What is the treatment for a 3-day history of cough, postnasal drip, and minor shortness of breath (SOB) with fatigue?

From the Guidelines

For a 3-day cough with postnasal drip, minor shortness of breath, and fatigue, I recommend a combination approach, prioritizing the patient's quality of life and minimizing potential harm, as the current evidence does not support the use of antibiotics for postinfectious cough 1.

Initial Assessment

The patient's symptoms suggest an upper respiratory viral infection, which typically resolves within 7-10 days.

• The medical history is crucial to determine whether the patient has any underlying conditions that may be contributing to the cough, such as asthma or gastroesophageal reflux disease (GERD) 1.
• A physical examination and medical history can help identify potential causes of the cough, but the timing and characteristics of the cough are of little diagnostic value 1.

Treatment Approach

• Start with an over-the-counter antihistamine like loratadine (10mg once daily) or cetirizine (10mg once daily) to reduce postnasal drip.
• Add guaifenesin (400mg every 4-6 hours) to thin mucus and make coughing more productive.
• For cough suppression, especially at night, use dextromethorphan (15-30mg every 4-6 hours, not exceeding 120mg daily) 1.
• Nasal saline rinses twice daily can help clear nasal passages.
• Stay well-hydrated with at least 8-10 glasses of water daily and use a humidifier at night.
• Rest adequately and consider acetaminophen (650mg every 6 hours) for discomfort.

Monitoring and Follow-up

• If symptoms worsen, persist beyond 10 days, or if the patient develops high fever, severe shortness of breath, or chest pain, seek medical attention promptly as this could indicate a bacterial infection requiring antibiotics or a more serious condition 1.
• Consider referral to a cough specialist if the cough persists despite initial treatment 1.
• In patients with chronic cough, systematically direct empiric treatment at the most common causes of cough (ie, UACS, asthma, NAEB, and GERD) 1.

From the FDA Drug Label

Warnings Do not use if you are now taking a prescription monoamine oxidase inhibitor (MAOI) (certain drugs for depression, psychiatric or emotional conditions, or Parkinson’s disease), or for 2 weeks after stopping the MAOI drug. If you do not know if your prescription drug contains an MAOI, ask a doctor or pharmacist before taking this product Allergy Alert: Contains sodium metabisulfite, a sulfite that may cause allergic-type reactions. Ask a doctor before use if you have • chronic cough that lasts as occurs with smoking, asthma or emphysema • cough that occurs with too much phlegm (mucus) Stop use and ask a doctor if • side effects occur. You may report side effects to FDA at 1-800-FDA-1088 • cough lasts more than 7 days, cough comes back, or occurs with fever, rash or headache that lasts. These could be signs of a serious condition. If pregnant or breast-feeding, ask a health professional before use.

For a 3-day duration of cough, postnasal drip, and minor shortness of breath (SOB) with fatigue, dextromethorphan can be used as a cough suppressant 2. However, it is essential to ask a doctor before use if the patient has a chronic cough or cough with too much phlegm (mucus). The patient should stop use and ask a doctor if the cough lasts more than 7 days or occurs with fever, rash, or headache.

• Key considerations:
  • Contraindications: MAOI use or within 2 weeks of stopping MAOI
  • Allergy alert: Sodium metabisulfite
  • Precautions: Chronic cough, cough with too much phlegm, pregnancy, or breast-feeding
  • Monitoring: Side effects, cough duration, and accompanying symptoms like fever, rash, or headache 2.

From the Research

Symptoms and Treatment

• The patient is experiencing a 3-day history of cough, postnasal drip, and minor shortness of breath (SOB) with fatigue 3, 4.
• Postnasal drip syndrome (PNDS) is often quoted as a common cause of chronic cough, but the mechanism by which PNDS stimulates the cough reflex is not well understood 3.
• A study found that only a small proportion of patients with purulent rhinosinusitis without coexisting chest disease complain of cough, suggesting that nasal disease may not be a common cause of chronic cough 3.

Evaluation and Management

• Chronic cough in adults can be caused by many etiologies, but four conditions account for most cases: upper airway cough syndrome, gastroesophageal reflux disease/laryngopharyngeal reflux disease, asthma, and nonasthmatic eosinophilic bronchitis 5.
• Patients should be evaluated clinically, and empiric treatment should be initiated based on associated symptoms 5.
• Chest radiography can rule out concerning infectious, inflammatory, and malignant thoracic conditions 5.
• Treatment for postnasal drip and associated cough may involve antitussive, anti-inflammatory, and broncholytic agents, such as rengalin 6.

Pathophysiology and Diagnosis

• Postnasal drip (PND) is a common complaint in primary care and ear-nose-throat offices, but its symptoms can be vague and variable, making diagnosis challenging 4, 7.
• The traditional pathophysiology of PND related to sinonasal disease does not clearly lead to chronic cough, and the cough from PND may be related to an airway sensory hypersensitivity rather than actual irritation from inflamed nasal secretions 4.
• Empiric treatment for PND symptoms should be guided by associated symptoms that suggest either a sinonasal cause or gastroesophageal reflux 7.