What is the initial treatment approach for a patient presenting with chronic cough and wheezing, likely due to asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Treatment Approach for Chronic Cough with Wheezing

For patients presenting with chronic cough and wheezing, the initial treatment approach should focus on addressing asthma with a combination of inhaled corticosteroids and β-agonists, as these are most likely to provide symptom relief and improve quality of life. 1

Initial Assessment

• Rule out serious conditions like pneumonia or pulmonary embolism that may present with cough and wheezing 1
• Check if the patient is taking an ACE inhibitor, which can cause chronic cough - if so, discontinue and replace with another medication 1
• Determine if the patient is a smoker - smoking cessation should be strongly advised as it can resolve cough symptoms within 4 weeks 1
• Obtain a chest radiograph to rule out significant pathology 1, 2

Treatment Algorithm

Step 1: Asthma Treatment

• For patients with chronic cough and wheezing, initiate treatment with:
  • Inhaled corticosteroids (ICS) combined with long-acting β-agonists (LABA) such as fluticasone/salmeterol twice daily 1, 3
  • For adults, start with one inhalation of fluticasone/salmeterol 100/50,250/50, or 500/50 twice daily, depending on severity 3
• Monitor for response within 2-4 weeks 1

Step 2: If Incomplete Response, Add Treatment for Upper Airway Cough Syndrome (UACS)

• Add a first-generation antihistamine/decongestant combination 1
• Expect some improvement within 1-2 weeks, though complete resolution may take several weeks 1
• Consider adding a topical nasal steroid if nasal symptoms persist 1

Step 3: If Still Inadequate Response, Address Gastroesophageal Reflux Disease (GERD)

• Initiate empiric treatment for GERD with proton pump inhibitors 1
• Continue previous treatments as cough is often multifactorial 1

Special Considerations

• If spirometry is available and does not show reversible airflow obstruction, consider bronchoprovocation challenge (BPC) to confirm asthma diagnosis 1
• For patients with suspected non-asthmatic eosinophilic bronchitis (NAEB), consider induced sputum testing for eosinophils or an empiric trial of corticosteroids 1
• In COPD patients with chronic cough and wheezing, fluticasone/salmeterol 250/50 twice daily is recommended for maintenance treatment 3

Common Pitfalls to Avoid

• Do not use LABA monotherapy for asthma as it increases the risk of serious asthma-related events 3
• Do not initiate treatment during acute deterioration of asthma or COPD 3
• Be aware that oral candidiasis may occur with ICS use - advise patients to rinse their mouth with water without swallowing after inhalation 3
• Monitor for pneumonia in COPD patients treated with ICS 3
• Do not delay empiric treatment while waiting for specialized tests, as sequential therapeutic trials are both diagnostic and therapeutic 4

When to Consider Referral

• If cough persists despite sequential trials of therapy for common causes 1
• If there are concerning features on chest radiography 2
• If there is poor response to appropriate therapy after 8 weeks 4