What is the initial approach and treatment for chronic persistent cough in both in-patient department (IPD) and out-patient department (OPD) settings in Indian clinical practice?

Chronic Persistent Cough Management in Indian Clinical Practice

OPD (Outpatient) Prescription

Start with a systematic empiric approach targeting the three most common causes: upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD), as these account for the majority of chronic cough cases. 1

Initial Assessment & Immediate Actions

Medication History:

• Discontinue ACE inhibitors immediately if patient is taking them - cough typically resolves within days to 2 weeks (median 26 days) 1, 2
• Replace with alternative antihypertensive (ARB or other class) 2

Smoking Status:

• Counsel immediate smoking cessation - 90% of chronic bronchitis patients achieve cough resolution within 4 weeks of quitting 2, 3
• Provide cessation support and pharmacotherapy if needed 1

Chest X-ray:

• Obtain to rule out serious pathology (mass, interstitial disease, infection, heart failure) 1
• If abnormal, pursue specific diagnosis before empiric treatment 1

Sequential Empiric Treatment Protocol

Week 1-2: First-Line Treatment for UACS

Rx:

• Tab. Brompheniramine 4mg + Pseudoephedrine SR 60mg - 1 tablet twice daily 2
• Critical: Must use first-generation antihistamines; newer non-sedating antihistamines are ineffective 2
• Expected response within 1-2 weeks, though complete resolution may take several weeks 2, 3

Week 2-4: Add Asthma Treatment if Incomplete Response

Rx:

• Inhaled Corticosteroid + Long-Acting Beta-Agonist combination 2, 3
  • Cap. Fluticasone 250mcg + Salmeterol 50mcg (Rotacaps/MDI) - 1 inhalation twice daily
  • OR Tab. Montelukast 10mg - once daily at bedtime (if ICS contraindicated) 1
• Continue antihistamine-decongestant 2, 3
• Monitor response over 2-4 weeks 3

Week 4-12: Add GERD Treatment if Still Inadequate Response

Rx:

• Tab. Pantoprazole 40mg or Esomeprazole 40mg - once daily before breakfast 2, 3
• Dietary modifications: avoid late meals, fatty foods, caffeine, alcohol 2
• Elevate head of bed 2
• Continue all previous treatments as cough is often multifactorial 2, 3
• Assess response over 1-3 months 2

Additional Investigations if No Response

• Spirometry with bronchodilator reversibility 3
• Methacholine challenge if spirometry normal but asthma suspected 3, 4
• Induced sputum for eosinophils (if available) to diagnose non-asthmatic eosinophilic bronchitis 3, 5
• 24-hour esophageal pH monitoring for GERD confirmation 6
• High-resolution CT chest if interstitial disease suspected 1, 5

Referral Criteria

Refer to pulmonologist/specialist if:

• Cough persists despite 8-12 weeks of sequential empiric therapy 3
• Abnormal chest X-ray requiring further evaluation 1
• Suspected interstitial lung disease, bronchiectasis, or malignancy 1
• Need for bronchoscopy or advanced testing 5, 6

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IPD (Inpatient) Prescription

Admit patients with chronic cough only if they have concerning features requiring urgent evaluation or are systemically unwell. 1

Indications for Admission

• Hemoptysis with significant volume 1
• Severe respiratory distress (tachypnea, hypoxemia, respiratory failure) 5
• Suspected pulmonary embolism 3
• Suspected active tuberculosis with systemic symptoms 1
• Fever, night sweats, significant weight loss suggesting serious underlying disease 1
• Suspected pneumonia not responding to outpatient treatment 5

Inpatient Management Protocol

Immediate Investigations:

• Complete blood count, ESR, CRP 6
• Chest X-ray PA and lateral views 1
• Arterial blood gas if respiratory distress 6
• Sputum for AFB (3 samples), Gram stain, culture-sensitivity 1
• ECG and echocardiography if cardiac cause suspected 6
• CT pulmonary angiography if pulmonary embolism suspected 6

Initial Treatment (while awaiting results):

For suspected infection:

• Inj. Ceftriaxone 1-2g IV once daily + Tab. Azithromycin 500mg once daily 1
• Add anti-tubercular therapy if high suspicion (endemic area, systemic symptoms, typical X-ray) 1

For bronchospasm/asthma exacerbation:

• Nebulization with Levosalbutamol 1.25mg + Ipratropium 500mcg - every 4-6 hours 1
• Tab. Prednisolone 40mg once daily for 5-7 days 1
• Inhaled Corticosteroid (Budesonide 400mcg twice daily via MDI with spacer) 1

For COPD exacerbation:

• Bronchodilators as above 1
• Tab. Prednisolone 40mg once daily for 5 days 1
• Antibiotics if purulent sputum 1

Supportive care:

• Oxygen supplementation to maintain SpO2 >90% 5
• IV fluids if dehydrated 5
• Continue ACE inhibitor discontinuation if applicable 2

Critical Pitfalls to Avoid

• Never assume single etiology - up to 62% of chronic cough cases have multiple simultaneous causes 1
• Maintain all partially effective treatments - stopping one effective therapy may cause recurrence even if other causes are being treated 1, 2
• Do not use second or third-generation antihistamines for UACS - they are ineffective for cough 2
• Do not delay tuberculosis evaluation in endemic areas - obtain sputum AFB early in evaluation 1
• Do not rely on cough characteristics for diagnosis - timing and quality lack diagnostic sensitivity and specificity 1
• Systematically evaluate common causes before pursuing rare diagnoses - UACS, asthma, and GERD account for >80% of cases 1, 7

Expected Timeline for Response

• ACE inhibitor discontinuation: Days to 2 weeks (median 26 days) 2
• UACS treatment: 1-2 weeks for initial improvement 2, 3
• Asthma treatment: 2-4 weeks 2, 3
• GERD treatment: 1-3 months 2, 3
• Overall resolution: May require maintaining all treatments for several months 2