What is the best approach to manage a cough that worsens at night in a patient with a history of right hemiplegia?

Management of Nocturnal Cough in a Patient with Right Hemiplegia

In a patient with right hemiplegia presenting with nocturnal cough, you must first assess for aspiration risk and impaired airway clearance due to reduced cough efficacy from neuromuscular weakness, then systematically evaluate for the three most common causes: upper airway cough syndrome, asthma, and gastroesophageal reflux disease. 1, 2, 3

Critical Initial Considerations in Hemiplegia

The history of right hemiplegia fundamentally changes your approach because:

• Impaired cough mechanics: Patients with neurological deficits affecting trunk and respiratory muscles have reduced peak expiratory flow and cannot generate effective cough, leading to secretion retention 3
• Aspiration risk: Hemiplegic patients may have dysphagia and impaired protective airway reflexes, making aspiration a critical consideration that can cause nocturnal cough 4
• Reduced clearance frequency: If coughing depends on caregiver assistance, these patients cough less frequently, allowing secretion accumulation 3

Immediately assess for dysphagia, as this is a red flag symptom requiring urgent evaluation for aspiration risk 4

Differential Diagnosis for Nocturnal Cough

Primary Causes to Evaluate

Asthma, infection, or heart failure are the three conditions that specifically cause coughing which wakes patients at night 1

However, the diagnostic approach must include:

1. Upper Airway Cough Syndrome (UACS): Accounts for 56% of chronic cough cases 5

   • Look for sensation of postnasal drainage, throat clearing, nasal discharge, or "tickle in throat" 5
   • Critical caveat: Up to 20% of UACS patients are completely unaware of postnasal drainage 5
   • Mucus accumulates during sleep and triggers morning cough upon waking 2

2. Gastroesophageal Reflux Disease (GERD):

   • Cough occurring mainly at night or after meals suggests GERD 1, 2
   • Important pitfall: Up to 75% of GERD-related cough occurs without typical heartburn (silent GERD) 2
   • Refluxed contents irritate airways during recumbency 2

3. Asthma:

   • Nocturnal or early morning cough due to circadian variations in airway responsiveness 2
   • Worsened by cold air or exercise 2

These three conditions together account for over 90% of chronic cough cases 2, 5, 6

Systematic Diagnostic Approach

Step 1: Focused History

Assess these specific features:

• Dysphagia or choking episodes: Red flag for aspiration 4
• Timing: Worse at night/after meals (GERD), upon waking (UACS), or waking from sleep (asthma/infection/heart failure) 1, 2
• Sputum production: Amount, color, consistency 4
• Associated symptoms: Throat clearing, postnasal drip sensation, wheezing, shortness of breath 4, 5
• Medication review: ACE inhibitors cause dry, nonproductive cough worse at night 2, 7, 8
• Smoking status: Dose-related cause of persistent cough 1, 2

Step 2: Physical Examination

• Assess for signs of heart failure (given nocturnal cough pattern) 1
• Evaluate for upper airway findings suggesting rhinitis or sinusitis 5
• Check for wheezing or prolonged expiration 8
• Assess cough strength and ability to clear secretions given hemiplegia 3

Step 3: Initial Testing

• Chest radiograph in most patients with chronic cough 4, 8
• Consider spirometry if asthma suspected 8

Treatment Algorithm

Immediate Actions

1. If on ACE inhibitor: Switch to another antihypertensive class immediately 2, 8
2. If dysphagia present: Urgent swallow evaluation and aspiration precautions 4
3. Optimize secretion clearance: Given impaired cough mechanics from hemiplegia, consider chest physiotherapy and assisted cough techniques 3

Empiric Treatment Trials

Because response to therapy is the pivotal diagnostic factor, proceed with sequential empiric trials 5:

1. First trial - UACS:

   • First-generation antihistamine/decongestant combination 5, 8
   • Trial warranted even without classic symptoms 5

2. Second trial - Asthma (if UACS treatment fails):

   • Inhaled bronchodilators or corticosteroids 8
   • Confirm diagnosis based on clinical response 8

3. Third trial - GERD (if above fail):

   • Empiric proton pump inhibitor therapy 8
   • Initiate without testing if reflux symptoms present 8

Special Considerations for Hemiplegia

• Elevate head of bed: Reduces both aspiration and GERD risk 2
• Avoid environmental irritants: Temperature changes can trigger sensitized cough reflex 2
• Consider assisted cough devices: If peak expiratory flow inadequate 3

When to Escalate Care

Refer to pulmonology if:

• No response to sequential empiric trials 8
• Red flag symptoms present: hemoptysis, hoarseness, recurrent pneumonia, digital clubbing 4
• High-resolution CT or bronchoscopy needed 8

The combination of nocturnal cough and hemiplegia mandates heightened vigilance for aspiration and impaired secretion clearance, which can lead to recurrent infections and increased morbidity if not addressed 4, 3