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 India

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 serious pathology. 1

Step 1: Initial Workup (Day 1)

Mandatory investigations:

• Chest X-ray - Must be done in all patients to exclude TB (critical in India), malignancy, interstitial lung disease, and heart failure 1
• Spirometry with bronchodilator response - Required in all chronic cough patients to identify airflow obstruction; normal spirometry does NOT exclude asthma 1

Immediate actions if applicable:

• Stop ACE inhibitors immediately if patient is taking them - cough resolves in median 26 days but may take up to 4 weeks 1
• Counsel smoking cessation as first-line if smoker - most resolve within 4 weeks 1

Step 2: Look for Red Flags (Immediate Investigation Required)

Refer urgently or investigate immediately if present: 1

• Hemoptysis
• Weight loss
• Fever and night sweats (think TB in Indian context)
• Abnormal chest X-ray findings

If red flags present, pursue specific diagnosis-based investigations rather than using the chronic cough algorithm. 1

Step 3: Empirical Treatment Protocol (Start Simultaneously)

Treatment A: Upper Airway Cough Syndrome (Most Common - 44% prevalence)

Start first-generation antihistamine-decongestant combination for 1-2 weeks: 1

• Chlorpheniramine + Pseudoephedrine combination 1
• Expect some improvement within days to 1-2 weeks; complete resolution may take several weeks to months 1

Treatment B: Asthma/Eosinophilic Bronchitis

Give oral prednisolone 30-40mg daily for 2 weeks as a diagnostic and therapeutic trial: 1

• No test reliably excludes steroid-responsive cough 1
• Lack of response rules out eosinophilic airway inflammation 1
• Remember: normal spirometry does NOT exclude asthma as a cause 1

If bronchial provocation testing available and spirometry normal, perform methacholine challenge 1

Treatment C: GERD (Often Silent - 75% Have NO Heartburn)

Start intensive acid suppression immediately: 1

• PPI: Omeprazole 40mg OR Pantoprazole 40mg TWICE daily 1
• Minimum duration: 3 months (this is critical - don't give up early) 1
• Add lifestyle modifications: avoid eating 2-3 hours before bed, elevate head of bed, weight loss if overweight 2

Important: Up to 75% of GERD-related cough patients have NO heartburn or regurgitation - treat empirically anyway 1

Step 4: Response Assessment and Next Steps

If Cough Improves/Resolves:

• Continue the treatment that worked
• For GERD: maintain lowest effective PPI dose 2
• For Upper Airway Cough Syndrome: may need several weeks to months for complete resolution 1

If Partial Response to PPI:

• Increase to twice-daily PPI dosing if not already on it 2
• Add prokinetic agent (metoclopramide) if prominent upper GI symptoms 2

If No Response After 3 Months:

• Consider 24-hour esophageal pH monitoring 2
• Consider upper GI endoscopy or barium swallow 2
• Consider referral to pulmonologist for refractory cases 3

Common Pitfalls to Avoid

Don't rely on cough characteristics (timing, quality, productive vs dry) for diagnosis - 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 - it requires minimum 3 months of intensive therapy 1

Don't assume absence of heartburn rules out GERD - most GERD-related cough has no GI symptoms 1

Don't use dextromethorphan for chronic cough - it's only for acute cough lasting less than 7 days; if cough persists beyond 7 days, it indicates a serious condition requiring investigation 4

Indian Context Considerations

• TB is a major differential - maintain high index of suspicion, especially with constitutional symptoms 1
• Cost-effectiveness matters - the sequential empirical approach is more cost-effective than extensive upfront testing 1
• First-generation antihistamines are readily available and affordable in India 1
• Generic PPIs (omeprazole, pantoprazole) are widely available 1, 2