What is the appropriate management for a patient presenting with a cough?

Management of Cough

Classify cough by duration—acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks)—as this determines your diagnostic and treatment pathway. 1

Immediate Actions

• Discontinue ACE inhibitors immediately if the patient is taking one, as this is a common and reversible cause of cough 1, 2
• Counsel smokers on cessation, as 90-94% experience cough resolution within the first year of quitting 1
• Assess for life-threatening conditions including pneumonia, pulmonary embolism, or systemic illness requiring urgent intervention 1, 3
• Evaluate respiratory distress indicators: markedly elevated respiratory rate, intercostal retractions, cyanosis, or altered mental status 1, 3
• Obtain a chest radiograph if pneumonia is suspected based on tachypnea, tachycardia, dyspnea, or abnormal lung findings 1, 3

Acute Cough (<3 Weeks)

For common cold-related cough, prescribe a first-generation antihistamine/decongestant combination plus naproxen to decrease cough severity and hasten resolution 4, 1, 3

• Do not use newer non-sedating antihistamines, as they are ineffective for cough 3
• Consider honey for cough suppression in patients over 1 year of age 3
• Dextromethorphan can provide symptom relief 5
• Do not prescribe antibiotics for viral acute bronchitis, as they are ineffective and promote resistance 5

For acute exacerbation of chronic bronchitis, prescribe a short course (10-15 days) of systemic corticosteroids 1, 3

Subacute Cough (3-8 Weeks)

Determine if the cough is postinfectious or non-infectious 4, 1

• If postinfectious, consider inhaled ipratropium as first-line therapy 4
• If ipratropium fails and cough adversely affects quality of life, add inhaled corticosteroids 4
• Do not prescribe antibiotics unless there is evidence of bacterial sinusitis or early Bordetella pertussis infection 4
• If non-infectious, evaluate and manage as chronic cough 4, 1

Chronic Cough (>8 Weeks)

Use a sequential and additive treatment approach targeting the three most common causes, which frequently coexist: upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD) 1, 3

Step 1: Treat Upper Airway Cough Syndrome (UACS)

• Prescribe an oral first-generation antihistamine/decongestant combination 1, 2
• Add a topical nasal corticosteroid if prominent upper airway symptoms are present 1

Step 2: Evaluate and Treat Asthma

• Perform spirometry as part of the basic evaluation 1
• If spirometry shows reversible airflow obstruction, treat with inhaled bronchodilators and inhaled corticosteroids 1, 3
• If spirometry is normal but asthma is suspected, consider bronchoprovocation challenge or empiric trial of inhaled corticosteroids and bronchodilators 1, 3
• For refractory cases, add a leukotriene receptor antagonist before escalating to systemic corticosteroids 3

Step 3: Evaluate and Treat Non-Asthmatic Eosinophilic Bronchitis (NAEB)

• Perform induced sputum test for eosinophils 1
• If testing is unavailable, use empiric treatment with inhaled corticosteroids 1, 3

Step 4: Evaluate and Treat GERD

• Initiate empiric treatment with a proton pump inhibitor (PPI) plus dietary and lifestyle modifications for patients with typical reflux symptoms 4, 1
• If no response after 2 weeks, add a prokinetic agent such as metoclopramide and ensure rigorous adherence to dietary measures 4
• Recognize that GERD-related cough may take several months to respond to medical therapy 4
• If cough persists despite adequate medical therapy, consider 24-hour esophageal pH monitoring, upper GI endoscopy, or barium swallow study 4

Advanced Evaluation for Persistent Cough

If cough persists after 4-6 weeks of empiric treatment for the top diagnoses, pursue advanced testing 1, 2

• Obtain high-resolution CT (HRCT) scan to evaluate for bronchiectasis or occult interstitial disease 4
• Perform bronchoscopy to look for occult airway disease (endobronchial tumor, sarcoidosis, suppurative infection, eosinophilic or lymphocytic bronchitis) 4
• Consider uncommon causes: non-acid reflux disease, swallowing disorder, congestive heart failure, or habit cough 4
• Refer to a specialist cough clinic when diagnosis remains unclear after thorough evaluation 1, 2

Refractory Chronic Cough

• Consider multimodality speech pathology therapy including cough suppression techniques, vocal hygiene, and psychoeducational counseling 2
• Trial gabapentin for refractory chronic cough 2
• Low-dose opiates can be considered for symptom control when all alternative treatments have failed, particularly in palliative care settings 2

Critical Pitfalls to Avoid

• Do not rely on cough characteristics alone (productive vs. dry, timing, quality), as they have little diagnostic value 4, 1
• Do not treat only one cause, as multiple factors often contribute simultaneously, requiring additive therapy 4, 1, 3
• Do not label as idiopathic until thorough assessment at a specialist clinic excludes uncommon causes 1, 2
• Do not use routine cough suppressants when cough clearance is important for secretion management 1
• Do not prescribe combination cough preparations without targeting specific underlying causes 6

Special Populations

Immunocompromised Patients

• Use the same initial algorithm but expand the differential diagnosis based on immune defect type and severity 1, 3
• In HIV patients with CD4+ <200 cells/μL, suspect Pneumocystis pneumonia, tuberculosis, and opportunistic infections 1
• In high-prevalence areas, obtain sputum smears, cultures for acid-fast bacilli, and chest radiograph to evaluate for tuberculosis 1