From the Guidelines
The patient's chronic cough and radiographic findings suggest chronic small airways disease with mild pulmonary fibrosis, and I recommend a pulmonology consultation for comprehensive evaluation and management, considering trials of therapies such as gabapentin or multimodality speech pathology therapy for refractory chronic cough, as suggested by the CHEST guidelines 1. The patient's symptoms and radiographic findings are consistent with interstitial lung disease (ILD), which can cause chronic cough and pulmonary fibrosis. According to the CHEST guidelines, for patients with ILD and refractory chronic cough, trials of therapies recommended for patients with unexplained chronic cough, such as gabapentin, should be considered 1.
- Key considerations in managing this patient's chronic cough include:
- Assessing for progression of the underlying ILD or complications from immunosuppressive treatment 1
- Considering further investigation or treatment trials for the cough, according to guidelines for acute, subacute, and chronic cough 1
- Avoiding routine prescription of inhaled corticosteroids for chronic cough in patients with pulmonary sarcoidosis, unless there is a specific indication 1
- Considering opiate therapy for symptom control in a palliative care setting, if alternative treatments have failed and the cough is adversely affecting the patient's quality of life 1 The patient's quality of life is likely to be significantly impaired by the chronic cough, and prompt evaluation and management by a pulmonologist are essential to address the underlying condition and provide symptomatic relief.
From the Research
Patient Profile
- 73-year-old patient reporting cough for 5 months
- Chest X-ray (CXR) shows no acute cardiopulmonary abnormality
- Findings suggest chronic small airways disease and radiographically mild pulmonary fibrosis
Treatment Options
- Combination therapy with inhaled corticosteroids and long-acting beta2-agonists (e.g., salmeterol and fluticasone) 2, 3, 4
- Tiotropium, a long-acting anticholinergic drug, as an alternative or add-on therapy 2, 5, 3, 6
- Comparison of fluticasone-based and budesonide-based triple therapies in COPD patients 4
Efficacy and Safety
- Combination of salmeterol and tiotropium with fluticasone improves lung function in COPD patients more than either bronchodilator alone 2
- Tiotropium add-on to inhaled corticosteroids provides beneficial effects comparable to adding a long-acting β2-agonist in terms of lung function measures, exacerbations, and asthma control 5
- Combination therapy with salmeterol/fluticasone and tiotropium leads to better control of symptoms and improved lung function, with no greater risk of side-effects, as compared to salmeterol/fluticasone or tiotropium alone 6
- Budesonide-based triple therapy may be associated with a lower incidence of severe pneumonia and possibly also of all-cause death, especially among patients with no prior exacerbations 4