What is the treatment for cough syncope?

Treatment of Cough Syncope

The primary treatment for cough syncope is direct suppression of the underlying cough through identification and treatment of the causative respiratory condition, combined with avoidance of triggering factors and patient education. 1

Initial Diagnostic Evaluation

Before initiating treatment, confirm true cough syncope and exclude life-threatening cardiac causes:

• Obtain a 12-lead ECG in all patients to rule out cardiac causes, as this is useful in the initial evaluation of all patients with syncope 1
• Focus history on the temporal relationship between coughing paroxysms and loss of consciousness, presence of prodromal symptoms, position during episodes, and frequency of events 1
• Perform cardiovascular examination with orthostatic blood pressure measurements 1
• Consider cardiac imaging (echocardiography) if structural heart disease is suspected, particularly since typical cough syncope patients (middle-aged, overweight males with COPD) carry inherent cardiovascular risk 1, 2

Treatment Algorithm

Step 1: Identify and Treat the Underlying Cause of Cough

For COPD patients:

• Optimize bronchodilator therapy and consider inhaled corticosteroids 1
• Stop ACE inhibitors immediately if the patient is taking one, as these are a common and reversible cause of chronic cough 1
• Smoking cessation is closely associated with decreased symptoms and should be strongly encouraged, as 82% of cough syncope patients are current or ex-smokers 3

For asthma patients:

• Provide appropriate bronchodilator and anti-inflammatory therapy 1
• Medical therapy for asthma can resolve syncope episodes 4

For upper airway cough syndrome (UACS):

• Begin with oral first-generation antihistamine/decongestant combination 1

For gastroesophageal reflux disease (GERD):

• Initiate proton pump inhibitor therapy if GERD is contributing to chronic cough 1

For respiratory infections:

• Provide appropriate antimicrobial therapy 1

Step 2: Direct Cough Suppression

When underlying causes are treated but cough persists:

• Use opioid-containing cough suppressants such as dihydrocodeine or hydrocodone for direct cough suppression 1
• Consider nebulized lidocaine as adjunctive therapy for refractory cases 5
• Low dose morphine has been shown to be helpful for idiopathic chronic cough 6

Step 3: Medication Adjustments

• Discontinue or reduce vasodilators and avoid agents that lower blood pressure 1
• Adjust diuretic therapy if contributing to volume depletion to prevent hypotension 1

Step 4: Patient Education and Lifestyle Modifications

• Educate patients about awareness and avoidance of triggers 1
• Teach recognition of prodromal symptoms 1
• Instruct on performing physical counterpressure maneuvers (isometric leg crossing, hand grip and arm tensing) to abort episodes and increase blood pressure during impending syncope 1

Important Caveats and Pitfalls

Do not assume cough syncope is benign without cardiac evaluation, as the typical patient demographic carries significant cardiovascular risk requiring ECG and potentially echocardiography 1

Use additive therapy rather than sequential therapy when multiple cough causes are suspected, as more than one cause of chronic cough may be present simultaneously 1

Do not overlook medication-induced cough, particularly ACE inhibitors, which are a common and reversible cause that must be identified and stopped 1

Recognize that cough suppression may be relatively contraindicated in conditions where cough clearance is important, such as pneumonia and bronchiectasis 6

Driving Restrictions

Patients with untreated cough syncope should not drive 1

After treatment, patients should observe a symptom-free waiting period of 1 month before resuming driving 1

When Additional Treatment is Necessary

Consider more aggressive intervention when:

• Very frequent syncope affects quality of life 1
• Syncope occurs with little or no warning 1
• Syncope happens during high-risk activities 1

Expected Outcomes

Treatment aimed at decreasing cough is highly effective: cough-related symptoms were abolished or improved in 97% of patients in follow-up studies, though cough syncope can result in severe bodily injury if left untreated 3