Honey: May be effective for cough >12 months of age (1–2.5 mL before bed). Contraindicated <12 months (botulism risk).

PBB: 2–4 weeks oral antibiotics (amoxicillin first-line, amoxicillin-clavulanate second-line). Ensure completion — relapse is common with short courses.

Bronchiectasis prevention: Three or more episodes of PBB per year warrants HRCT and specialist referral to exclude evolving bronchiectasis.

Refer to RCH Melbourne CPG or CHQ Queensland guidelines for institution-specific paediatric protocols.

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Elderly (≥65 years)

ACE inhibitor cough: Higher prevalence in elderly; medication review is essential. Switch to ARB (e.g. irbesartan 150 mg PO daily).

Aspiration: Common in elderly with neurological conditions (stroke, Parkinson disease, dementia), dysphagia, or reduced conscious state. Consider videofluoroscopic swallowing study (VFSS).

Immunosenescence: Higher risk of pertussis due to waning immunity — ensure booster vaccination if not received in adulthood.

Malignancy: New cough in an elderly smoker is lung cancer until proven otherwise — low threshold for CT chest.

Anticholinergic antihistamines (dexchlorpheniramine) carry significant risk in the elderly — falls, confusion, urinary retention, constipation. Prefer second-generation agents (loratadine) when antihistamine is required.

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Renal Impairment

Codeine: Active metabolite (morphine-6-glucuronide) accumulates in renal failure — avoid or use with extreme caution. Contraindicated in eGFR <30 mL/min.

Antibiotics: Adjust macrolide doses for severe renal impairment (azithromycin does not require adjustment). Amoxicillin: reduce dose or extend interval if eGFR <30 mL/min.

PPIs: No dose adjustment for renal impairment, but long-term PPI use associated with hypomagnesaemia — monitor.

Pulmonary-renal syndromes: Haemoptysis + declining renal function should prompt urgent ANCA and anti-GBM antibody testing (GPA, Goodpasture syndrome).

Always check eGFR before prescribing and adjust medications accordingly. Refer to eTG Renal dosing guidelines.

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Hepatic Impairment

PPIs: Max 20 mg esomeprazole in severe hepatic impairment (Child-Pugh C).

Antihistamines: First-generation antihistamines are hepatically metabolised — use with caution in hepatic impairment. Loratadine dose should be reduced.

Coagulopathy: Hepatic coagulopathy may present as or exacerbate haemoptysis — check INR and consider vitamin K, FFP, or cryoprecipitate as indicated.

Hepatotoxicity from cough medications is uncommon but monitor LFTs with prolonged macrolide use.

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Immunocompromised

Expanded differential: Include opportunistic infections: Pneumocystis jirovecii pneumonia (PJP/PCP), CMV pneumonitis, invasive aspergillosis, non-tuberculous mycobacteria (NTM), and reactivation TB.

HIV: CD4 <200 → PJP prophylaxis (trimethoprim-sulfamethoxazole). Chronic cough with bilateral ground-glass opacities = PJP until proven otherwise.

Transplant recipients: Lung transplant patients have the highest risk of all opportunistic pulmonary infections. CMV, aspergillosis, and acute rejection all present with cough.

Biologics/DMARDs: TNF-alpha inhibitors (adalimumab, infliximab) increase risk of TB reactivation — screen with IGRA/Mantoux before commencing.

Any new cough in an immunocompromised patient requires a lower threshold for imaging and investigation. Empiric antibiotics should not delay microbiological sampling.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience a significantly higher burden of respiratory disease compared to non-Indigenous Australians. Chronic cough is a common and important symptom in Indigenous communities and may indicate serious underlying conditions including bronchiectasis, rheumatic heart disease, tuberculosis, and chronic suppurative lung disease. A culturally safe, low-threshold approach to investigation is essential.

Bronchiectasis prevalence

Aboriginal and Torres Strait Islander children, particularly those in remote Northern Territory and Queensland communities, have among the highest rates of bronchiectasis in the world. Chronic wet cough in Indigenous children should be treated aggressively and investigated early (HRCT if ≥3 PBB episodes/year or persistent wet cough >4 weeks despite antibiotics).

Rheumatic heart disease

RHD remains a significant cause of chronic cough (due to mitral valve disease and pulmonary congestion) in Indigenous Australians, particularly in the NT, WA, and QLD. Any Indigenous child or young adult with chronic cough should have cardiac auscultation and echocardiography considered. The RHD Control Programme provides secondary prophylaxis.

