What is the best course of treatment for a 17-year-old patient with a persistent dry and wet cough, sensation of hair in the throat, and tachycardia (elevated heart rate) after using albuterol, who has tried prednisone, amoxicillin (amoxicillin), and Augmentin (amoxicillin/clavulanate) with temporary relief?

Management of Persistent Post-Infectious Cough in a 17-Year-Old

This is post-infectious cough that has failed initial therapies, and the next step is inhaled ipratropium bromide 2-3 puffs four times daily, combined with a first-generation antihistamine-decongestant for upper airway symptoms, while discontinuing albuterol due to ineffectiveness and tachycardia. 1, 2

Immediate Assessment and Diagnosis

This clinical presentation fits post-infectious cough: initial URI symptoms followed by persistent cough for 2 weeks, with the characteristic pattern of dry cough during the day and wet cough at night, plus the sensation of "hair in the throat" suggesting post-nasal drip. 1, 3

Critical First Step: Rule Out Pertussis

You must obtain a nasopharyngeal culture immediately because post-tussive symptoms (though vomiting isn't explicitly mentioned here, the paroxysmal nature is suggested) warrant pertussis exclusion, even in vaccinated adolescents. 2, 3 If pertussis is confirmed, prescribe azithromycin or clarithromycin immediately and isolate for 5 days from treatment start. 2

Why Current Treatments Failed

Albuterol Should Be Stopped

• Albuterol is causing tachycardia (145 bpm initially, 120 bpm on albuterol alone) and providing no benefit, which is expected because this is not asthma—it's post-infectious airway inflammation without bronchospasm. 4
• The FDA label confirms albuterol can produce significant cardiovascular effects including elevated heart rate, especially problematic in this patient. 4

Antibiotics Were Inappropriate

• Amoxicillin and Augmentin have no role in post-infectious viral cough unless there's confirmed bacterial sinusitis or pertussis. 1, 2 The temporary improvement was likely coincidental or placebo effect. 1
• Antibiotics are explicitly contraindicated because the cause is not bacterial infection. 1

Prednisone Was Premature

• Prednisone should be reserved for severe paroxysms after other therapies fail, not as initial treatment. 1, 3 It was jumped to too early in this case. 2

Correct Treatment Algorithm

Step 1: Inhaled Ipratropium Bromide (First-Line)

Prescribe ipratropium bromide 2-3 puffs (17-34 mcg per puff) four times daily. 1, 2, 3 This has the strongest evidence for attenuating post-infectious cough with fewer systemic side effects than alternatives. 2 Most patients show improvement within 1-2 weeks. 1

Step 2: Add Upper Airway Treatment

The "hair in throat" sensation indicates upper airway involvement (post-nasal drip/upper airway cough syndrome). 5

Prescribe a first-generation antihistamine-decongestant combination:

• Brompheniramine/pseudoephedrine OR chlorpheniramine/phenylephrine 2
• Start once-daily at bedtime for 2-3 days to minimize sedation, then advance to twice-daily 2
• Add intranasal corticosteroid spray (fluticasone or mometasone) to decrease airway inflammation 2

Critical pitfall to avoid: Do NOT use nasal decongestant sprays (oxymetazoline) for more than 3-5 days due to rebound congestion risk. 2

Step 3: Supportive Care

• Continue menthol cough drops and diffuser—these provide symptomatic relief and are safe. 1
• Consider guaifenesin (FDA-approved expectorant) to help loosen phlegm, particularly for the nighttime wet cough. 1

If No Improvement After 2 Weeks

Evaluate for Asthma/Eosinophilic Bronchitis

Despite the failed albuterol trial, consider inhaled corticosteroids (not oral prednisone yet) if quality of life remains significantly affected. 1, 3 The treatment algorithm recommends inhaled corticosteroids as second-line after ipratropium. 3

Prescribe fluticasone 220 mcg or budesonide 360 mcg twice daily for 4-6 weeks. 5, 6 Response may take up to 8 weeks in some patients. 5

Evaluate for GERD

If cough persists beyond 2 weeks of adequate upper airway and bronchodilator therapy, GERD must be considered even without typical GI symptoms. 5, 2

Initiate high-dose PPI therapy:

• Omeprazole 40 mg twice daily (before breakfast and dinner) 2
• Add dietary modifications: avoid late meals, elevate head of bed, avoid trigger foods 2
• GERD-related cough requires 2 weeks to several months for response—some patients need 8-12 weeks, so adequate treatment duration is essential. 2

When to Escalate to Oral Prednisone

Only prescribe oral prednisone (30-40 mg daily for 5-10 days) if:

1. Severe paroxysms significantly impair quality of life, AND
2. Ipratropium and inhaled corticosteroids have failed, AND
3. Other common causes (UACS, asthma, GERD) have been ruled out or adequately treated 5, 1, 3

Red Flags Requiring Advanced Evaluation

Order chest X-ray if: 5

• Cough persists beyond 8 weeks (reclassifies as chronic cough) 1, 3
• Any hemoptysis, fever, weight loss, or night sweats develop 7
• Physical exam reveals crackles, clubbing, or other concerning findings 5

Consider high-resolution CT chest and bronchoscopy if all empiric therapies fail and chest X-ray is normal. 2

Timeline Expectations

• Ipratropium response: 1-2 weeks 1
• Upper airway treatment response: Days to 1-2 weeks 1
• Inhaled corticosteroid response: Up to 8 weeks 5, 3
• GERD treatment response: 2 weeks to several months 2

If cough persists beyond 8 weeks total duration, reclassify as chronic cough and systematically evaluate for UACS, asthma, and GERD with the understanding that chronic cough is frequently multifactorial. 1, 2 Continue effective therapies while adding the next intervention rather than stopping and switching. 1