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The first S3 evidence- and consensus-based guideline of the German Respiratory Society (DGP) on the diagnosis and treatment of patients with acute and chronic cough was published in 2004. S2k (consensus-based) updates were made in 2010 and 2019 []. The German Society for General Practice and Family Medicine (DEGAM) published its S3 guideline on cough for general practitioners in 2014 and 2021 []. This is the English translation of the new 2025 published Cough Guidelines of the German Respiratory Society [1A]. The guideline group was established according to the specifications of the Association of the Scientific Medical Societies (AWMF) by the DGP. Participants included representatives of the participating specialties accredited by their respective specialist societies and a patient representative. The guidelines were coordinated by a representative of AWMF. The lead author is Peter Kardos (Frankfurt am Main). The addressees of this new S2k guideline on cough (German ICD-10 classification codes: R05 and U69.6) are pulmonologists who diagnose and treat adult patients – usually referred by general practitioners. The Society for Pediatric Pneumology (GPP) [] is also preparing a pediatric S2k guideline for cough. These guidelines provide a freely accessible, up-to-date scientific basis for the diagnosis and treatment of all patients with cough.

The current guidelines also address gastroenterologists and ear, nose, and throat specialists on reflux-related cough or cough triggered by the upper airway (so-called “upper airway cough syndrome”). We describe idiopathic chronic cough (UCC) and refractory chronic cough (RCC), which has been established as a separate disease entity with adding the German ICD code U69.6 to the international symptom code for cough R05.

1. The most important change is the new form of the guideline: we have limited the guidelines to 12 essential clinical “key questions”, i.e., the most important aspects of the diagnosis and treatment of various phenotypes of cough. The questions and recommendations in short form have been tabulated. For each question/recommendation, a background text with literature was created and the evidence for each recommendation was formulated as strong or weak. If for a “key question” no clear evidence was available, we used a “maybe” formulation, e.g., a specific treatment or diagnostic procedure may be prescribed as a joint individual decision – in consensus with the informed patient. In the following “overview of recommendations,” we use the following graphic characters: “Maybe” if no sufficient evidence exists: ⇔ The development and consensus-building process took place under the methodological supervision of the representative of AWMF; all statements and recommendations were voted on in face-to-face or virtual consensus conferences. The statement in key question 5 (SARS-CoV-2 infection and cough) was adopted by the majority; for almost all other recommendations and statements, there was strong consensus (100% agreement) in the guidelines. 2. The scope of the guidelines was significantly reduced by the “key questions” methodology. This makes it more suitable for practical applications.

All statements and recommendations were classified as newsworthy, modified or unchanged if compared to the 2020 guidelines. The guidelines are available and searchable in the Smartphone Application Leila PRO, available in App Stores and usable free of charge. Every patient retains the right to an individual diagnosis and treatment. In a specific, justifiable case, it may make sense to deviate from the guideline recommendations.

Cough is a very common symptom of many different diseases. For the purpose of diagnostic confirmation and therapeutic intervention, it has proven most useful to classify cough according to its duration [–].

The most common cause of coughing is an acute, spontaneously resolving viral illness of the upper and/or lower respiratory tract (“common cold”). If a physician is consulted, generally the medical history and a physical examination should be carried out to make this diagnosis (see the Choosing Wisely [“Klug entscheiden”] initiative of the German Society of Internal Medicine []). In the case of chronic cough, a diagnostic workup is essential because of the resulting therapeutic consequences. It should begin as soon as the patient presents. In about 30–40% of patients [, ] who consult a specialist due to chronic cough, no clear cause can be identified. Such cases are referred to as UCC or RCC if there is a possible cause, such as reflux, but the cough does not respond to guideline-based reflux therapy. A population-based study in Canada found that 3.3% of all patients suffer from RCC []. Taking into account the need for a complex diagnostic workup for chronic cough, cough of shorter than 8 but longer than 3 weeks duration is classified as subacute. It is often the result of a prolonged infection or a seasonal allergy and does not usually require technical examinations. However, the classification of cough by duration is arbitrary and there is a smooth transition between the categories.

