From the Guidelines
As a neurologist treating a patient with a 10-year chronic cough, you should refer them to a pulmonologist or primary care physician for appropriate evaluation and management. Chronic cough (lasting more than 8 weeks) typically falls outside neurology's scope, except in rare neurogenic causes. Before referral, consider whether the cough could be related to neurological conditions you manage, such as vagal nerve dysfunction, multiple sclerosis, or as a side effect of medications like ACE inhibitors 1. Document your assessment, including any neurological findings, and communicate with the receiving physician about your concerns. While awaiting referral, you might suggest symptomatic relief with over-the-counter cough suppressants containing dextromethorphan (15-30mg every 4-6 hours) or benzonatate (100-200mg three times daily). The most common causes of chronic cough include post-nasal drip, asthma, gastroesophageal reflux disease, and chronic bronchitis, which require specialized evaluation including pulmonary function tests, imaging, and possibly endoscopy to diagnose and treat effectively 1. It's also important to note that chronic cough can be multifactorial, and treatment should focus on the most common causes, which may include a combination of UACS, asthma, and GERD 1. In terms of treatment, an empiric integrative approach may be useful, starting with the most common causes and maintaining all partially effective treatments 1. Neuromodulatory therapies, such as gabapentin, may also be considered for the treatment of unexplained chronic cough, although the evidence is limited and the potential for adverse effects should be carefully weighed 1.
Some key points to consider when evaluating and managing chronic cough include:
- Focusing on the detection and treatment of UACS, asthma, NAEB, or GERD, alone or in combination, in patients with a normal chest roentgenogram finding who are non-smokers and are not receiving therapy with an ACE inhibitor 1
- Considering the possibility of multiple causes of chronic cough and maintaining all partially effective treatments 1
- Using an empiric integrative approach to treatment, starting with the most common causes and adjusting as needed 1
- Being aware of the potential for neuromodulatory therapies, such as gabapentin, to be effective in treating unexplained chronic cough, although the evidence is limited 1
From the Research
Chronic Cough Diagnosis and Treatment
- A 10-year chronic cough in a patient may have various underlying causes, including gastroesophageal reflux disease (GERD) 2, 3.
- Studies suggest that a therapeutic trial of proton-pump inhibitor therapy with or without a prokinetic agent can be effective in diagnosing and treating GERD-related cough 2.
- Proton-pump inhibitor therapy has been shown to be successful in eliminating or markedly improving cough in patients with GERD-related cough 2.
Role of Proton Pump Inhibitors
- Proton pump inhibitors (PPIs) may improve nocturnal asthma symptoms and pulmonary function in patients with GERD-related asthma 3.
- PPI treatment may also relieve GERD-related chronic cough, although larger studies are needed to confirm this 3.
- The use of PPIs in patients with chronic obstructive pulmonary disease (COPD) is still uncertain, with low to very low-certainty evidence available 4.
Neuropulmonology Considerations
- Neuropulmonology refers to the complex interconnection between the central nervous system and the respiratory system 5.
- Neurologic injury or disease can result in pulmonary dysfunction, including aspiration pneumonia, neurogenic pulmonary edema, and acute respiratory distress syndrome 5.
- Abnormal respiratory patterns and sleep-disordered breathing can also occur in patients with neurologic conditions 5.
Next Steps
- Consider referring the patient to a pulmonologist or gastroenterologist to rule out GERD or other pulmonary conditions 2, 3.
- A therapeutic trial of proton-pump inhibitor therapy may be considered to diagnose and treat GERD-related cough 2.
- Further evaluation and management of the patient's chronic cough should be guided by the results of diagnostic tests and specialist consultations.