What is the best treatment approach for a 59-year-old male with a history of epilepsy and scoliosis, presenting with a chronic cough bothersome at night, and a high-resolution computed tomography (CT) scan showing mild bronchiolitis?

Treatment for Chronic Cough with Bronchiolitis in a Wheelchair-Bound Patient

For a 59-year-old male with chronic cough due to mild bronchiolitis, prolonged antibiotic therapy is recommended as the first-line treatment to improve cough symptoms and prevent progression of airway disease. 1

Diagnostic Considerations

The patient presents with:

• Chronic cough bothersome at night
• History of epilepsy and scoliosis
• Wheelchair-bound and deconditioned status
• HRCT showing mild bronchiolitis
• Afebrile status

This clinical picture is consistent with nonbronchiectatic suppurative airway disease (bronchiolitis), which can be a significant cause of chronic cough when more common causes have been excluded 1.

Treatment Algorithm

First-Line Treatment:

1. Prolonged antibiotic therapy
   • Indicated for infectious bacterial bronchiolitis 1
   • Should be continued until significant clinical improvement occurs
   • Consider macrolides (e.g., azithromycin) which have both antimicrobial and anti-inflammatory properties

Additional Therapeutic Considerations:

1. Airway clearance techniques

   • Particularly important for a wheelchair-bound patient with likely reduced mobility
   • May include:
     • Chest physiotherapy
     • Postural drainage
     • Assisted coughing techniques

2. Bronchodilators

   • Can help relieve bronchospasm and improve airway clearance
   • Consider short-acting beta-agonists for symptomatic relief

3. Address nighttime cough specifically

   • Elevate head of bed
   • Consider low-dose antihistamine at bedtime if post-nasal drip component is suspected

Special Considerations for This Patient

Scoliosis Impact

The patient's scoliosis may contribute to his respiratory symptoms, as scoliosis:

• Decreases chest wall compliance
• Places respiratory muscles at mechanical disadvantage
• Can lead to atelectasis and air-trapping 2
• May exacerbate symptoms of bronchiolitis

Mobility Limitations

Being wheelchair-bound and deconditioned:

• Increases risk of mucus retention
• May reduce effectiveness of normal cough clearance mechanisms
• Requires adapted airway clearance techniques

Monitoring and Follow-up

1. Clinical response assessment

   • Evaluate improvement in cough frequency and severity after 2-4 weeks
   • Monitor for development of antibiotic resistance or side effects

2. Consider repeat imaging

   • If symptoms persist despite appropriate therapy
   • HRCT remains the gold standard for evaluating bronchiolitis with 95% accuracy 3

3. Consider bronchoscopy

   • If no improvement with initial therapy
   • To rule out infection and evaluate inflammatory cellularity 1, 3

Potential Pitfalls and Caveats

1. Rule out common causes first

   • Upper airway cough syndrome (UACS)
   • Asthma
   • Gastroesophageal reflux disease (GERD)
   • These account for 85% of chronic cough cases in adults 4

2. Consider multifactorial etiology

   • Chronic cough is often caused by multiple factors 1
   • The patient's epilepsy medications should be reviewed for potential cough side effects

3. Avoid unnecessary CT scans

   • CT should be performed only in selected patients with chronic cough when common causes are excluded 1
   • This patient's CT has already confirmed bronchiolitis

4. Recognize limitations of chest radiography

   • May miss up to 50% of significant airway inflammatory pathology 3
   • HRCT is superior for detecting bronchiolitis

By following this treatment approach focused on prolonged antibiotic therapy and appropriate airway clearance techniques, the patient's chronic cough due to bronchiolitis should improve, leading to better quality of life and prevention of further airway damage.