From the Guidelines
The best approach for managing a patient with persistent hacking cough and normal CT chest involves a stepwise evaluation and treatment plan, prioritizing common causes like upper airway cough syndrome, asthma, or gastroesophageal reflux disease (GERD) first, as suggested by the most recent guidelines 1.
Initial Evaluation and Treatment
- Consider common causes like upper airway cough syndrome (post-nasal drip), asthma, or gastroesophageal reflux disease (GERD) as the initial step in the evaluation process.
- Initial empiric treatment may include: + A first-generation antihistamine-decongestant combination such as chlorpheniramine 4mg plus pseudoephedrine 60mg three times daily for 2-3 weeks for suspected post-nasal drip. + A trial of inhaled corticosteroids like fluticasone 110mcg two puffs twice daily for 4 weeks, possibly with a short-acting bronchodilator like albuterol 90mcg 2 puffs as needed, for suspected asthma. + Lifestyle modifications and a proton pump inhibitor such as omeprazole 20mg daily for 4-8 weeks for GERD, as supported by evidence from studies on GERD-induced chronic cough 2, 3.
Further Evaluation and Treatment
- If the initial approaches fail, consider less common causes like angiotensin-converting enzyme inhibitor-induced cough (requiring medication change), non-asthmatic eosinophilic bronchitis (diagnosed via sputum analysis), or psychogenic cough.
- Persistent symptoms warrant pulmonary function testing, possibly with methacholine challenge, and referral to a pulmonologist or ENT specialist, as recommended by recent guidelines on chronic cough management 4, 1.
- The use of gabapentin for unexplained chronic cough may be considered, as suggested by recent studies 4, but its potential benefits and risks should be carefully weighed.
Key Considerations
- A normal CT chest does not rule out significant pulmonary or extrapulmonary causes of cough, and further evaluation is often necessary.
- The role of chest CT in the initial evaluation of chronic cough is still debated, but it may be useful in selected patients with persistent symptoms despite initial clinical evaluation and empiric treatment, as indicated by recent appropriateness criteria 5, 6, 1.
- A stepwise approach, addressing the most common etiologies first while providing symptomatic relief during the diagnostic process, is effective in managing patients with persistent hacking cough and normal CT chest, as supported by the most recent evidence 1.
From the Research
Approach to Managing Persistent Hacking Cough
The management of a patient with a persistent hacking cough and a normal computed tomography (CT) chest scan involves a systematic approach to identify and treat the underlying cause.
- The most common causes of chronic cough in adults are: + Upper airway cough syndrome + Asthma + Nonasthmatic eosinophilic bronchitis + Gastroesophageal reflux disease/laryngopharyngeal reflux disease 7, 8, 9
- Initial evaluation should include: + Clinical assessment + Spirometry, if indicated + Chest radiography to rule out concerning infectious, inflammatory, and malignant thoracic conditions 7, 8, 9
- Empiric treatment should be initiated based on the most likely cause, and patients with refractory chronic cough may warrant referral to a pulmonologist or otolaryngologist 7, 8, 9
- In some cases, a trial of gabapentin, pregabalin, and/or speech therapy may be considered for patients with refractory chronic cough 7, 8, 9
Consideration of Less Common Causes
Less common causes of chronic cough, such as angiotensin-converting enzyme inhibitor use, environmental triggers, tobacco use, chronic obstructive pulmonary disease, and obstructive sleep apnea, should also be considered and evaluated 7, 8.
- A thorough medical history and physical examination can help identify these potential causes
- Additional diagnostic tests, such as bronchoscopy and nasendoscopy, may be warranted in some cases 8
Importance of Systematic Approach
A systematic approach to managing chronic cough can help identify the underlying cause and improve symptoms 10.
- A simple and systematic approach, including empirical treatment trials, can be effective in managing chronic cough in primary care
- Referral to secondary care may be necessary in some cases, but a systematic approach can help identify patients who can be managed in primary care 10