Another feature of the classification of chronic cough is the categorization into productive and dry (irritant) cough. Productive cough means secretion of 5–30 mL phlegm (corresponding to 1 teaspoon to two tablespoons) [, ] or more in 24 h. However, the urge to cough – a consequence of the irritation and hypersensitivity of the cough receptors – is often perceived by the patient as “phlegm”, although there is no mechanical cough trigger, i.e., sputum or mucus coating on the mucous surface in the pharynx, larynx, or bronchi. The diagnostic and therapeutic workup for chronic productive cough (e.g., chronic bronchitis, chronic obstructive pulmonary disease [COPD], bronchiectasis) [, ] differs from the procedure for chronic dry cough, and the prognosis is worse compared to dry cough []. Assignment of typical characteristics of the sputum to possible clinical entities is as follows: - Mucous (slimy): smoker’s chronic bronchitis Purulent (yellow/green): COPD exacerbation, asthma, eosinophilic bronchitis, bronchiectasis Blood; hemoptysis, exacerbated bronchiectasis, COPD, tumor, coagulation disorder – caveat red flag Bronchial casts: allergic bronchopulmonary aspergillosis, severe asthma, COPD

The viral common cold is the most common cause of acute cough. It can affect both the upper and lower respiratory tract, and it is almost impossible to distinguish between a cold and acute bronchitis []. Typical additional symptoms are “general malaise”, chills, increased temperature, sore throat, runny nose, obstructed nasal breathing, and sneezing. Frequently, coughing is the most disturbing and longest lasting (2–3 weeks) but also self-limiting symptom []. If there is a typical history of common cold and no clinical evidence of red flags – (question 3) that would suggest prompt action – it is advisable to wait up to 8 weeks before initiating basic diagnostic procedures. Most usual causes of the common cold are rhinovirus (30–50% of cases), as well as corona virus, parainfluenza virus, respiratory syncytial virus, influenza virus, adenovirus, enterovirus and metapneumovirus. Bacterial pathogens: isolated acute bacterial bronchitis is mostly due to Mycoplasma pneumoniae , Chlamydia pneumoniae , and Bordetella pertussis ; acute bacterial sinusitis to Streptococcus haemolyticus , Haemophilus influenzae , Streptococcus pneumoniae , and Staphylococcus aureus . Bacterial infections are much less frequent than viral infections. If the patient desires relieving treatment, expectorants (ambroxol, N-acetylcysteine), antitussives (dextromethorphan), and phytopharmaceuticals can be prescribed. The efficacy of dextromethorphan [] and several herbal drugs was shown in RCTs. They shorten the duration and relieve symptoms of the common cold [–].

Allergic rhinitis (“hay fever”), often associated with sinusitis, conjunctivitis, pharyngitis, and laryngitis, can also elicit acute cough []. The differential diagnosis to viral infections consists in the current allergen exposure and in the results of the allergy test. The symptoms differ from viral infections: Itchy eyes, nose, and throat as well as multiple sneezing attacks are often the main symptoms. Treatment options include nasal corticosteroids, systemic and topical antihistamines [, ].

Among acute cough patients in a clinic in Japan, asthma was diagnosed in 29.5% of cases and cough-variant asthma in 19.6% []. Asthma due to acute infections or intermittent allergen exposure is a common cause of acute dry cough. Usually, asthmatic cough responds well to asthma treatment [].

The cough reflex protects against the consequences of aspiration. Aspiration of foreign bodies elicits acute coughing, particularly in children aged 1–3 years. Care-dependent elderly patients with an impaired cough reflex – for example, after a stroke – the acute cough may be too weak to eliminate the foreign material with consequent aspiration pneumonia. Appropriate diagnostic tools for foreign body aspiration are a chest X-ray and/or a CT scan alongside with a diagnostic and therapeutic bronchoscopy.

The diagnosis is based on medical history, physical examination, lung function analysis including determination of CO diffusion capacity and blood gas analysis. Inpatient observation is often necessary, and intensive medical treatment is frequently required. Poison control centers ( www.medknowledge.de/patienten/notfaelle/vergiftungszentralen.htm ) can provide information on inhaled noxious substances and treatment options. Suitable first-line treatment consists of high-dose inhaled corticosteroids (ICS).

Acute cough is a classic symptom of pneumonia. Regarding diagnosis and treatment, please refer to the current guideline from the Paul Ehrlich Society and DGP [].

Acute or acute worsening of chronic cough is the defining feature of an exacerbation of chronic bronchitis or of COPD, often accompanied by sputum production. For diagnosis and treatment of exacerbations, please refer to the new GOLD recommendation (2026 GOLD Report – Global Initiative for Chronic Obstructive Lung Disease – GOLD ( goldcopd.org ) and the National Disease Management Guideline (NVL) COPD (2021 edition) (AWMF guideline register).

Acute cough with and without hemoptysis occurs in 22.9% and 7.6% of cases with confirmed pulmonary embolism, respectively. Small recurrent pulmonary emboli are easily missed on examination. The diagnostic procedure and treatment can be found in the AWMF S2k guideline ( https://www.awmf.org/uploads/tx_szleitlinien/065-002l_S2k_VTE_2016-01.pdf ).

