What are the next best options for a 71-year-old patient with persistent cough despite treatment with cough medication, prednisone, and Symbicort (budesonide/formoterol)?

From the Guidelines

For a 71-year-old with persistent cough despite cough medication, prednisone, and Symbicort, the next best option is to conduct a comprehensive evaluation to identify the underlying cause, including a pulmonary consultation, chest X-ray or CT scan, and additional testing such as pulmonary function tests and ENT evaluation. The patient's symptoms and medical history should be thoroughly assessed to determine the potential causes of the cough, including gastroesophageal reflux disease (GERD), asthma, and nonasthmatic eosinophilic bronchitis (NAEB) 1. Given the patient's age and persistent cough, it is essential to consider the possibility of multiple contributing factors, and targeted therapy based on the specific diagnosis is more effective than empiric treatment 1. Medication adjustments could include trying a different inhaled corticosteroid/long-acting beta-agonist combination, adding a long-acting muscarinic antagonist, or considering a trial of a proton pump inhibitor if reflux is suspected 1. Environmental triggers should also be identified and avoided when possible, and if the cough produces sputum, a sample should be collected for culture to rule out infection 1. A therapeutic trial of multimodality speech pathology therapy or gabapentin may also be considered, as these have been associated with improvement in quality of life in patients with unexplained chronic cough 1. Ultimately, the goal is to identify the underlying cause of the cough and develop an effective treatment plan to improve the patient's quality of life.

From the Research

Next Steps for Chronic Cough Management

The patient's persistent cough despite medication, prednisone, and Symbicort suggests a need for further evaluation and management. The following options can be considered:

• Referral to a pulmonologist or otolaryngologist for specialized care, as suggested by 2, 3, 4
• Trial of gabapentin, pregabalin, and/or speech therapy for refractory chronic cough, as recommended by 2, 4
• Physiotherapy and speech and language therapy combined with a trial of gabapentin or amitriptyline for chronic refractory cough, as suggested by 4
• Further diagnostic tests, such as bronchoscopy and nasendoscopy, if initial test findings are unremarkable, as recommended by 4

Diagnostic Evaluation

A thorough diagnostic evaluation is crucial to identify the underlying cause of the chronic cough. The following tests can be considered:

• Chest radiography to rule out concerning infectious, inflammatory, and malignant thoracic conditions, as recommended by 2, 4
• Spirometry to evaluate lung function, as suggested by 2, 4, 5, 6
• Assessment of medications, environment, occupation, and potential chemical triggers, as recommended by 4

Considerations for Refractory Chronic Cough

Refractory chronic cough can be challenging to manage, and a multidisciplinary approach may be necessary. The following considerations can be taken into account:

• The patient's cough may be related to an underlying condition, such as gastroesophageal reflux disease, asthma, or nonasthmatic eosinophilic bronchitis, as suggested by 2, 3, 4
• The patient's medications, including angiotensin-converting enzyme inhibitors, may be contributing to the cough, as recommended by 2, 4