What is the management approach for a patient with persistent cough in Indian medical practice?

Management of Persistent Cough in Indian Medical Practice: A Practical Guide for MD Medicine JR3

Initial Approach: Start with the Basics

Begin empirical treatment for the three most common causes (Upper Airway Cough Syndrome, Asthma, and GERD) after ruling out serious pathology with chest X-ray and spirometry, as this sequential approach is more cost-effective than extensive upfront testing. 1

Mandatory First Steps

• Chest X-ray: Must be done in all patients to exclude malignancy, tuberculosis (especially important in India), interstitial lung disease, and heart failure 1
• Spirometry: Required in all chronic cough patients to identify airflow obstruction and assess bronchodilator response 1
• Medication review: Stop ACE inhibitors immediately if patient is taking them - cough resolves in median 26 days but may take up to 4 weeks 1
• Smoking history: If current smoker, counsel cessation as first-line - most resolve within 4 weeks 1

The Sequential Treatment Algorithm

Step 1: Upper Airway Cough Syndrome (UACS) - Start Here First

Trial first-generation antihistamine-decongestant combination for 1-2 weeks as UACS is the most common cause (44% prevalence) and response guides further management. 1

• Use combinations like chlorpheniramine + pseudoephedrine 1
• Expect some improvement within days to 1-2 weeks; complete resolution may take several weeks to months 1
• If partial response with persistent nasal symptoms, add topical nasal corticosteroid (e.g., mometasone or fluticasone) 1
• If still no improvement, order sinus imaging (X-ray or CT) to look for sinusitis 1
• Air-fluid levels = treat with antibiotics (amoxicillin-clavulanate for 2-3 weeks) 1
• Mucosal thickening in context of persistent cough = treat presumptively for sinusitis 1

Step 2: Asthma/Eosinophilic Bronchitis - If UACS Treatment Fails or Partial Response

Give 2-week trial of oral prednisolone (30-40mg daily) as no test reliably excludes steroid-responsive cough, and lack of response rules out eosinophilic airway inflammation. 1

• Normal spirometry does NOT exclude asthma as cause of cough 1
• If bronchial provocation testing available and spirometry normal, perform methacholine challenge 1
• Negative methacholine excludes asthma but NOT steroid-responsive cough 1
• If prednisolone trial works, transition to inhaled corticosteroids (budesonide 400-800mcg BD or equivalent) + bronchodilators 1
• Consider adding leukotriene receptor antagonist (montelukast 10mg OD) 1
• If sputum induction available, check for eosinophilia (>3%) - this confirms need for inhaled steroids 1

Step 3: Gastroesophageal Reflux Disease (GERD) - Often Overlooked

Start intensive acid suppression with PPI (omeprazole 40mg or pantoprazole 40mg twice daily) plus lifestyle modifications for minimum 3 months, as reflux-related cough often occurs without GI symptoms and requires prolonged treatment. 1, 2

• Critical point: Up to 75% of GERD-related cough patients have NO heartburn or regurgitation 2
• Lifestyle modifications: avoid eating 2-3 hours before bed, elevate head of bed, avoid trigger foods, weight loss if overweight 2
• Add alginate (liquid antacid) after meals and at bedtime 1
• Response may take several months - don't give up early 2
• If minimal response after 8 weeks on twice-daily PPI, consider adding prokinetic (domperidone 10mg TDS or metoclopramide 10mg TDS) 2
• Consider 24-hour pH monitoring or upper GI endoscopy if available and no response 2

Multiple Causes are Common

Recognize that 2 or all 3 common causes (UACS + Asthma + GERD) frequently coexist - maintain all partially effective treatments and don't stop one when starting another. 1

• If partial response to UACS treatment, continue it while adding asthma trial 1
• If partial response to asthma treatment, continue it while adding GERD therapy 1
• Only when all three have been adequately treated can you determine if cough is truly refractory 1

Red Flags Requiring Immediate Investigation

• Hemoptysis: Requires immediate chest X-ray and risk stratification; consider TB, malignancy, bronchiectasis 3
• Weight loss, fever, night sweats: Urgent evaluation for TB (very important in Indian context) or malignancy 3
• Abnormal chest X-ray: Pursue specific diagnosis based on findings - don't use chronic cough algorithm 1
• Recurrent pneumonia: Needs CT chest and bronchoscopy 4

When Standard Approach Fails

Additional Investigations to Consider

• Bronchoscopy: If foreign body aspiration suspected or persistent cough with normal other investigations 1
• HRCT chest: May reveal bronchiectasis, interstitial lung disease, or other pathology missed on plain X-ray 1
• ENT referral: For laryngoscopy if upper airway symptoms persist despite treatment 1
• Induced sputum: If available, check for eosinophilia after excluding common causes 1

Refractory Chronic Cough Management

If cough persists after 3 months of optimized treatment for all common causes, consider cough hypersensitivity syndrome and trial gabapentin 300mg OD, titrating up to 1800mg/day in divided doses. 5, 4

• Alternative: pregabalin 75mg BD, can increase to 150mg BD 5, 4
• These neuromodulators reduce heightened cough reflex sensitivity 5, 4
• Consider speech therapy/cough suppression techniques if available 5, 4
• Referral to specialist cough clinic or pulmonologist recommended 1

Common Pitfalls to Avoid

• Don't rely on cough characteristics (timing, quality, productive vs dry) - they lack diagnostic sensitivity and specificity 1
• Don't use single PEF measurements - use spirometry with FEV1 for accurate assessment 1
• Don't give up on GERD treatment too early - requires minimum 3 months of intensive therapy 1, 2
• Don't forget TB - always consider in Indian context, especially with constitutional symptoms 3
• Don't continue ACE inhibitors "to see if cough improves" - stop them immediately 1
• Don't treat only one cause when multiple conditions coexist - address all simultaneously 1
• Don't order bronchoscopy routinely - reserve for specific indications (foreign body, abnormal imaging, hemoptysis) 1

Practical Timeline for Indian Practice Setting

• Week 0-2: Antihistamine-decongestant trial for UACS 1
• Week 2-4: If no/partial response, add 2-week prednisolone trial 1
• Week 4-16: If no/partial response, add PPI twice daily + lifestyle modifications (continue for 3 months minimum) 1, 2
• Week 16+: If still persistent, consider refractory cough and neuromodulator therapy 5, 4