What is the appropriate management for a patient with an intractable cough?

Management of Intractable Cough

The management of intractable cough should follow a systematic approach targeting the most common causes first, then proceeding to less common causes, and finally considering symptomatic treatment when specific causes cannot be identified or treated effectively. 1

Initial Assessment

• Determine if the cough is acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks) to guide treatment approach 1, 2
• Obtain a chest radiograph to rule out significant pathology such as malignancy, pneumonia, or other structural lung disease 3, 1
• Perform spirometry to identify potential airway obstruction or asthma 3
• Discontinue ACE inhibitors if the patient is taking them, as they are a common cause of persistent dry cough 3, 1
• Advise smoking cessation for smokers, as this can resolve cough symptoms within 4 weeks 1

Systematic Treatment Approach for Common Causes

1. Upper Airway Cough Syndrome (UACS)

• Begin with a first-generation antihistamine/decongestant combination 1
• Consider intranasal corticosteroids (e.g., fluticasone) for patients with allergic rhinitis 4

2. Asthma and Nonasthmatic Eosinophilic Bronchitis (NAEB)

• For suspected asthma, initiate treatment with inhaled corticosteroids combined with bronchodilators 1, 5
• For NAEB, first-line treatment is inhaled corticosteroids 1
• Consider a trial of oral prednisone (30-40 mg daily for a short period) for severe cough when other common causes have been ruled out 2

3. Gastroesophageal Reflux Disease (GERD)

• Initiate empiric treatment with proton pump inhibitors if cough persists after addressing UACS and asthma 1
• Add prokinetic therapy if there is little or no response to PPI therapy 1

Management of Refractory Cough

When cough persists despite treatment of common causes:

• Consider multimodality speech pathology therapy that includes cough suppression techniques, vocal hygiene, and psychoeducational counseling 3
• Trial gabapentin for refractory chronic cough 3
• Consider low-dose opiates for symptom control when all alternative treatments have failed, particularly in palliative care settings 3, 1
• Diazepam may be beneficial in select cases of intractable cough that fails to respond to usual treatments 6

Special Considerations

• For patients with dysphagia and cough, videofluoroscopic swallow evaluation (VSE) or fiberoptic endoscopic evaluation of swallowing (FEES) should be performed to identify appropriate treatment 3
• Patients with dysphagia should be managed by organized multidisciplinary teams 3
• Consider bronchoscopy if foreign body aspiration is suspected or when other targeted investigations are normal 3
• Patients with intractable aspiration may be considered for surgical intervention 3

Common Pitfalls to Avoid

• Do not rely solely on cough characteristics for diagnosis, as they have limited diagnostic value 7
• Avoid treating only one potential cause, as multiple factors often contribute to chronic cough 1, 7
• Do not prescribe antibiotics for postinfectious cough unless there is evidence of bacterial infection 2
• Recognize that chronic cough is often caused by multiple, simultaneously contributing causes 7
• Avoid prolonged empiric treatment without reassessment, as this can delay diagnosis of serious underlying conditions 8

When to Refer to a Specialist

• When cough persists despite sequential trials of therapy for common causes 1
• When the diagnosis remains unclear after basic investigations 3
• For patients with significant comorbidities that complicate management 3
• When cough severely impacts quality of life despite appropriate treatment 3, 8