What is the best course of treatment for a patient experiencing severe coughing (persistent cough) with vomiting?

Severe Cough with Vomiting: Treatment Approach

Start with inhaled ipratropium bromide 2-3 puffs four times daily as first-line therapy, as this is the only medication with fair-quality evidence for post-infectious cough and will address the severe paroxysmal nature causing vomiting. 1, 2

Immediate Diagnostic Considerations

The combination of severe cough with vomiting is a critical clinical feature that narrows your differential significantly:

• Pertussis must be ruled out first when post-tussive vomiting is present, even in vaccinated patients, as breakthrough infections occur and early macrolide treatment diminishes paroxysms and prevents transmission. 1, 2, 3
• Obtain nasopharyngeal culture if pertussis is suspected based on paroxysmal coughing episodes, post-tussive vomiting, or inspiratory whooping sound. 2, 3
• If pertussis is confirmed or highly suspected, prescribe macrolide antibiotics immediately (azithromycin or clarithromycin) to reduce coughing severity and prevent spread. 2, 3

Post-Infectious Cough Treatment Algorithm

If pertussis is excluded and this represents post-infectious cough (most likely scenario):

First-Line Therapy

• Prescribe inhaled ipratropium bromide 2-3 puffs four times daily, which has the strongest evidence for attenuating post-infectious cough with fewer systemic side effects compared to other options. 1, 2
• Add a first-generation antihistamine/decongestant combination (brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine) starting once-daily at bedtime for 2-3 days, then advance to twice-daily to minimize sedation. 1
• Add intranasal corticosteroid spray (fluticasone or mometasone) to decrease airway inflammation. 1

Second-Line Options (If No Improvement in 1-2 Weeks)

• Add central-acting antitussives for severe cough disrupting sleep or quality of life: codeine 15-30 mg or dextromethorphan 30 mg every 6 hours. 1, 4, 5
• Consider inhaled corticosteroids (budesonide or fluticasone) if cough persists and adversely affects quality of life. 1, 2
• Reserve oral prednisone 30-40 mg daily for 5-7 days only after ruling out asthma and GERD, as systemic corticosteroids should be avoided unless severe paroxysms occur. 1, 2

Systematic Evaluation if Treatment Fails After 2 Weeks

After 2 weeks of adequate therapy without improvement, evaluate sequentially for asthma/non-asthmatic eosinophilic bronchitis and GERD. 1

Asthma Evaluation

• Initiate combination inhaled bronchodilators and inhaled corticosteroids as first-line if asthma is suspected. 3
• Perform spirometry to assess for airflow obstruction patterns. 3

GERD Evaluation (If Asthma Treatment Fails)

• Patients with severe cough and vomiting who fit the clinical profile for GERD should be prescribed antireflux treatment even without typical GI symptoms, as GERD can present with cough alone. 6
• Initiate high-dose PPI therapy (omeprazole 40 mg twice daily), dietary modifications (no >45g fat/24h, avoid coffee, tea, soda, chocolate, mints, citrus, tomatoes, alcohol), and lifestyle changes. 6, 1
• GERD-related cough may require 2 weeks to several months for response, with some patients needing 8-12 weeks, so adequate treatment duration is essential before declaring failure. 6, 1
• Add prokinetic therapy if PPI alone is ineffective. 6

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for post-infectious viral cough, as they provide no benefit (reducing cough by only half a day), contribute to resistance, and cause adverse effects including allergic reactions and C. difficile infection. 1, 2, 7
• Do not use nasal decongestant sprays for more than 3-5 days due to rebound congestion risk. 1
• Do not diagnose "unexplained cough" until completing systematic evaluation of upper airway cough syndrome, asthma, and GERD with adequate treatment trials. 1
• Do not assume GERD is ruled out simply because of prior antireflux surgery, as reflux can persist. 6

Advanced Testing if All Empiric Therapy Fails

• Order chest radiograph to rule out persistent pneumonia, masses, interstitial disease, or congestive heart failure. 1
• Order high-resolution CT chest to evaluate for bronchiectasis, interstitial lung disease, or occult masses. 1
• Consider 24-hour esophageal pH monitoring if GERD remains suspected despite failed empiric therapy, as this is the most sensitive and specific test. 6, 1
• Consider bronchoscopy to evaluate for endobronchial lesions, sarcoidosis, eosinophilic bronchitis, or occult infection. 1

Antireflux Surgery Consideration

In patients with chronic cough due to GERD that has failed maximal medical therapy (intensive antireflux diet, maximum acid suppression, prokinetic therapy) for a minimum of 3 months, and who have positive 24-hour esophageal pH monitoring showing persistent reflux despite treatment, antireflux surgery is recommended if the patient reports unsatisfactory quality of life. 6