What is the initial management for a patient presenting with cough and inspiratory wheezing?

Initial Management of Cough with Inspiratory Wheezing

The initial management requires immediate assessment for life-threatening causes, followed by empiric bronchodilator therapy while pursuing diagnostic evaluation for the most likely etiologies: asthma, pertussis, or upper airway obstruction.

Immediate Assessment and Risk Stratification

• Evaluate for respiratory distress including markedly elevated respiratory rate, intercostal retractions, grunting, cyanosis, or altered mental status, which indicate need for urgent intervention 1, 2
• Assess for risk factors including comorbidities, frailty, immunosuppression, or impaired ability to cough and clear secretions 1, 2
• Obtain focused history to determine ACE inhibitor use (discontinue immediately if present), smoking status, duration of cough, and presence of paroxysmal coughing, post-tussive vomiting, or whooping sound 1, 2

Critical Diagnostic Consideration: Inspiratory vs Expiratory Wheezing

The presence of inspiratory wheezing is a crucial distinguishing feature that narrows your differential diagnosis significantly. While expiratory wheezing typically indicates lower airway obstruction (asthma, bronchitis), inspiratory wheezing suggests either:

• Pertussis infection (whooping cough with inspiratory whoop) 3
• Upper airway obstruction (subglottic stenosis, foreign body, or other fixed obstruction) 4

Initial Diagnostic Testing

• Obtain chest radiograph if pneumonia is suspected based on tachypnea, tachycardia, dyspnea, or abnormal lung findings 1, 2
• Perform spirometry to assess for airflow obstruction and characteristic patterns (flattened inspiratory/expiratory peaks suggest fixed extrathoracic obstruction) 3, 2, 4
• Order nasopharyngeal culture if pertussis is suspected (cough ≥2 weeks with paroxysms, post-tussive vomiting, or inspiratory whooping sound) - isolation of bacteria is the only certain diagnostic method 3

Empiric Treatment Algorithm

First-Line Therapy: Bronchodilator Trial

• Administer inhaled albuterol 2.5 mg by nebulizer or 400 mcg by metered-dose inhaler with spacer 3, 5
• This serves both therapeutic and diagnostic purposes - response suggests reversible airway disease (asthma), while lack of response points toward fixed obstruction or pertussis 3
• Pretreatment with bronchodilator is essential before initiating inhaled corticosteroids to prevent cough and bronchospasm from the inhaler itself 6

If Asthma is Suspected (Expiratory Component Present)

• Initiate combination therapy with inhaled bronchodilators and inhaled corticosteroids as first-line treatment 3
• Asthma should always be considered in chronic cough, as it is extremely common and frequently presents with cough as the predominant symptom 3
• If spirometry is normal but clinical suspicion remains high, consider methacholine challenge testing or empiric trial of antiasthmatic therapy 3, 2

If Pertussis is Suspected (Inspiratory Whoop, Paroxysmal Cough)

• Prescribe macrolide antibiotic immediately (azithromycin, clarithromycin, or erythromycin) if cough has been present ≥2 weeks with characteristic features 3
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 3
• Isolate patient for 5 days from start of antibiotic treatment 3
• Treatment beyond a few weeks is unlikely to help but should still be offered to prevent transmission 3

If Upper Airway Obstruction is Suspected (Fixed Inspiratory Limitation)

• Refer urgently for bronchoscopy if spirometry shows flattened inspiratory and expiratory peaks characteristic of fixed extrathoracic obstruction 4
• This requires specialist evaluation and may need rigid bronchoscopy with balloon dilatation 4

Common Pitfalls to Avoid

• Do not rely on cough characteristics alone for diagnosis, as they have limited diagnostic value 1, 2
• Do not use newer generation non-sedating antihistamines for acute cough, as they are ineffective 3, 1
• Do not assume pertussis is ruled out in vaccinated individuals - breakthrough infections occur and should be diagnosed when clinical features are present 3
• Do not prescribe inhaled corticosteroids without bronchodilator pretreatment, as this can paradoxically worsen cough and cause bronchospasm 6
• Do not use long-acting β-agonists, antihistamines, or corticosteroids alone for confirmed pertussis, as there is no evidence of benefit 3

Refractory Cases

• Add leukotriene receptor antagonist if cough persists despite inhaled corticosteroids and bronchodilators, after excluding poor compliance or contributing conditions 3
• Consider short course of oral corticosteroids (prednisone 30-40 mg daily for 1-2 weeks) for severe/refractory asthmatic cough 3
• Pursue advanced testing (high-resolution CT, bronchoscopy) if cough persists after 4-6 weeks of appropriate empiric treatment 1, 2