Pertussis and vaccination

Pertussis disproportionately affects Indigenous infants, with higher rates of hospitalisation and death. Maternal pertussis vaccination (third trimester) and timely childhood vaccination are critical. The NIP funds pertussis-containing vaccines for all Australian children (2, 4, 6, 18 months, 4 years, and adolescent booster). Culturally appropriate promotion through Aboriginal Medical Services (AMS) is essential.

Tuberculosis

TB notification rates are 6–8 times higher in Aboriginal and Torres Strait Islander Australians compared to non-Indigenous Australians. Any chronic cough >2 weeks in a person from a high-prevalence community requires sputum AFB testing and CXR. The NT TB Programme and RHDAustralia provide guidance on contact tracing and latent TB treatment.

Environmental factors

Overcrowded housing, indoor wood-fire smoke exposure, and limited ventilation contribute to recurrent respiratory infections and chronic cough in remote communities. Trachoma and scabies programmes address some environmental health determinants; respiratory health requires similar coordinated investment.

Access to investigation

Spirometry, HRCT, and bronchoscopy are often unavailable in remote settings. Fly-in/fly-out (FIFO) respiratory specialist services, telehealth consultations, and aeromedical retrieval (RFDS) are critical pathways for investigation. Portable spirometry and point-of-care testing (CRP, PCR) are increasingly available through the RANZCR and state health programmes.

Cultural safety

Health literacy considerations, yarning-based consultations, involvement of Aboriginal Health Workers/Practitioners (AHW/Ps), and use of culturally appropriate educational materials are essential. Smoking is a sensitive topic — approach with respect and link to Tackling Indigenous Smoking (TIS) programme. Sorry Business and community obligations may affect attendance — flexible follow-up arrangements are important.

📚 References

1. Irwin RS, French CL, Chang AB, Altman KW. Classification of cough as a symptom in adults and management algorithms: CHEST guideline and expert panel report. Chest. 2018;153(1):196–209.
2. Morice AH, Millqvist E, Bieksiene K, et al. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J. 2020;55(1):1901136.
3. Chang AB, Oppenheimer JJ, Weinberger M, et al. Use of management pathways or algorithms in children with chronic cough: CHEST guideline and expert panel report. Chest. 2017;151(4):875–883.
4. Australian Government Department of Health and Aged Care. Australian Immunisation Handbook. Pertussis (whooping cough). Updated 2024. Available at: immunisationhandbook.health.gov.au.
5. AIHW. Aboriginal and Torres Strait Islander Health Performance Framework: Respiratory disease. Canberra: AIHW; 2023.
6. Goyal V, Grimwood K, Marchant J, Masters IB, Chang AB. Does failed chronic cough treatment with antibiotics define a distinct clinical phenotype? Pediatr Pulmonol. 2015;50(3):248–252.
7. Chang AB, Bell SC, Torzillo PJ, et al. Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand: Thoracic Society of Australia and New Zealand guidelines. Med J Aust. 2015;202(3):130.
8. Gibson PG, Chang AB, Glasgow NJ, et al. CICADA: Cough in Children and Adults: Diagnosis and Assessment. Australian cough guidelines summary statement. Med J Aust. 2010;192(5):265–271.
9. Sakr L, Dutau H. Massive hemoptysis: an update on the role of bronchial artery embolization. Respiration. 2010;79(1):38–45.
10. Society of Thoracic Surgeons. Massive hemoptysis: a flow-based management algorithm. Ann Thorac Surg. 2021;112(5):1602–1612.
11. RHDAustralia (ARF/RHD writing group). National Guidelines for Prevention, Diagnosis and Management of Acute Rheumatic Fever and Rheumatic Heart Disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
12. Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Bronchiolitis; Cough. Updated 2024. Available at: rch.org.au/clinicalguide.
13. Kahrilas PJ, Altman KW, Chang AB, et al. Chronic cough due to gastroesophageal reflux in adults: CHEST guideline and expert panel report. Chest. 2016;150(6):1341–1360.
14. Therapeutic Goods Administration (TGA). Cough and cold medicines for children — review of safety and efficacy. Australian Government Department of Health; 2012.
15. Wark PAB, Gibson PG. Asthma exacerbations · 3: Pathology. Thorax. 2006;61(9):809–816.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).