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

Management of Persistent Cough for MD Medicine JR3 Residents in Indian Practice

Start with a chest X-ray and spirometry immediately, then begin empirical treatment for the three most common causes (Upper Airway Cough Syndrome, Asthma, and GERD) simultaneously while ruling out ACE inhibitor use and smoking. 1

Step 1: Initial Workup (Day 1)

Mandatory investigations:

• Chest X-ray to exclude TB (critical in Indian context), malignancy, interstitial lung disease, and heart failure 1
• Spirometry with bronchodilator response to identify airflow obstruction - normal spirometry does NOT exclude asthma 1
• Stop ACE inhibitors immediately if patient is taking them (cough resolves in median 26 days, may take up to 4 weeks) 1
• Counsel smoking cessation as first-line if smoker (most resolve within 4 weeks) 1

Red flags requiring immediate investigation:

• Hemoptysis, weight loss, fever, night sweats - think TB or malignancy 1
• Abnormal chest X-ray - pursue specific diagnosis-based investigations rather than chronic cough algorithm 1

Step 2: Empirical Treatment (Start Simultaneously)

Treatment A: Upper Airway Cough Syndrome (44% prevalence - most common)

• First-generation antihistamine + decongestant combination for 1-2 weeks 1
• Use chlorpheniramine + pseudoephedrine combination 1
• Expect improvement within days to 1-2 weeks; complete resolution may take several weeks to months 1

Treatment B: Asthma/Eosinophilic Bronchitis

• Oral prednisolone 30-40mg daily for 2 weeks - no test reliably excludes steroid-responsive cough 1
• Lack of response rules out eosinophilic airway inflammation 1
• If spirometry normal and bronchial provocation testing available, perform methacholine challenge 1

Treatment C: GERD (75% have NO heartburn/regurgitation)

• PPI twice daily (omeprazole 40mg or pantoprazole 40mg BD) + lifestyle modifications for minimum 3 months 1
• Lifestyle modifications: avoid eating 2-3 hours before bed, elevate head of bed, weight loss if overweight, avoid trigger foods, smoking cessation 2
• Do NOT give up early - GERD-related cough requires prolonged treatment (minimum 3 months) 1, 2
• If inadequate response, add prokinetic agent like metoclopramide 2

Step 3: Response Assessment

After 1-2 weeks:

• If Upper Airway Cough Syndrome treatment working → continue for complete resolution 1
• If steroid trial shows improvement → confirms eosinophilic airway inflammation, continue asthma management 1

After 3 months:

• If GERD treatment working → maintain lowest effective PPI dose 2
• If partial GERD response → already on twice-daily dosing, add prokinetic 2
• If no GERD response → consider 24-hour esophageal pH monitoring or upper GI endoscopy 2

Step 4: Refractory Cases

If no response to all three empirical treatments:

• Consider referral to pulmonologist 3, 4
• Consider cough hypersensitivity syndrome → trial of gabapentin or pregabalin 4
• Consider speech therapy 4
• Advanced imaging with chest CT if red flags or persistent symptoms despite optimal treatment 4

Critical Pitfalls to Avoid

• Do NOT rely on cough characteristics (timing, quality, productive vs dry) for diagnosis - they lack diagnostic sensitivity and specificity 1
• Do NOT use single PEF measurements - use spirometry with FEV1 instead 1
• Do NOT stop GERD treatment before 3 months - this is the most common mistake 1, 2
• Do NOT assume normal spirometry excludes asthma as a cause of cough 1
• Do NOT forget TB in Indian context - always rule out with chest X-ray and clinical assessment 1

Indian Practice Context Considerations

• TB prevalence is high - maintain high index of suspicion with any red flags 1
• Cost-effectiveness matters - empirical treatment approach is more cost-effective than extensive upfront testing 1
• Multiple causes often coexist (up to 62% have more than one cause) - treat all three simultaneously rather than sequentially 3, 5