How do you manage coughs due to various causes?

Management of Different Types of Cough

The most effective approach to managing cough requires systematic identification of the underlying cause and targeted treatment, rather than symptomatic therapy alone. 1, 2

Classification and Initial Assessment

Acute Cough (< 3 weeks)

• First determine if cough represents serious illness (pneumonia, pulmonary embolism) or non-life-threatening condition 1
• Key assessment points:
  • Presence of fever, dyspnea, hemoptysis, weight loss (red flags)
  • Recent respiratory infection
  • Exposure to irritants/allergens
  • Current medications (especially ACE inhibitors)

Subacute Cough (3-8 weeks)

• Determine if post-infectious or non-infectious 1, 2
• Post-infectious causes:
  • Upper airway cough syndrome (UACS)
  • Transient bronchial hyperresponsiveness
  • Pertussis (suspect if paroxysmal cough with post-tussive vomiting)

Chronic Cough (> 8 weeks)

• Most common causes: UACS, asthma, non-asthmatic eosinophilic bronchitis (NAEB), GERD 1, 2

Treatment Algorithm by Cough Type

1. Acute Viral/Post-Viral Cough

• First-line: Inhaled ipratropium bromide to reduce bronchial hyperresponsiveness 2
• Second-line: Inhaled corticosteroids if quality of life affected 2
• For symptomatic relief: Dextromethorphan (non-narcotic antitussive) 3
  • Extended-release formulations provide up to 12 hours of relief
  • Avoid combination products 4

2. Upper Airway Cough Syndrome (Post-nasal Drip)

• First-line: First-generation antihistamine/decongestant combination for 2-4 weeks 2
  • Example: Brompheniramine with sustained-release pseudoephedrine
• Monitor response: Improvement typically within 2 weeks

3. Asthma-Related Cough

• First-line: Inhaled corticosteroids and bronchodilators for 4 weeks 2
• Diagnostic approach: Bronchoprovocation challenge (BPC) if spirometry normal 1
  • PC20 < 8 mg/ml highly specific for asthma diagnosis 5

4. GERD-Related Cough

• Treatment: Proton pump inhibitor with lifestyle modifications for 4-8 weeks 2
• Important note: May require longer treatment duration for symptom resolution

5. Non-Asthmatic Eosinophilic Bronchitis

• Diagnostic test: Induced sputum for eosinophils 1
• Treatment: Corticosteroids (inhaled first, oral if needed) 1, 2

6. ACE Inhibitor-Induced Cough

• Management: Discontinue ACE inhibitor and replace with alternative medication 1
• Time course: Cough typically resolves within 1-4 weeks after discontinuation

7. Pertussis

• Treatment: Macrolide antibiotic (erythromycin or azithromycin) 2
• Isolation: 5 days from start of treatment
• Note: Early treatment (within first few weeks) most effective 2

8. Idiopathic/Refractory Cough

• Options:
  • Neuromodulators (gabapentin) 2
  • Speech pathology therapy for cough suppression techniques 2
  • Low-dose morphine for severe cases 1
  • Nebulized local anesthetics (lidocaine, mepivicaine) in selected cases 1

Special Considerations

Pediatric Cough Management

• Definition: Chronic cough in children is > 4 weeks 2, 6
• Wet cough: Consider protracted bacterial bronchitis requiring antibiotics 6
• Dry cough: Less likely to be asthma without other features 2
• Consider: Tic cough (formerly habit cough) in unexplained cases 2

Important Cautions

• Avoid cough suppression in productive cough where clearance is important (pneumonia, bronchiectasis) 1
• Antibiotics not indicated for post-viral cough unless bacterial infection confirmed 2
• Sequential and additive therapy often needed as multiple causes may coexist 1
• Smoking cessation essential for smokers with chronic cough 1

Follow-up and Referral

• Referral indications:
  • Failure to respond to empiric treatment
  • Presence of red flags (hemoptysis, weight loss)
  • Suspected serious underlying pathology
• Imaging: CT scan more sensitive than chest X-ray for structural lung abnormalities 2

This systematic approach to cough management addresses the underlying causes rather than merely suppressing symptoms, leading to better outcomes and improved quality of life for patients with both acute and chronic cough.