What is the initial management for a patient presenting with a nocturnal cough?

Initial Management of Nocturnal Cough

For patients presenting with nocturnal cough, first-line therapy should be a first-generation antihistamine/decongestant combination to treat Upper Airway Cough Syndrome (UACS), which is the most common cause of chronic cough. 1

Diagnostic Approach

When evaluating nocturnal cough, consider the following common causes:

1. Upper Airway Cough Syndrome (UACS) - Most common cause
2. Asthma/Bronchial hyperresponsiveness - Common cause, especially if cough worsens at night
3. Gastroesophageal reflux disease (GERD) - Common cause of nocturnal cough
4. Postinfectious cough - If cough persists 3-8 weeks after respiratory infection

Red Flags Requiring Urgent Evaluation

• Hemoptysis
• Persistent fever
• Weight loss
• Abnormal respiratory findings
• Prominent dyspnea

Treatment Algorithm

Step 1: First-Line Treatment for UACS

• First-generation antihistamine/decongestant combination (e.g., brompheniramine with sustained-release pseudoephedrine) for 2-4 weeks 1, 2
• First-generation antihistamines with sedative properties are particularly useful for nocturnal cough 1

Step 2: If No Response After 2-4 Weeks, Consider Asthma

• Perform spirometry or bronchoprovocation challenge if available
• If testing unavailable or positive, initiate:
  • Inhaled corticosteroids and bronchodilators for 4 weeks 1
  • For persistent nocturnal cough in children, high-dose inhaled corticosteroids have shown benefit (fluticasone 1mg twice daily for 3 days followed by 500μg twice daily for 11 days) 3

Step 3: If Cough Persists, Consider GERD

• Initiate proton pump inhibitor (PPI) therapy (e.g., omeprazole 20-40mg twice daily before meals) for 8 weeks 1
• Add prokinetic agents (e.g., metoclopramide 10mg three times daily) if needed 1
• Consider combination of twice daily PPIs and nocturnal H2 antagonists for full acid suppression 1

Step 4: For Postinfectious Cough

• If cough developed after respiratory infection and persists 3-8 weeks:
  • Consider inhaled ipratropium bromide as first-line therapy 2
  • Short course of inhaled corticosteroids if cough affects quality of life 2

Special Considerations

Medication-Induced Cough

• ACE inhibitors - If patient is taking an ACE inhibitor, discontinue and replace with alternative agent (e.g., ARB) 1, 2
• Proton pump inhibitors - Rarely, PPIs themselves can cause cough (monitor for worsening cough after initiating PPI therapy) 4

Non-Pharmacological Approaches

• Eliminate medications potentially worsening reflux (bisphosphonates, nitrates, calcium channel blockers, theophylline) 1
• For simple cough suppression, consider:
  • Menthol inhalation (provides short-term relief) 1
  • Honey and lemon (simple home remedy) 1
  • Dextromethorphan (non-sedating antitussive) 1

When to Refer

• If cough persists after sequential empiric treatments for UACS, asthma, and GERD
• If diagnostic testing reveals concerning findings
• If cough persists beyond 8 weeks despite appropriate therapy 1, 2

Important Caveats

• Avoid antibiotics for postinfectious cough as they provide no benefit and contribute to resistance 2
• Codeine and pholcodine have no greater efficacy than dextromethorphan but have worse side effect profiles 1
• Multiple causes of cough may coexist, requiring sequential and additive therapy 1
• Improvement typically occurs within 2 weeks of appropriate therapy; reassess if no improvement 2