What are the treatments for chronic coughing spells?

Treatment of Chronic Cough

The treatment of chronic cough requires a systematic approach targeting the most common underlying causes: upper airway cough syndrome (postnasal drip), gastroesophageal reflux disease (GERD), and asthma/eosinophilic bronchitis, with empiric therapy initiated based on clinical profile before extensive testing. 1, 2

Initial Diagnostic Considerations

Before treating chronic cough, you must first exclude or address:

• ACE inhibitor use - discontinue if present, as this is a common reversible cause 2, 3
• Active smoking - cessation is essential and must be addressed first 1, 2
• Chest radiography - perform to rule out malignancy, infection, or interstitial lung disease 1, 3

First-Line Treatment Algorithm

For GERD-Related Chronic Cough

Start empiric treatment immediately if the patient fits the clinical profile (with or without heartburn symptoms), rather than waiting for diagnostic testing. 1

The intensive medical regimen includes: 1, 2

• Dietary modifications: limit fat to <45g per 24 hours, eliminate coffee, tea, soda, chocolate, mints, citrus products (including tomatoes), and alcohol 1
• Lifestyle changes: smoking cessation and limiting vigorous exercise that increases intra-abdominal pressure 1
• Proton pump inhibitor (PPI) therapy for acid suppression 1
• Prokinetic therapy (such as metoclopramide) - add either initially or if no response to diet and PPI alone 1

Critical timing: Assess response after 1-3 months of therapy. 1, 2 If empiric treatment fails, this does not rule out GERD as the cause - the therapy may not have been intensive enough. 1

Escalation strategy: If H2-antagonists were used initially, switch to PPI as proton pump inhibition may be effective when H2-antagonism has failed. 1

For Upper Airway Cough Syndrome (Postnasal Drip)

• First-generation antihistamine-decongestant combination is recommended as first-line therapy 2

For Asthma or Eosinophilic Bronchitis

• Perform bronchial provocation testing to assess for bronchial hyperresponsiveness 1, 2
• Test for eosinophilic bronchitis (induced sputum or therapeutic trial) 1, 2
• Inhaled corticosteroids for 2 weeks if testing is positive 2
• Avoid inhaled corticosteroids if tests for bronchial hyperresponsiveness and eosinophilia are negative, as they are ineffective for unexplained chronic cough 1, 2

Treatment for Unexplained/Refractory Chronic Cough

When cough persists beyond 8 weeks despite systematic investigation and adequate therapeutic trials according to guidelines: 1

Recommended Therapies

Speech pathology-based multimodality therapy is suggested as a treatment option for unexplained chronic cough. 1, 2

Gabapentin is the recommended neuromodulator, showing positive effects on cough-related quality of life. 1, 4, 5

Alternative neuromodulators include: 4, 5

• Amitriptyline as a second-line option 5
• Pregabalin as an alternative 6, 4
• Morphine showed positive effects but is not strongly recommended due to side effect profile 1

Combining speech pathology with neuromodulators may provide enhanced treatment response of longer duration. 4

Special Considerations for Interstitial Lung Disease

If chronic cough is due to interstitial lung disease (ILD), this should be a diagnosis of exclusion after ruling out postnasal drip, asthma, and GERD. 1

• For idiopathic pulmonary fibrosis (IPF): Corticosteroids may provide symptomatic improvement but do not prolong survival or improve quality of life and carry significant side effects - use requires individualized risk-benefit analysis 1
• For sarcoidosis: Oral corticosteroids may improve symptoms but lack durable benefit; consider oral followed by inhaled corticosteroids 1
• For hypersensitivity pneumonitis: Remove offending exposure and use systemic corticosteroids if physiologic impairment is present 1

Surgical Intervention

Antireflux surgery should be considered for GERD-related chronic cough when: 1

• 24-hour esophageal pH monitoring (performed before treatment) was positive
• Patient fits clinical profile suggesting GERD as likely cause
• Cough has not improved after minimum 3 months of intensive medical therapy
• Serial pH monitoring shows medical therapy has failed to control reflux
• Patient reports unsatisfactory quality of life

Common Pitfalls to Avoid

• Do not assume GERD is ruled out if empiric therapy fails - the regimen may need intensification or pH monitoring on therapy 1, 2
• Normal esophagoscopy does not exclude GERD as a cause of chronic cough 1
• Allow adequate treatment time - GERD therapy requires 1-3 months for assessment 1, 2
• Do not use inhaled corticosteroids for unexplained chronic cough without documented bronchial hyperresponsiveness or eosinophilia 1, 2
• Multiple causes may coexist - consider simultaneous treatment approaches 2

Symptomatic Relief Options

While addressing underlying causes: 2

• Menthol lozenges or vapor for symptomatic relief
• Honey and lemon as home remedies