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

Management of Cough

Classify cough by duration and systematically treat the most common causes using sequential, additive therapy—starting with discontinuing ACE inhibitors if present, then targeting upper airway cough syndrome, asthma, and gastroesophageal reflux disease, as multiple causes frequently coexist. 1

Initial Classification and Assessment

Cough must be categorized by duration to guide your diagnostic and therapeutic approach: 1

• Acute cough lasts less than 3 weeks 2, 1
• Subacute cough lasts 3-8 weeks 2, 1
• Chronic cough persists beyond 8 weeks 2, 1

Immediately discontinue ACE inhibitors if the patient is taking one, as this is a common and reversible cause of chronic cough. 1, 2 Do not wait to see if other treatments work first.

Counsel all smokers on cessation, as 90-94% experience cough resolution within the first year of quitting. 1

Assess for life-threatening conditions requiring urgent intervention, including pneumonia, pulmonary embolism, or systemic illness. 1, 3 Look specifically for tachypnea, tachycardia, dyspnea, intercostal retractions, cyanosis, or altered mental status. 3

Obtain a chest radiograph if pneumonia is suspected based on abnormal vital signs or lung findings. 1, 3

Management of Acute Cough (<3 weeks)

For common cold, prescribe a first-generation antihistamine/decongestant combination plus naproxen. 2, 1 This combination has been shown in double-blind placebo-controlled studies to decrease cough severity and hasten resolution. 2 Do not use newer non-sedating antihistamines, as they are ineffective for cough. 3

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

Do not prescribe antibiotics for acute bronchitis unless there is clear evidence of bacterial infection, as most cases are viral. 2

Management of Subacute Cough (3-8 weeks)

First, determine whether the cough followed a respiratory infection (postinfectious) or not. 2, 1

For postinfectious cough: 2

• Inhaled ipratropium may attenuate the cough 2
• If cough persists and affects quality of life despite ipratropium, consider inhaled corticosteroids 2
• Antibiotics have no role unless bacterial sinusitis or early Bordetella pertussis infection is confirmed 2

If the subacute cough does not appear postinfectious, evaluate and manage it as chronic cough. 2

Management of Chronic Cough (>8 weeks)

Sequential and Additive Treatment Approach

The three most common causes are upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD)—and they frequently coexist, requiring simultaneous treatment. 1, 2

Step 1: Upper Airway Cough Syndrome (UACS)

Initiate an oral first-generation antihistamine/decongestant combination. 1, 2 If prominent upper airway symptoms are present, add a topical nasal corticosteroid. 1

Step 2: Asthma or Non-Asthmatic Eosinophilic Bronchitis (NAEB)

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 still suspected, consider a bronchoprovocation challenge or an empiric trial of inhaled corticosteroids and bronchodilators. 1

For NAEB, perform an induced sputum test for eosinophils if available, or use empiric treatment with inhaled corticosteroids. 1

Step 3: Gastroesophageal Reflux Disease (GERD)

For patients with prominent GERD symptoms, initiate empiric treatment with a proton pump inhibitor (PPI), dietary modifications, and lifestyle changes before performing esophageal pH testing. 1, 2

Response time is variable—some patients respond within 2 weeks, while others may take several months, especially after adding prokinetic therapy with metoclopramide. 2

If there is partial or no improvement, consider 24-hour esophageal pH monitoring, upper GI endoscopy, or barium swallow. 2 Add metoclopramide and ensure rigorous adherence to dietary measures before labeling the patient as having medically refractory GERD. 2

Maintain All Partially Effective Treatments

Do not discontinue treatments that provide partial benefit, as multiple causes often contribute simultaneously. 1, 4 Use additive therapy to address all contributing factors. 2

Advanced Evaluation for Persistent Cough

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

• High-resolution CT scan to evaluate for bronchiectasis or occult interstitial disease 2, 1
• Bronchoscopy to look for occult airway disease (endobronchial tumor, sarcoidosis, suppurative infection, eosinophilic or lymphocytic bronchitis) 2
• In tuberculosis-endemic areas, obtain sputum samples with acid-fast staining or bronchoscopy 2

Consider uncommon causes such as nonacid reflux disease, swallowing disorders, congestive heart failure, or habit cough based on clinical findings. 2

Refer to a cough specialist if a complete workup and appropriate therapeutic trials fail to identify the cause before labeling as unexplained (idiopathic) cough. 2, 1, 4

Critical Pitfalls to Avoid

Do not rely on cough characteristics (timing, quality, productivity) for diagnosis, as they have little diagnostic value. 2, 1, 4

Do not treat only one cause—multiple factors often contribute simultaneously, requiring additive therapy. 1, 4

Do not label as idiopathic until thorough assessment at a specialist clinic excludes uncommon causes. 1, 4

Do not use routine cough suppressants when cough clearance is important for secretion management. 1 Dextromethorphan should not be used if the patient has chronic cough that occurs with smoking, asthma, emphysema, or excessive phlegm. 5

Do not use dextromethorphan in patients taking MAOIs or within 2 weeks of stopping an MAOI. 5 If cough lasts more than 7 days or recurs with fever, rash, or headache, stop the medication and seek medical evaluation. 5

Special Populations

In 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