What is the best management approach for upper airway cough syndrome?

Management of Upper Airway Cough Syndrome (UACS)

The best management approach for upper airway cough syndrome (UACS) is to begin with a first-generation antihistamine-decongestant combination as first-line therapy, followed by intranasal corticosteroids if symptoms persist. 1, 2

First-Line Treatment Algorithm

1. First-generation antihistamine-decongestant (A/D) combination

   • Examples: dexbrompheniramine maleate plus sustained-release pseudoephedrine
   • Duration: Initial trial for 1-2 weeks, may continue for several weeks if effective
   • Expected response: Some improvement within days to 1-2 weeks; complete resolution may take several weeks 1
   • Caution: Use with care in patients with glaucoma, prostatic hypertrophy, or hypertension due to side effects including sedation, dry mouth, urinary retention 2

2. If partial response to A/D therapy:

   • For persistent nasal symptoms: Add topical nasal therapy
     • Intranasal corticosteroids (1-2 sprays in each nostril once or twice daily)
     • Nasal anticholinergic agents (e.g., ipratropium bromide)
     • Nasal antihistamines 1, 2

3. If symptoms persist despite topical therapy:

   • Obtain sinus imaging (plain films or CT scan based on clinical judgment)
   • For air-fluid levels: Add antibiotics and short-term topical nasal decongestant
   • For mucosal thickening: Treat presumptively for sinusitis 1

Second-Line Approaches

1. For refractory cases:

   • ENT specialist consultation
   • Consider serum Ig level measurement to rule out hypogammaglobulinemia
   • Allergy testing if allergic component suspected
   • Evaluation of home/workplace for environmental triggers 1, 2

2. For cases with nasal polyps and chronic sinusitis:

   • Consider aspirin challenge (if no contraindications)
   • If positive, consider aspirin desensitization and chronic aspirin therapy 1

Non-Pharmacological Interventions

• Saline nasal irrigation to improve mucociliary clearance
• Adequate hydration
• Warm facial packs
• Sleeping with head elevated
• Avoiding irritants (cigarette smoke, pollution, allergens) 2

Important Clinical Considerations

• Multifactorial nature: UACS often coexists with asthma and GERD; all causes must be treated for cough resolution 1, 3
• Diagnostic confirmation: UACS is a clinical diagnosis of exclusion with no specific diagnostic test; diagnosis is confirmed when treatment leads to symptom resolution 3
• Prevalence: UACS, asthma, and GERD account for 90% of chronic cough cases, with UACS being the most common 1, 3
• Subtypes: UACS can be associated with allergic rhinitis, non-allergic rhinitis, or chronic rhinosinusitis 4

Common Pitfalls to Avoid

1. Overuse of antibiotics: Most cases of rhinosinusitis are viral (only 0.5-2.0% bacterial); approximately 60% of presumed bacterial cases resolve without antibiotics 2

2. Relying on newer-generation antihistamines: Evidence suggests that older-generation H1 antihistamines are effective for UACS, while newer-generation antihistamines are not 5

3. Missing coexisting conditions: Failure to recognize and treat multiple causes of chronic cough (UACS, asthma, GERD) will result in persistent symptoms 1

4. Inadequate treatment duration: Complete resolution of cough may take several weeks to months; premature discontinuation of therapy may lead to treatment failure 1

5. Using OTC cough medications in children: First-generation antihistamine/decongestant combinations are not recommended for children under 6 years due to safety concerns 2

By following this stepwise approach to UACS management, clinicians can effectively address this common cause of chronic cough and improve patient quality of life.