What to do for a persistent cough after using albuterol (salbutamol), Tessalon Perles (benzocaine), and QVAR (beclomethasone)?

Management of Persistent Cough After Albuterol, Tessalon Perles, and QVAR

For persistent cough despite albuterol, Tessalon Perles, and QVAR (beclomethasone), add inhaled ipratropium bromide as the next step, followed by a short course of oral prednisone (30-40 mg daily) if ipratropium fails and other common causes have been excluded. 1

Immediate Next Steps

First-Line Addition: Inhaled Ipratropium

• Ipratropium bromide is the only inhaled anticholinergic specifically recommended for cough suppression in postinfectious or persistent cough. 1
• This medication may attenuate the cough through its anticholinergic effects on airway secretions and bronchial smooth muscle. 1
• Ipratropium has fair evidence (Grade B recommendation) for reducing cough frequency in patients with persistent cough not responding to initial bronchodilator and inhaled corticosteroid therapy. 1

Second-Line: Oral Corticosteroids

• If ipratropium fails and the cough adversely affects quality of life, prescribe prednisone 30-40 mg daily for a short, finite period (typically 5-7 days). 1
• This approach is specifically recommended for severe paroxysms of postinfectious cough when other common causes (upper airway cough syndrome, asthma, gastroesophageal reflux) have been ruled out. 1
• The evidence level is low but the net benefit is intermediate (Grade C recommendation). 1

Important Diagnostic Considerations

Rule Out ACE Inhibitor-Induced Cough

• If the patient is taking any ACE inhibitor (captopril, enalapril, lisinopril, ramipril, perindopril, etc.), this must be stopped immediately as it is the most common medication-related cause of persistent dry cough. 1, 2, 3
• ACE inhibitor cough occurs in 5-50% of patients (higher in Chinese populations), is characteristically non-productive with a persistent tickle in the throat, and typically resolves within 1-2 weeks of discontinuation. 1, 2
• Switch to an angiotensin receptor blocker (ARB) such as losartan 25-50 mg daily or candesartan 4-8 mg daily if the ACE inhibitor was being used for hypertension or heart failure. 2, 3

Consider Pertussis

• If cough has lasted ≥2 weeks with paroxysms, post-tussive vomiting, or inspiratory whooping sound, obtain nasopharyngeal culture or swab for Bordetella pertussis (Grade B recommendation). 1
• If pertussis is confirmed or highly suspected, treat with a macrolide antibiotic (azithromycin or clarithromycin) and isolate for 5 days. 1

Assess for Non-Eosinophilic Bronchitis or Asthma

• The patient has already tried QVAR (beclomethasone), but if this was only used briefly or at low doses, consider increasing the dose or extending the duration before abandoning inhaled corticosteroids. 1, 4
• Extra-fine beclomethasone 400 mcg twice daily for 7 days followed by 200 mcg twice daily for 4 days has shown efficacy in reducing postinfectious persistent cough (p<0.05). 4

Third-Line Options If Above Measures Fail

Central Antitussives

• Codeine (30 mg three times daily) or dextromethorphan (30 mg as needed) should be considered when other measures fail. 1
• These have fair evidence (Grade B for codeine) for chronic bronchitis but limited efficacy for upper respiratory infection-related cough. 1
• Codeine reduces cough frequency by 40-60% in chronic bronchitis patients but has side effects including drowsiness, constipation, and potential dependence. 1, 5

Peripheral Cough Suppressants

• Levodropropizine or moguisteine are recommended for short-term symptomatic relief in chronic or acute bronchitis (Grade A recommendation), though these may not be readily available in all countries. 1

What NOT to Do

Ineffective Interventions

• Albuterol alone is not recommended for cough not due to asthma (Grade D recommendation). 1
• Over-the-counter combination cold medications (except older antihistamine-decongestant combinations) are not recommended until proven effective in trials. 1
• Zinc preparations are not recommended for acute cough due to common cold (Grade D). 1
• Mucolytic agents have no role in cough suppression for chronic bronchitis (Grade D). 1

Common Pitfall: QVAR-Induced Cough

• Paradoxically, beclomethasone (QVAR) itself can cause cough and wheezing in 20% of asthmatic patients. 6
• If the cough worsened after starting QVAR, consider that the inhaled corticosteroid may be the culprit rather than the solution. 6
• Pretreatment with albuterol before QVAR inhalation can attenuate this side effect in some patients. 6

Algorithm Summary

1. Stop any ACE inhibitor immediately if present 1, 2, 3
2. Add ipratropium bromide (first-line addition) 1
3. If no improvement in 1-2 weeks, add prednisone 30-40 mg daily for 5-7 days 1
4. If still persistent, add codeine 30 mg three times daily or dextromethorphan 1
5. Consider pertussis testing if paroxysmal features present 1
6. Evaluate whether QVAR itself is causing cough - if so, pretreat with albuterol or discontinue 6