What are the next steps for a patient with a persistent non-productive cough for 3 weeks, unresponsive to Zithromax (azithromycin) or steroids, with a negative chest X-ray (CXR) and no other symptoms?

From the Guidelines

For a persistent non-productive cough lasting 3 weeks that hasn't responded to azithromycin or steroids and has a negative chest X-ray, I recommend trying a proton pump inhibitor like omeprazole 20 mg daily for 4-8 weeks to address possible gastroesophageal reflux disease (GERD), as suggested by the most recent and highest quality study 1. This approach is based on the understanding that GERD is a common cause of chronic cough, even in the absence of gastrointestinal symptoms, and that a therapeutic trial of antireflux therapy is a reasonable next step in the evaluation of chronic cough, as outlined in the 2016 CHEST guideline and expert panel report 1. The patient's clinical profile, including a normal chest radiograph and lack of response to antibiotics and steroids, suggests that GERD should be considered as a potential cause of the cough, and empiric treatment with a proton pump inhibitor is a reasonable approach, as supported by the study 1. Key points to consider in the management of this patient include:

• The importance of a thorough evaluation to rule out other potential causes of chronic cough, as outlined in the guideline 1
• The potential benefits of antireflux therapy in patients with chronic cough, even in the absence of gastrointestinal symptoms, as suggested by the study 1
• The need for careful monitoring and follow-up to assess the response to treatment and adjust the management plan as needed, as recommended by the guideline 1. It is also important to note that if the patient's symptoms persist despite treatment with a proton pump inhibitor, further evaluation with pulmonary function testing or referral to an ENT specialist or pulmonologist may be necessary to investigate less common causes of persistent cough, as suggested by the study 1.

From the Research

Next Steps for Non-Productive Cough

Given the patient's non-productive cough lasting 3 weeks with no relief from Z-pack or steroids, and a negative chest X-ray (CXR), the following steps can be considered:

• Evaluate the patient clinically, including spirometry if indicated, to rule out underlying conditions such as upper airway cough syndrome, gastroesophageal reflux disease (GERD), asthma, or nonasthmatic eosinophilic bronchitis 2.
• Consider empiric treatment for potential causes, such as GERD, which can be managed with proton pump inhibitors (PPIs) 3, 4, 5.
• Since the patient has not responded to initial treatments, referral to a pulmonologist or otolaryngologist may be warranted for further evaluation and management 2.
• Non-pharmacological therapies, such as education, cough suppression, breathing techniques, mindfulness, and continuous positive airway pressure, may also be considered for managing chronic cough 6.

Potential Causes and Considerations

• Upper airway cough syndrome, GERD, asthma, and nonasthmatic eosinophilic bronchitis are common causes of chronic cough in adults 2.
• Proton pump inhibitors (PPIs) can be effective in managing GERD symptoms, including chronic cough 3, 4, 5.
• The choice of PPI may not significantly impact treatment outcomes, as they have similar potency and efficacy 4.
• Long-term, high-dose PPI therapy may be necessary for managing eosinophilic esophagitis, but it also carries potential side effects and risks 5.