What are the possible causes and treatments for a worsening cough and snoring during winter?

Worsening Cough and Snoring in Winter: Causes and Management

Winter-related worsening of cough and snoring most commonly results from upper airway disease (rhinosinusitis, post-nasal drip) exacerbated by cold, dry air and increased indoor allergen exposure, and should be treated with intranasal corticosteroids as first-line therapy for one month. 1

Primary Causes to Consider

Upper Airway Disease (Most Common)

• Upper airway disease causes cough accompanied by nasal stuffiness, sinusitis, and post-nasal drip sensation 1
• Winter conditions worsen rhinosinusitis due to cold air irritation and reduced humidity
• In the presence of prominent upper airway symptoms, a 1-month trial of topical corticosteroid is recommended 1
• Symptoms and clinical findings alone are not reliable discriminators—response to treatment confirms the diagnosis 1

Obstructive Sleep Apnea (OSA) Connection

• OSA should be considered when cough remains unexplained following investigations for common causes 2
• The presence of nocturnal cough, snoring, and gastro-oesophageal reflux together are helpful in identifying patients requiring further investigation 2
• Daytime somnolence is often absent in OSA-related cough 2
• Winter weight gain and reduced physical activity can worsen OSA severity

Gastro-oesophageal Reflux Disease (GORD)

• GORD causes chronic cough in 5-41% of cases and frequently coexists with OSA 1, 2
• Reflux may worsen in winter due to dietary changes and increased recumbent time
• Proton pump inhibitors (PPIs) such as omeprazole 20-40 mg twice daily taken before meals for at least 8 weeks are recommended 1
• Full acid suppression may require combination of twice-daily PPIs and nocturnal H2 antagonists 1

Asthma and Its Variants

• Cough variant asthma and eosinophilic bronchitis respond to inhaled corticosteroids 1
• Cold air is a potent trigger for bronchial hyperresponsiveness
• Consider bronchial provocation testing if spirometry is normal but cough persists 3

Diagnostic Approach Algorithm

Step 1: Identify Red Flags Requiring Urgent Evaluation

• Haemoptysis, prominent systemic illness, suspicion of lung cancer 1
• Fever, malaise, purulent sputum suggesting serious lung infection 1
• Progressive breathlessness requiring assessment for asthma or anaphylaxis 1

Step 2: Characterize the Cough and Snoring Pattern

• Assess whether cough is dry or productive, nocturnal predominance, and relationship to position 3
• Evaluate snoring severity and presence of witnessed apneas
• Look specifically for nasal stuffiness, sinus pressure, and post-nasal drip sensation 1

Step 3: Physical Examination Findings

• Examine for inflamed nasal mucosa and posterior pharynx with adherent or draining secretions 1
• Assess for signs of rhinosinusitis 1
• Upper airway examination for anatomic obstruction 4

Treatment Algorithm

First-Line: Upper Airway Disease Management

• Intranasal corticosteroids for 1 month trial 1
• This addresses the most common cause of winter-exacerbated cough and can improve both symptoms
• Response to treatment confirms the diagnosis when symptoms and signs are unreliable 1

For Dry, Non-Productive Cough Component

• Simple home remedies like honey and lemon should be tried first 1, 5
• Dextromethorphan 30-60 mg provides optimal cough suppression if pharmacological treatment is needed 1, 5
• Standard over-the-counter dosing is often subtherapeutic 1, 5
• First-generation sedating antihistamines are particularly suitable for nocturnal cough 1, 5
• Avoid codeine—it has no greater efficacy than dextromethorphan but significantly more adverse effects 1, 5

If Upper Airway Treatment Fails After 1 Month

• Consider GORD as next most likely cause, especially if snoring is present 1, 2
• Start omeprazole 20-40 mg twice daily before meals for at least 8 weeks 1
• Add prokinetic agent (metoclopramide 10 mg three times daily) if needed 1
• Eliminate medications worsening reflux (bisphosphonates, nitrates, calcium channel blockers) 1

If Snoring Persists or OSA Suspected

• Nocturnal cough plus snoring plus reflux symptoms warrant sleep study evaluation 2
• Continuous positive airway pressure (CPAP) therapy is effective in alleviating OSA-related cough 2
• Optimize GORD therapy as OSA and reflux frequently coexist 2

Consider Asthma Variants

• Trial of inhaled corticosteroids if bronchial hyperresponsiveness suspected 1
• Leukotriene receptor antagonists have evidence at step 3 of asthma management 1
• Follow national asthma guidelines for dosing and duration 1

Common Pitfalls to Avoid

• Do not rely on symptoms alone to diagnose post-nasal drip—they are unreliable discriminators 1
• Do not use subtherapeutic doses of dextromethorphan (standard OTC dosing is often inadequate) 1, 5
• Do not prescribe codeine-based antitussives—they offer no advantage over dextromethorphan with worse side effects 1, 5
• Do not assume daytime somnolence must be present for OSA—it is often absent in OSA-related cough 2
• Do not stop PPI therapy prematurely—at least 8 weeks is required for GORD-related cough 1
• Do not overlook the need for combination therapy—multiple causes often coexist 1

When to Refer or Investigate Further

• If cough persists beyond 8 weeks despite appropriate trials, consider diagnoses other than postinfectious or upper airway disease 3
• Perform bronchial provocation testing if spirometry normal but cough persists 3
• Consider sleep study if nocturnal cough, snoring, and reflux symptoms cluster together 2
• Specialist referral for bronchoscopy is mandatory with haemoptysis or suspected foreign body 1