What is the next step in managing a 77-year-old patient with a persistent cough unresponsive to pantoprazole (proton pump inhibitor), normal pulmonary function tests (PFTs) and a previous normal chest x-ray?

From the Guidelines

The next step in managing this 77-year-old patient with persistent cough unresponsive to pantoprazole would be to perform a high-resolution chest CT scan, as recommended by the most recent and highest quality study 1. This imaging study can detect subtle lung abnormalities, bronchiectasis, interstitial lung disease, or early malignancies that may not be visible on a standard chest x-ray. Given the patient's advanced age and persistent symptoms despite acid suppression therapy, we need to rule out more serious underlying conditions.

After obtaining the CT scan, referral to a pulmonologist would be appropriate for further evaluation, which might include consideration of bronchoscopy if the CT shows concerning findings. Additional diagnostic tests to consider include:

• a 24-hour esophageal pH monitoring to definitively rule out refractory GERD, as suggested by 1
• sinus imaging to evaluate for post-nasal drip
• potentially an echocardiogram to assess for heart failure contributing to the cough Medication review is also essential, as ACE inhibitors are a common cause of chronic cough in elderly patients, as noted in 1. Throughout this process, symptomatic management can include a trial of an inhaled corticosteroid like fluticasone 44mcg 2 puffs twice daily for 2-4 weeks, or a first-generation antihistamine with a decongestant if post-nasal drip is suspected.

It's worth noting that the evidence suggests that wide application of chest CT in symptomatic patient cohorts may not be diagnostically rewarding, as stated in 1. However, in this case, given the patient's persistent symptoms and lack of response to initial treatment, a high-resolution chest CT scan is a reasonable next step to rule out underlying conditions that may be contributing to the cough.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps in Managing Persistent Cough

The patient's persistent cough, unresponsive to pantoprazole, with normal pulmonary function tests (PFTs) and a previous normal chest x-ray, requires further evaluation.

• The patient's normal PFTs, including a FEV1 of 105% predicted and FVC of 95% predicted, with no significant post-bronchodilator response, suggest that asthma is unlikely to be the cause of the cough 2.
• The fact that the cough has not responded to pantoprazole, a proton pump inhibitor, suggests that gastroesophageal reflux disease (GERD) may not be the primary cause of the cough, although it is still possible that the cough is related to GERD or another condition 3.
• Given the patient's age and the chronic nature of the cough, it is essential to consider other potential causes, such as pulmonary infections or interstitial lung disease, even if the chest x-ray was normal 4, 5.
• A high-resolution computed tomography (HRCT) scan of the chest may be useful in evaluating the patient's cough, as it can demonstrate pulmonary infiltrates or other abnormalities not visible on a plain chest x-ray 4.
• The patient's symptoms and test results should be evaluated in the context of their overall clinical presentation, and a therapeutic trial of select medications or further testing, such as bronchoscopy or pulmonary function tests, may be necessary to establish a diagnosis 2.
• Consultation with a pulmonologist or other specialist may be indicated if the diagnosis is unclear or if specific therapy is mandated 2.
• It is also important to note that physician practice patterns, such as ordering chest x-rays, can be influenced by various factors, including patient age, symptoms, and physical examination findings 6.