What is the initial management for a patient with tracheal diverticulitis and chronic cough?

Initial Management of Tracheal Diverticulitis with Chronic Cough

For a patient with tracheal diverticulitis and chronic cough, initial management should be conservative with antibiotics for infection control, combined with systematic treatment of the chronic cough using the standard algorithm targeting upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD), reserving surgical excision only for cases with recurrent infections or compression symptoms. 1, 2

Understanding Tracheal Diverticulitis

Tracheal diverticulum is a benign outpouching of the tracheal wall that rarely causes symptoms but can present with chronic cough and recurrent respiratory infections when complicated by secondary bacterial infection or compression of adjacent structures. 1, 2 Most cases are asymptomatic and discovered incidentally, but when symptomatic, patients present with non-specific symptoms including pharyngeal discomfort, cough, dyspnea, and recurrent respiratory infections. 1, 3

Initial Conservative Management

Antibiotic Therapy for Infection

• Administer antibiotics if there is evidence of secondary bacterial infection (fever, elevated inflammatory markers, or signs of active infection). 2
• The infected tracheal diverticulum responds well to conservative antibiotic therapy in most cases. 2

Systematic Treatment of Chronic Cough

Step 1: Rule Out and Address Reversible Causes

• Discontinue ACE inhibitors immediately if the patient is taking them, as cough typically resolves within days to 2 weeks (median 26 days). 4
• Strongly counsel smoking cessation, as 90% of patients with chronic bronchitis will have resolution of cough after quitting. 4

Step 2: Empiric Treatment for UACS

• Initiate a first-generation antihistamine/decongestant combination (such as brompheniramine with sustained-release pseudoephedrine) as the first-line empiric therapy. 4
• This addresses postnasal drip and upper airway irritation that commonly contributes to chronic cough. 4
• Expect response within 1-2 weeks, though complete resolution may take several weeks. 5

Step 3: Add Asthma Treatment if Incomplete Response

• Start inhaled corticosteroids combined with bronchodilators after 2-4 weeks if cough persists. 4, 5
• Asthma should always be considered as a potential etiology because it is common and cough may be the only manifestation. 4
• Monitor for response within 2-4 weeks. 5

Step 4: Add GERD Treatment if Still Inadequate Response

• Initiate proton pump inhibitor therapy with dietary modifications (limit fat to <45g/24h, avoid coffee, tea, soda, chocolate, mints, citrus, tomatoes, alcohol). 4
• Continue all previous treatments as chronic cough is frequently multifactorial. 4, 5
• Assess response over 1-3 months. 4

Diagnostic Confirmation

• Thoraco-cervical multi-slice spiral CT is the key diagnostic tool to visualize the tracheal diverticulum and assess for complications. 1, 2
• Fiber-optic bronchoscopy confirms the diagnosis and excludes other airway pathology. 1, 2
• Barium contrast study can rule out esophageal communication if needed. 1

When to Consider Surgical Referral

Refer for surgical excision only if: 1, 2

• Recurrent respiratory infections persist despite adequate antibiotic therapy
• Compression of adjacent organs causes significant symptoms (such as recurrent laryngeal nerve paralysis causing dysphonia) 3
• Conservative management fails after appropriate trials

Critical Pitfalls to Avoid

• Do not assume the tracheal diverticulum is the sole cause of chronic cough – systematically evaluate and treat the common causes of chronic cough (UACS, asthma, GERD) as these frequently coexist and may be the primary drivers of symptoms. 4
• Do not rush to surgery – most tracheal diverticula are asymptomatic or respond to conservative management; surgical excision is reserved for specific complications. 1, 2
• Do not treat only one cause – use sequential and additive therapy as multiple conditions often contribute simultaneously to chronic cough. 4, 5
• Do not use newer non-sedating antihistamines – they are ineffective for cough and should not be used; first-generation antihistamines are required. 4

Expected Timeline

• Antibiotic response for infected diverticulum: days to weeks 2
• UACS treatment response: 1-2 weeks for initial improvement 5
• Asthma treatment response: 2-4 weeks 5
• GERD treatment response: 1-3 months 4
• Overall chronic cough resolution may require maintaining all partially effective treatments for several months 4