What is the management approach for a patient with a persistent cough after carotid endarterectomy (CEA)?

Management of Persistent Cough After Carotid Endarterectomy

For patients with persistent cough following carotid endarterectomy (CEA), a systematic evaluation for common causes of cough should be conducted, with sequential empiric treatment directed at the most likely etiologies including upper airway cough syndrome, asthma, and gastroesophageal reflux disease. 1

Initial Assessment

• Rule out serious complications of CEA that may present with cough:

  • Wound hematoma causing airway compression 2, 3
  • Wound infection (occurs in <1% of cases) 4
  • Respiratory complications (reported in 0.8% of CEA patients) 5

• Key history elements to evaluate:

  • Timing of cough onset in relation to CEA
  • Characteristics: productive vs. non-productive
  • Associated symptoms (dyspnea, stridor, fever)
  • Worsening factors (position changes, meals)
  • Medication review (particularly ACE inhibitors)

Diagnostic Approach

1. Immediate concerns:

   • Examine the surgical site for hematoma, infection, or wound complications
   • Assess for stridor or respiratory distress requiring urgent intervention

2. Basic workup:

   • Chest radiograph to rule out pneumonia or pulmonary edema
   • Review of medications (ACE inhibitors must be discontinued if present) 1

3. If no urgent cause identified, evaluate for common causes of chronic cough:

   • Upper Airway Cough Syndrome (UACS)
   • Asthma/bronchial hyperresponsiveness
   • Gastroesophageal Reflux Disease (GERD)
   • Post-infectious cough

Treatment Algorithm

Step 1: Address CEA-Specific Concerns

• If wound hematoma present → urgent surgical evacuation 2, 3
• If wound infection suspected → incision and drainage with antibiotics 4

Step 2: Discontinue ACE Inhibitors

• Stop ACE inhibitors regardless of temporal relationship to cough onset
• Cough resolution typically occurs within days to 2 weeks (median 26 days) 6

Step 3: Sequential Empiric Treatment for Common Causes

1. Upper Airway Cough Syndrome (UACS):

   • First-generation antihistamine/decongestant combination for 2-4 weeks 6
   • Example: brompheniramine with sustained-release pseudoephedrine

2. If cough persists, evaluate for asthma:

   • Ideally perform bronchial provocation challenge (BPC) 1
   • If BPC unavailable, trial of inhaled corticosteroids and bronchodilators for 4 weeks 6

3. If cough still persists, evaluate for GERD:

   • Intensive acid suppression with twice-daily proton pump inhibitors 6
   • Add lifestyle modifications (elevate head of bed, avoid eating before bedtime)
   • Continue therapy for minimum of 3 months 6
   • Consider 24-hour esophageal pH monitoring if symptoms persist 1, 6

4. For refractory cough:

   • Consider high-resolution CT scan of the chest 6
   • Consider bronchoscopy to evaluate for occult airway disease 1
   • Consider neuromodulators like gabapentin for cough hypersensitivity 6

Special Considerations

• Cardiovascular complications are the most common medical complications after CEA (7.1%), so monitor for cardiac symptoms 5

• Respiratory complications are less common (0.8%) but can be serious 5

• Wound hematoma causing airway compression is a life-threatening emergency requiring immediate surgical intervention 2, 3

• Post-CEA cough may be related to manipulation of the carotid body or irritation of vagal nerve branches during surgery

Follow-up

• Re-evaluate after 4-6 weeks if cough persists despite treatment 6
• Consider referral to specialist (pulmonologist, otolaryngologist) if cough remains unresolved after sequential therapy

Remember that multiple causes of cough may coexist, requiring additive therapy rather than switching between treatments 1. The systematic approach outlined above will address the most common causes of persistent cough following carotid endarterectomy.