Acute left heart failure with pulmonary congestion can lead to bronchial hyper-responsiveness [], bronchial obstruction (formerly known as cardiac asthma), and cough. Furthermore, bradycardia in high-grade atrioventricular (AV) block is associated with a reduction in cardiac output, consecutive pulmonary congestion and coughing. Coughing can itself trigger a grade II or III AV block – presumably via severe vagotonia []. Total AV block is discussed as a possible pathomechanism of cough syncope [].

Cough lasting 3–8 weeks is considered subacute cough. Subacute cough is usually of post-viral origin. The most common pathogens for prolonged infection are adenovirus, respiratory syncytial virus, Bordetella pertussis , influenza virus [] and SARS-CoV-2 [] (see background text question 5). Other usual pathogens are Mycoplasma pneumoniae and Chlamydia pneumoniae .

Whooping cough is increasingly found as the cause of a postinfectious, protracted cough. An acute infection with B. pertussis can cause an acute febrile illness with a characteristic “pertussiform” long-lasting staccato cough, mainly in (unvaccinated) children, but adults may also be affected (e.g., during the 2024 pertussis endemics in the Czech Republic [] and Denmark []). Particularly in the presence of bronchial asthma or COPD, pertussis-related complications emerge with an incidence of 10% of cases []. The treatment of choice is macrolide antibiotics, which are only effective during the catarrhal phase. Antitussives can provide relief.

Regardless of the causative pathogen, post-viral rhinosinusitis can last up to 12 weeks. It has a biphasic and self-limiting course [] (see background text question 7).

If the cough persists for longer than 3 weeks after an acute respiratory infection, a postinfectious cough may be present, which usually lasts no longer than 8 weeks and is self-limiting []. The diagnosis of postinfectious cough (without exacerbated bronchial hyper-responsiveness) is based on a careful history of the past infection and by ruling out other causes. It may be symptomatically treated like the common cold. In contrast to a pertussis infection, the cough in these patients may respond to ICS [].

A temporary increase in bronchial reactivity triggering the cough reflex – without or with mild bronchial obstruction – can develop in the context of an acute infection, regardless of the type of the pathogen. It is often associated with eosinophilia, but without other signs of asthma []. Usually, this cough subsides spontaneously after 8 weeks. ICS shorten the duration of the cough []. Generally, an ICS or ICS/LABA therapy for 10–14 days is sufficient.

Antibiotics are generally not indicated for acute cough due to the common cold [], which is usually a viral infection. Antibiotics have little effect on viral infections. In otherwise healthy subjects they are not indicated for acute cough. Their unnecessary prescription is the most important cause for developing microbial resistance both in the individual and in the society ().

Initially acute and subacute cough do not require immediate, comprehensive workup of potential causes because mostly they are self-limiting viral infections. Chronic cough (lasting 8 weeks or longer) requires timely workup without delay and the introduction of targeted treatment [, , , ]. In emergencies with a possibly dangerous threat (red flags) – depending on the clinical situation – immediate action, hospitalization, may be necessary, regardless of the duration of the cough (acute, subacute, or chronic). From the history and clinical examination, several indicators are summarized for acute and subacute cough in and summarizes the most common red flags for chronic cough. In any case, workup should be initiated without delay in clinical emergencies immediately.

Chronic cough is a frequent symptom of all pulmonary and a few non-pulmonary diseases. We focus in this background information not on the classic respiratory diseases, which are listed in Box 1; for detailed information, see respective textbooks and guidelines. In addition, key questions 5, 7, 8, 9, and 10 deal with further chronic diseases usually associated with the symptom cough. Key question 6 is dedicated to chronic refractory and idiopathic cough, a disease in its own right that is diagnosed when – despite thorough diagnostic workup – no underlying cause for the cough is found.

The symptom chronic cough affects quality of life beyond the level of the underlying disease [–] and may also cause important psychiatric comorbidities, particularly depression and anxiety []. The sensitivity of the cough reflex is increased to varying degrees in most pulmonary diseases, which determines the severity, frequency, and intensity of the cough. In asthma [, ] and bronchiectasis, cough is a cardinal symptom with important impact on the severity of the underlying disease. Interestingly, however, the assessment of asthma control according to the specialist S2k guideline [] of the German Respiratory Society, the NVL National Asthma Guidelines, and the GINA document does not include cough as a coefficient of severity or asthma control. Thus, a patient can have fully controlled asthma, still coughing day and night. Furthermore, the Bronchiectasis Severity Index also does not include cough as a relevant factor of the severity of bronchiectasis ( https://register.awmf.org/de/leitlinien/detail/020-030 ). Further information on underlying diseases and symptoms: see with the red flags. Box 2 refers to rare diseases, less obvious causes of chronic cough.