What is the initial management for a patient experiencing a paroxysm of cough?

Initial Management of Paroxysm of Cough

For patients experiencing a paroxysm of cough, inhaled ipratropium bromide should be considered as first-line therapy as it may attenuate the cough by reducing bronchial hyperresponsiveness. 1, 2

Diagnostic Approach

When evaluating a patient with paroxysmal cough, consider the duration of symptoms:

• Acute cough (<3 weeks): Likely viral respiratory infection
• Subacute cough (3-8 weeks): Consider post-infectious cough
• Chronic cough (>8 weeks): Evaluate for other etiologies 3

Key diagnostic considerations:

• If cough has lasted ≥2 weeks with paroxysms, post-tussive vomiting, and/or inspiratory whooping sound, suspect pertussis infection unless another diagnosis is proven 1
• For suspected pertussis, obtain nasopharyngeal aspirate or Dacron swab for culture to confirm diagnosis 1

Management Algorithm

1. For Post-Infectious Paroxysmal Cough:

• First-line: Inhaled ipratropium bromide 1, 2
• If inadequate response: Consider inhaled corticosteroids 1
• For severe paroxysms: Consider prednisone 30-40 mg daily for a short, finite period when other common causes of cough have been ruled out 1
• When other measures fail: Central-acting antitussives such as codeine or dextromethorphan 1, 2

2. For Suspected or Confirmed Pertussis:

• Immediate treatment: Macrolide antibiotic (erythromycin 1-2g/day in adults, or newer macrolides like azithromycin) 1
• Isolation: Patient should be isolated for 5 days from start of treatment 1
• Important note: Early treatment (within first few weeks) will diminish coughing paroxysms and prevent disease spread; treatment beyond this period may be offered but response is unlikely 1
• Avoid ineffective treatments: Long-acting β-agonists, antihistamines, corticosteroids, and pertussis Ig show no benefit for pertussis patients 1

Important Clinical Pearls

• Antibiotics have no role in post-infectious cough unless bacterial infection (like pertussis or sinusitis) is confirmed 1, 2
• Multiple pathogenetic factors may contribute to post-infectious cough, including postviral airway inflammation, bronchial hyperresponsiveness, mucus hypersecretion, and impaired mucociliary clearance 1
• For persistent cough despite treatment, consider other common causes such as upper airway cough syndrome, asthma, or gastroesophageal reflux disease 1, 4
• If cough persists beyond 8 weeks, reclassify as chronic cough and evaluate for other etiologies 1, 5

Cautions and Pitfalls

• Don't delay treatment for suspected pertussis while awaiting confirmation, as early therapy is most effective 1
• PCR testing for pertussis is available but not recommended due to lack of universally accepted, validated techniques for routine clinical testing 1
• Avoid unnecessary antibiotic use for non-bacterial causes of cough 2
• Central-acting antitussives should be used with caution due to potential side effects and only when other measures fail 2, 6