What is the next step in managing a 38-year-old male nonsmoker presenting with cough and greenish sputum?

Management of a 38-Year-Old Male Nonsmoker with Cough and Greenish Sputum

The next step in managing a 38-year-old male nonsmoker with cough and greenish sputum should be a chest radiograph followed by empiric treatment targeting the most common causes, starting with upper airway cough syndrome (UACS). 1, 2

Initial Evaluation

1. Chest Radiograph

   • Mandatory first step for evaluating persistent cough, especially with productive sputum 1
   • Helps rule out serious underlying conditions and guides further management 2

2. Sputum Evaluation

   • Indicated for productive cough with purulent (greenish) sputum
   • Should include:
     • Sputum smear and culture for bacteria
     • Cell differentiation to evaluate for inflammatory response 1

3. Medication Review

   • Check if patient is taking ACE inhibitors (should be discontinued if present) 2, 1

Treatment Algorithm

Step 1: Treat for Upper Airway Cough Syndrome (UACS)

• First-line: First-generation antihistamine/decongestant combination for 2-4 weeks 1, 2
• Example: Brompheniramine with sustained-release pseudoephedrine
• UACS is the most common cause of chronic cough in nonsmokers with normal chest radiographs 2

Step 2: If cough persists, consider and treat for asthma

• Evaluate for possible cough-variant asthma
• Trial of inhaled corticosteroids and bronchodilators for 4 weeks 1, 2
• Consider bronchoprovocation challenge if available 2

Step 3: If cough still persists, treat for GERD

• Proton pump inhibitor with lifestyle modifications for 4-8 weeks 1
• GERD can cause cough without typical reflux symptoms ("silent GERD") 2

Step 4: Consider other causes

• Nonasthmatic eosinophilic bronchitis (NAEB)
• Postinfectious cough (if recent respiratory infection)
• Bronchiectasis
• Consider referral to specialist if cough persists despite above treatments 1

Important Considerations

• Alpha-1 antitrypsin testing is not indicated as a next step in this clinical scenario, as it is not among the common causes of cough in a nonsmoker with acute/subacute presentation 2
• Alpha-1 antitrypsin deficiency testing would be considered in patients with early-onset emphysema, family history of the condition, or unexplained liver disease

Follow-up

• Arrange follow-up within 4-6 weeks
• Re-evaluate if cough persists beyond expected timeframe
• Consider referral to pulmonology if treatment fails or if concerning features develop 1

The empiric, sequential approach to diagnosis and treatment is supported by evidence and is more cost-effective than extensive testing at the outset 2. This approach targets the most common causes of cough while allowing for timely identification of less common conditions if initial treatments fail.