What is the appropriate diagnosis and treatment for a 58-year-old female smoker with a 2-month history of cough, dyspnea (difficulty breathing), and intermittent respiratory distress?

Diagnosis and Management of Chronic Cough with Dyspnea in a Long-Term Smoker

Immediate Diagnostic Priority

This patient requires urgent chest radiography and smoking cessation counseling, with systematic evaluation for the three most common causes of chronic cough: upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD), while maintaining high suspicion for smoking-related lung disease including COPD and malignancy. 1

Critical Initial Assessment

Smoking History and Cessation

• With a 49-year smoking history (smoking since age 9), immediate smoking cessation is mandatory as cigarette smoking commonly causes chronic productive cough meeting criteria for chronic bronchitis 1
• The majority of smokers will have cough resolution within 4 weeks of cessation, though some may take longer 1
• In patients with severe COPD, cough may persist despite cessation due to frequent exacerbations 1

Chest Radiography

• Obtain chest radiograph immediately to exclude serious pathology including lung cancer, given the extensive smoking history and new 2-month cough 1
• If chest radiograph shows a mass or findings suggestive of bronchogenic carcinoma, proceed directly to investigation of that finding 1
• If the patient has risk factors for lung cancer (which this patient clearly does) or hemoptysis, bronchoscopy is indicated even with normal chest radiograph 1

Red Flag Assessment

• The sensation of "throat collapsing" and inability to breathe during coughing fits suggests possible:
  • Severe bronchospasm or airway hyperreactivity
  • Tracheobronchomalacia (airway collapse)
  • Vocal cord dysfunction
• These episodes of respiratory distress lasting seconds require urgent evaluation as they may represent life-threatening airway obstruction 1

Systematic Diagnostic Approach for Chronic Cough

Step 1: Rule Out ACE Inhibitor Use

• Determine if patient is taking an ACE inhibitor 1
• If yes, discontinue immediately regardless of temporal relationship, as cough typically resolves within days to 2 weeks (median 26 days) 1

Step 2: Evaluate for COPD

• Given the 49-year smoking history, COPD is highly likely 1
• Perform spirometry to assess for airflow obstruction (FEV1/FVC ratio) 1
• Patients with moderate COPD present with breathlessness on exertion, cough ± sputum, and may have wheezes on examination 1
• The degree of airways obstruction cannot be predicted from symptoms or signs alone 1

Step 3: Sequential Empirical Treatment for Common Causes

If chest radiograph is essentially normal, proceed with algorithmic treatment for the three most common causes in descending order of prevalence: 1

First: Upper Airway Cough Syndrome (UACS)

• Begin with oral first-generation antihistamine/decongestant combination 1
• UACS is the most common cause of chronic cough in immunocompetent nonsmokers with normal chest radiographs 1
• Treat empirically even without classic postnasal drip symptoms 1

Second: Asthma/Airway Hyperreactivity

• If cough persists after UACS treatment, evaluate for asthma 1
• The medical history is not reliable for ruling in or ruling out asthma 1
• Ideally perform bronchoprovocation challenge if spirometry does not show reversible airflow obstruction 1
• The episodes of inability to breathe during coughing fits may represent bronchospasm 1
• Consider trial of inhaled corticosteroids and bronchodilators 1

Third: Gastroesophageal Reflux Disease (GERD)

• If cough persists after treating UACS and asthma, treat empirically for GERD 1
• GERD is the third most common cause of chronic cough 1
• Treatment should be given in sequential and additive steps because more than one cause may be present 1

Step 4: Consider Non-Asthmatic Eosinophilic Bronchitis (NAEB)

• NAEB is frequent enough to warrant early consideration 1
• May require induced sputum analysis or bronchoscopy with bronchoalveolar lavage 1

High-Risk Considerations Requiring Urgent Investigation

Lung Cancer Screening

• This patient has extremely high risk for lung cancer given:
  • 49 pack-year smoking history (assuming 1 pack/day average)
  • Age 58 years
  • New cough of 2 months duration 1
• If bronchoscopy reveals suspicion of airway involvement by malignancy, proceed even with normal chest radiograph 1
• Cough is present in 25-84% of initial lung cancer presentations 1

Serious Infection Risk

• Consider community-acquired MRSA with PVL toxin in patients presenting with acute severe community-acquired pneumonia, dyspnea, productive cough, and chest pain 1
• Initial empirical antibiotic therapy should include MRSA coverage if pneumonia is suspected 1

Management Algorithm

If COPD is Confirmed:

• Smoking cessation is almost always effective for cough resolution 1
• Initiate bronchodilator therapy 1
• Assess for acute exacerbation requiring antibiotics or corticosteroids 1
• Monitor for progression to severe disease with cor pulmonale 1

If Malignancy is Found:

• For stage I-II non-small cell lung cancer, surgery is treatment of choice and cough will typically cease if tumor is successfully removed 1
• For advanced disease, consider external beam radiation and/or chemotherapy 1
• For palliation of cough in lung cancer, use centrally acting cough suppressants such as dihydrocodeine or hydrocodone 1
• Endobronchial interventions (debridement, brachytherapy, tumor ablation, or stent placement) are recommended for improvement in cough and quality of life 1

If Common Causes are Treated Without Resolution:

• Perform chest CT scan and bronchoscopic evaluation 1
• Consider uncommon causes including:
  • Pulmonary alveolar proteinosis (especially in active smokers) 1
  • Connective tissue disorders 1
  • Tonsillar hypertrophy or supraglottic pathology 1

Critical Pitfalls to Avoid

• Do not delay chest radiography in any patient with chronic cough and significant smoking history 1
• Do not assume cough is simply "smoker's cough" without systematic evaluation for treatable causes and serious pathology 1
• Do not change treatment within the first 72 hours unless clinical state worsens 1
• Do not diagnose unexplained (idiopathic) cough until thorough diagnostic evaluation is complete and specific appropriate treatment has been tried and failed 1
• Do not ignore the episodes of respiratory distress - these require urgent evaluation for life-threatening airway obstruction or severe bronchospasm 1
• Do not treat empirically with antibiotics unless purulent sputum develops or clinical deterioration suggests secondary bacterial infection 2

Immediate Next Steps

1. Obtain chest radiograph today 1
2. Initiate smoking cessation counseling and support immediately 1
3. Perform spirometry to assess for COPD 1
4. Begin empirical treatment with first-generation antihistamine/decongestant 1
5. Schedule follow-up within 2 weeks to assess response and adjust treatment 2
6. Maintain high index of suspicion for lung cancer and proceed with bronchoscopy if indicated 1