What is the role of inhalers, such as fluticasone propionate (fluticasone) and albuterol, in the treatment of upper airway cough syndrome?

Role of Inhalers in Upper Airway Cough Syndrome Treatment

Intranasal corticosteroids like fluticasone are recommended as first-line treatment for Upper Airway Cough Syndrome (UACS) with prominent upper airway symptoms, while inhaled bronchodilators like albuterol have limited utility unless there is concurrent asthma. 1

Diagnosis and Initial Approach

UACS (formerly known as postnasal drip syndrome) is one of the most common causes of chronic cough, accounting for a significant portion of the 90% of chronic cough cases attributed to UACS, asthma, and gastroesophageal reflux 2.

Key diagnostic features:

• Sensation of secretions draining into posterior pharynx
• Nasal stuffiness or congestion
• Associated sinusitis symptoms
• Diagnosis often confirmed by response to empiric therapy

Treatment Algorithm for UACS

First-line treatments:

1. For UACS with prominent upper airway symptoms:

   • Intranasal corticosteroids (e.g., fluticasone) for 1 month initially 1
   • May continue for up to 3 months if effective
   • Targets the underlying inflammation causing postnasal drip

2. For UACS without prominent allergic features:

   • First-generation antihistamine-decongestant combinations
   • Specifically dexbrompheniramine maleate (6 mg twice daily) plus sustained-release pseudoephedrine sulfate (120 mg twice daily) for at least 3 weeks 1

Role of Inhalers in UACS Treatment

Intranasal Corticosteroids

• Efficacy: Intranasal corticosteroids have demonstrated effectiveness for cough associated with upper airway symptoms 3, 1
• Duration: A 1-month trial is recommended initially, with potential continuation for 3 months if effective 1
• Evidence: While randomized controlled trials are limited, prospective studies suggest that topical nasal steroids given for 2-8 weeks are effective for cough with postnasal drip 3

Inhaled Bronchodilators (e.g., Albuterol)

• Limited role in pure UACS: Albuterol and other bronchodilators have no established role in treating isolated UACS 1
• Only indicated when UACS coexists with asthma: In patients with both conditions, bronchodilators may help manage the asthma component 3, 4

Inhaled Corticosteroids (e.g., Fluticasone)

• Not first-line for isolated UACS: Inhaled (as opposed to intranasal) corticosteroids are not specifically recommended for UACS alone 1
• Indicated for asthma-related cough: When UACS coexists with asthma, inhaled corticosteroids are recommended for the asthma component 3
• Evidence for cough reduction: A randomized controlled trial showed that inhaled fluticasone (500 μg twice daily) reduced cough in otherwise healthy adults, with better effects in non-smokers 5

Special Considerations

When UACS Coexists with Asthma

When a patient has both UACS and asthma contributing to cough:

1. For the asthma component:

   • Inhaled corticosteroids (e.g., fluticasone) are first-line treatment 3
   • Consider adding leukotriene receptor antagonists if response is incomplete 3
   • Beta-agonists (albuterol) can be considered in combination with inhaled corticosteroids 3

2. For the UACS component:

   • Intranasal corticosteroids for prominent upper airway symptoms 1
   • First-generation antihistamine-decongestant combinations as described above 1

Potential Side Effects and Precautions

For inhaled fluticasone:

• May cause upper airway symptoms including laryngeal irritation and paradoxical bronchospasm 6
• Potential for systemic absorption with higher doses, leading to adrenal suppression 6
• Use with caution in patients with severe milk protein allergy due to lactose in the powder formulation 6

Treatment Failure

If symptoms persist despite appropriate treatment:

1. Reassess diagnosis and consider other causes of chronic cough
2. Consider stepping up therapy (e.g., increasing intranasal corticosteroid dose)
3. Evaluate for other common causes of chronic cough (asthma, gastroesophageal reflux)
4. Consider referral to specialist for further evaluation

Conclusion

For UACS treatment, intranasal corticosteroids play a key role when upper airway symptoms are prominent, while inhaled bronchodilators and corticosteroids are primarily indicated when UACS coexists with asthma or other lower airway conditions. Treatment should target the specific underlying mechanisms causing the cough for optimal symptom relief.