What's the next step for a patient with persistent coughing 15 days after a viral infection, despite treatment with levocetirizine (antihistamine), paracetamol (acetaminophen), and montelukast (leukotriene receptor antagonist)?

Management of Persistent Post-Viral Cough

For a patient with persistent cough 15 days after a viral infection that has not responded to levocetirizine, paracetamol, and montelukast, the next step should be a trial of inhaled ipratropium bromide as it has demonstrated efficacy in attenuating post-infectious cough in controlled trials. 1

Diagnosis

• The patient's presentation is consistent with post-infectious cough, defined as cough persisting for 3-8 weeks following an acute respiratory infection 2, 1
• Current treatment with antihistamine (levocetirizine), anti-inflammatory (paracetamol), and leukotriene receptor antagonist (montelukast) has been ineffective 1
• Post-infectious cough often involves multiple pathogenetic factors including:
  • Post-viral airway inflammation
  • Bronchial hyper-responsiveness
  • Mucus hypersecretion
  • Impaired mucociliary clearance 2

Treatment Algorithm

First-Line Therapy (Next Step)

• Inhaled ipratropium bromide should be initiated as it has demonstrated efficacy in attenuating post-infectious cough 2, 1
• Antibiotics have no role in treatment unless there is confirmed bacterial infection 2, 1

Second-Line Therapy

• If cough persists despite ipratropium, add inhaled corticosteroids 2, 1
• Inhaled corticosteroids work by suppressing airway inflammation and bronchial hyperresponsiveness 1

For Severe Cases

• For severe paroxysms of cough, consider oral prednisone 30-40 mg daily for a short, finite period 2
• This should only be considered after ruling out other common causes of cough such as upper airway cough syndrome, asthma, or gastroesophageal reflux disease 2, 1

When Other Measures Fail

• Central-acting antitussive agents such as codeine and dextromethorphan should be considered when other treatments fail 2, 1

Special Considerations

Rule Out Pertussis

• If cough has paroxysms, post-tussive vomiting, or inspiratory whooping sound, consider pertussis infection 2
• Pertussis requires specific diagnosis (nasopharyngeal culture) and treatment with macrolide antibiotics 2, 1

Consider Other Causes if Cough Persists

• If cough persists beyond 8 weeks, it should be reclassified as chronic cough 2, 3
• Most common causes of chronic cough include:
  • Upper airway cough syndrome (UACS)
  • Asthma
  • Gastroesophageal reflux disease (GERD) 2, 4, 3
• Further evaluation may include chest imaging, spirometry, or referral to a specialist 3

Monitoring and Follow-up

• Follow up within 4-6 weeks after initiating treatment 1
• If cough persists beyond 8 weeks, further evaluation for chronic cough causes is warranted 2, 1
• For refractory cases, consider neuromodulatory treatments such as low-dose opioids, gabapentin, pregabalin, or speech therapy 5, 6

Common Pitfalls to Avoid

• Continuing ineffective treatments without escalating therapy 1
• Inappropriate use of antibiotics for viral post-infectious cough 2, 1
• Overlooking underlying conditions that may contribute to persistent cough 2, 3
• Failing to recognize when post-infectious cough has evolved into chronic cough 2, 1