What is the recommended treatment for upper airway cough syndrome?

Treatment of Upper Airway Cough Syndrome

For upper airway cough syndrome (UACS), first-generation antihistamine-decongestant combinations are the recommended first-line treatment, specifically dexbrompheniramine maleate (6 mg twice daily) plus sustained-release pseudoephedrine sulfate (120 mg twice daily) for a minimum of 3 weeks. 1

First-Line Treatment Algorithm

1. Initial Therapy:

   • First-generation antihistamine-decongestant (A/D) combination
     • Preferred: Dexbrompheniramine maleate (6 mg BID) + sustained-release pseudoephedrine sulfate (120 mg BID)
     • Alternative: Azatadine maleate (1 mg BID) + sustained-release pseudoephedrine sulfate (120 mg BID)
   • Duration: Minimum 3 weeks 2, 1
   • For patients with sedation concerns: Start with once-daily dosing at bedtime before advancing to twice-daily 1

2. If No Response After 3-4 Weeks:

   • Proceed to sinus imaging to evaluate for chronic sinusitis 2
   • If sinusitis is identified, initiate:
     • Antibiotic effective against H. influenzae, mouth anaerobes, and S. pneumoniae (3 weeks)
     • Continue A/D combination (3 weeks)
     • Add nasal decongestant (5 days)
     • When cough resolves, continue intranasal corticosteroids for 3 months 2

Special Considerations

For Specific Underlying Conditions:

• Allergic Rhinitis:

  • Intranasal corticosteroids (1-month trial initially, may continue for 3 months if effective) 1
  • Non-sedating antihistamines may be added (though ineffective for cough alone) 1

• Rhinitis Due to Physical/Chemical Irritants:

  • Avoidance of exposure
  • Improved ventilation
  • Filters
  • Personal protective devices in occupational settings 2

• Rhinitis Medicamentosa:

  • Discontinue or wean off the offending agent (can be done one nostril at a time)
  • Consider A/D or nasal corticosteroids as supportive therapy 2

Alternative Options for Patients with Contraindications:

• For patients who cannot tolerate first-generation A/D combinations (e.g., those with glaucoma, prostatic hypertrophy, or hypertension):
  • Ipratropium bromide nasal spray for rhinorrhea-predominant symptoms 1
  • Consider leukotriene receptor antagonists as adjunctive therapy 1

Important Clinical Pearls

1. Newer-generation (non-sedating) antihistamines are ineffective for treating cough associated with UACS 1, 3

2. Response to treatment is both diagnostic and therapeutic - improvement typically occurs within days to 2 weeks of starting therapy 1, 4

3. Common side effects of first-generation A/D combinations include:

   • Dry mouth, sedation, dizziness
   • Insomnia, jitteriness
   • Urinary retention
   • Tachycardia and hypertension 1

4. Pediatric considerations:

   • First-generation A/D combinations are recommended only for children over 6 years (maximum 3 weeks)
   • Not recommended for children under 6 years due to safety concerns 1

5. When UACS treatment fails:

   • Consider other common causes of chronic cough (asthma, gastroesophageal reflux)
   • These three conditions account for 90% of chronic cough cases 4
   • Consider eosinophilic airway inflammation, which is observed in 30-50% of chronic cough sufferers 5

Diagnostic Considerations

UACS is a clinical diagnosis with no pathognomonic findings. The diagnosis is often confirmed by response to empiric therapy 1, 4. Before initiating treatment, consider:

• Evaluation for specific cough characteristics (wet vs. dry, timing, associated symptoms)
• Chest radiograph and spirometry to rule out other causes
• Assessment for risk factors for asthma if clinically suspected 1

By following this treatment algorithm and considering the specific underlying conditions, most patients with UACS should experience significant improvement in their chronic cough symptoms.