What is the care plan for a nonproductive cough?

Care Plan for Nonproductive Cough

Initial Diagnostic Approach

For nonproductive cough, systematically evaluate and treat the three most common causes—upper airway cough syndrome (UACS), asthma/cough-variant asthma, and gastroesophageal reflux disease (GERD)—using sequential empiric therapy, as the character and timing of cough cannot reliably distinguish between etiologies. 1

Critical First Steps

• Do not use cough characteristics (timing, quality, or absence of sputum) to rule in or rule out specific diagnoses, as each common cause can present as isolated nonproductive cough without other clinical findings ("silent" presentations). 1

• Determine cough duration to guide management:

  • Acute (<3 weeks): Most commonly viral upper respiratory tract infection 1
  • Subacute (3-8 weeks): Consider postinfectious cough versus chronic causes 1
  • Chronic (>8 weeks): Requires systematic evaluation for UACS, asthma, and GERD 1

• Verify the patient is not taking an ACE inhibitor and is a non-smoker with normal chest radiograph before proceeding with the algorithm below. 1

Treatment Algorithm for Nonproductive Cough

Step 1: Empiric Trial for Upper Airway Cough Syndrome (UACS)

Begin with a first-generation antihistamine/decongestant combination (e.g., brompheniramine with sustained-release pseudoephedrine) before extensive diagnostic workup. 1

• First-generation antihistamines are effective; newer nonsedating antihistamines are ineffective and should not be used. 1
• Continue treatment for adequate duration (typically 1-2 weeks minimum) to assess response. 1
• If cough resolves, UACS is confirmed as the diagnosis. 1
• If no response after empiric antihistamine/decongestant therapy, obtain sinus imaging, as chronic sinusitis can present with completely nonproductive cough. 1

Step 2: Evaluate and Treat for Asthma/Cough-Variant Asthma

If UACS treatment fails, asthma must always be considered as it is a common condition frequently associated with isolated cough. 1

• Perform spirometry and methacholine challenge testing to confirm bronchial hyperresponsiveness. 1, 2
• Histamine challenge correctly predicts cough-variant asthma in 88% of positive tests and effectively rules out asthma when negative. 2
• Diagnosis is established only after resolution of cough with specific antiasthmatic therapy (inhaled corticosteroids ± bronchodilators). 1, 3
• Consider nonasthmatic eosinophilic bronchitis if asthma testing is negative but eosinophilic inflammation is present; this also responds to inhaled corticosteroids. 3

Step 3: Evaluate and Treat for Gastroesophageal Reflux Disease (GERD)

If both UACS and asthma treatments fail, evaluate for GERD, which can cause isolated nonproductive cough without typical reflux symptoms. 1

• Consider 24-hour esophageal pH monitoring, which effectively rules out GERD when negative. 2
• Initiate empiric GERD therapy with proton pump inhibitors and lifestyle modifications. 1
• GERD treatment may require extended duration (8-12 weeks) before cough improvement occurs. 1

Step 4: Sequential and Additive Therapy

Multiple causes may coexist simultaneously; if partial response occurs, add treatment for additional etiologies rather than discontinuing initial therapy. 1

• Up to 62% of chronic cough cases have multiple contributing causes. 2
• Continue effective treatments while adding new interventions. 1

Symptomatic Management for Nonproductive Cough

Antitussive Options

For symptomatic relief of nonproductive cough interfering with daily activities or sleep, dextromethorphan 60 mg provides optimal cough suppression. 4, 5

• Dextromethorphan is preferred over codeine, which has no greater efficacy but significantly more adverse effects. 4
• Do not use dextromethorphan if taking MAO inhibitors or within 2 weeks of stopping MAOIs. 6
• First-generation antihistamines (e.g., chlorpheniramine) combined with antitussives are particularly valuable for nocturnal cough due to sedative effects. 4, 5
• Menthol inhalation provides acute but short-lived cough suppression. 4

When to Avoid Antitussives

Never use cough suppressants for productive/wet cough, as they interfere with beneficial mucus clearance. 4

Advanced Evaluation for Refractory Cases

If all empiric treatments fail after adequate trials:

• Obtain high-resolution CT scan to evaluate for bronchiectasis or occult interstitial disease. 1
• Perform bronchoscopy to detect occult airway disease (endobronchial tumor, sarcoidosis, eosinophilic or lymphocytic bronchitis). 1
• Consider uncommon causes: nonacid reflux, swallowing disorders, congestive heart failure, or habit cough based on clinical findings. 1
• Referral to a cough specialist is appropriate before labeling as unexplained/idiopathic cough. 1

Common Pitfalls to Avoid

• Do not diagnose bacterial sinusitis during the first week of acute upper respiratory symptoms, as viral infections cause indistinguishable findings. 1
• Do not use subtherapeutic doses of medications, which provide inadequate relief. 4
• Do not stop effective therapy prematurely; adequate treatment duration is essential for response assessment. 1
• Do not assume single etiology; evaluate and treat sequentially for all common causes as multiple conditions frequently coexist. 1, 2