What is the next step in managing a patient with persistent cough and shortness of breath, worsened by recumbency, despite normal echocardiogram and chest x-ray, and lack of improvement with initial treatment?

Next Step: High-Resolution CT Scan of the Chest

Given persistent cough and dyspnea worsening with recumbency for 2 months after initial infection, with normal echocardiogram and chest x-ray, and failure of initial empiric treatment, you should proceed to high-resolution CT (HRCT) of the chest. 1, 2

Why HRCT Now

The American College of Chest Physicians and American College of Radiology explicitly recommend HRCT after sequential empiric treatment for common causes has failed and adequate treatment duration has been allowed 2. Your patient has already completed initial empiric therapy without improvement, making this the appropriate next step 1.

HRCT is superior to chest radiography for detecting occult pathology:

• Up to 42% of patients with presumed normal chest x-rays have abnormalities on HRCT 2
• HRCT is diagnostic in 24% of chronic cough patients who had normal radiographs and failed initial protocols 2
• Bronchiectasis, which accounts for up to 8% of chronic cough cases, is missed on chest radiography in 34% of CT-proven cases 2, 3

What HRCT Will Evaluate

The scan should specifically assess for:

• Bronchiectasis (most common finding at 28% in patients with normal chest x-rays) 3
• Bronchial wall thickening (21% of cases) 3
• Interstitial lung disease 1
• Occult mediastinal lymphadenopathy 1
• Early parenchymal abnormalities not visible on plain radiography 1

Critical Consideration: Positional Symptoms

The worsening with recumbency is particularly important and suggests:

• GERD-related cough (if not already adequately treated) 1, 2
• Post-infectious bronchial hyperreactivity 4
• Occult cardiac pathology (though your echocardiogram was normal) 1

Before Proceeding to HRCT: Ensure Adequate Empiric Treatment

Verify that initial treatment was truly adequate: 2

• If upper airway cough syndrome (UACS) was treated: first-generation antihistamine-decongestant should have been given for 1-2 weeks minimum 1
• If asthma was treated: inhaled corticosteroids ± bronchodilators should have been tried for several weeks 2
• If GERD was treated: intensive acid suppression with proton pump inhibitors must be given for at least 3 months 1, 2

Common pitfall: GERD treatment is frequently inadequate in duration. Many patients require 3 months of high-dose PPI therapy, and some need prokinetic agents added 1, 2. The positional nature of your patient's symptoms makes inadequately treated GERD a strong consideration.

If HRCT is Normal

Should HRCT reveal no abnormalities, the American College of Chest Physicians recommends bronchoscopy to evaluate for 1:

• Occult endobronchial tumor 1
• Sarcoidosis 1
• Eosinophilic or lymphocytic bronchitis 1
• Suppurative lower airway infection 1

Red Flags Already Present

Your patient does NOT appear to have concerning red flags that would warrant more urgent investigation (hemoptysis, significant weight loss, fever, systemic illness) 2, 3. However, the 2-month duration and failure of initial treatment justify advanced imaging now rather than continuing empiric trials 1.