What is the best treatment approach for a patient with an irritant-induced cough and no history of underlying respiratory disease?

Management of Irritant-Induced Cough

For a patient with irritant-induced cough and no underlying respiratory disease, immediately remove the patient from the irritant exposure, then treat symptomatically with adequate hydration, honey for cough suppression (if over 1 year old), and a first-generation antihistamine/decongestant combination if symptoms persist beyond initial removal from the irritant. 1, 2

Initial Assessment and Immediate Action

• Remove the patient from the irritating exposure immediately as this is the primary intervention for environmental or occupational irritant-induced cough 1
• Classify the cough duration: acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks) to guide your approach 3, 2
• Assess for respiratory distress including increased respiratory rate, intercostal retractions, breathlessness, or cyanosis 3
• Rule out serious illness such as pneumonia or pulmonary embolism through history and physical examination 1

History and Physical Examination Specifics

• Document the specific irritant exposure (chemical, dust, fumes, allergen) and timing of exposure relative to cough onset 1
• Verify the patient is NOT taking ACE inhibitors, as these are a common cause of drug-induced cough 1, 3
• Confirm smoking status and counsel for cessation if applicable 1, 3
• Examine for signs of upper airway irritation or rhinitis 3
• Perform lung auscultation to rule out wheezing or abnormal breath sounds 2

Symptomatic Treatment for Acute Irritant-Induced Cough

• Recommend adequate fluid intake to avoid dehydration 3, 2
• Consider honey for cough suppression in patients over 1 year of age 3, 2
• Use acetaminophen (paracetamol) for associated discomfort or fever 3, 2
• For persistent cough with postnasal drip symptoms, prescribe a first-generation antihistamine/decongestant combination 1, 2
• Dextromethorphan can be used as a cough suppressant for symptomatic relief of cough due to minor throat and bronchial irritation from inhaled irritants 4
• Guaifenesin may help loosen mucus if the cough becomes productive 5

When to Escalate Evaluation

If cough persists beyond 3 weeks despite removal from irritant and symptomatic treatment:

• Obtain a chest radiograph to rule out pneumonia or other pathology 3, 2
• Perform spirometry to assess for reversible airflow obstruction suggesting asthma 1, 3
• Consider that the irritant may have triggered transient bronchial hyperresponsiveness, which should be treated with inhaled bronchodilators 3, 6

Common Pitfalls to Avoid

• Do not prescribe antibiotics for irritant-induced cough unless bacterial infection is clearly suspected based on fever, purulent sputum, and abnormal lung findings 2
• Do not rely on cough characteristics alone (timing, sound, productivity) as these have limited diagnostic value 1, 6
• Do not use combination cough preparations without specific indication for each component 7
• If cough becomes chronic (>8 weeks), do not continue symptomatic treatment alone—systematically evaluate for upper airway cough syndrome, asthma, non-asthmatic eosinophilic bronchitis, and gastroesophageal reflux disease 1

Follow-Up Instructions

• Instruct the patient to return immediately if breathing difficulty develops 2
• Schedule follow-up if cough worsens or persists beyond 7 days despite appropriate management 2
• If cough transitions to subacute (3-8 weeks), treat as postinfectious cough with first-generation antihistamine/decongestant and consider inhaled bronchodilators for bronchial hyperresponsiveness 3, 6