What is the best course of action for a patient with symptoms of wheeze, cough, and sinus pressure, without a known history of asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Approach to Wheeze, Cough, and Sinus Pressure Without Known Asthma or COPD

Begin with an empiric trial of a first-generation antihistamine-decongestant combination for upper airway cough syndrome (UACS), as this is the most common cause of chronic cough and the recommended first-line approach. 1, 2

Immediate Diagnostic Steps

• Obtain a chest radiograph immediately to exclude pneumonia, malignancy, tuberculosis, and other serious pathology—this is mandatory for any patient with these symptoms. 2, 3
• Perform spirometry with bronchodilator testing to objectively assess for airflow obstruction and reversibility, as this is required to diagnose asthma or COPD and cannot be reliably excluded by clinical examination alone. 1, 2
• Review all medications, specifically asking about ACE inhibitors, which must be discontinued immediately if present as they are a common reversible cause of cough. 2

Critical History Elements to Elicit

• Smoking history and exposure to occupational dusts, fumes, or biomass fuels, as these are major risk factors for COPD even without a prior diagnosis. 1
• History of childhood respiratory infections, atopy, or allergies, as asthma may present with isolated cough without wheeze ("cough variant asthma"). 1
• Symptoms of postnasal drainage, throat clearing, or nasal congestion, which point toward UACS as the primary cause. 1
• Reflux symptoms including heartburn or regurgitation, though GERD can cause cough without any typical reflux symptoms ("silent GERD"). 1

Empiric Treatment Algorithm

First-Line: Treat for UACS

• Start a first-generation antihistamine-decongestant combination (not newer non-sedating antihistamines, which are ineffective for cough). 1, 2
• Expect noticeable improvement within days to 1-2 weeks, with complete resolution potentially taking several weeks to months. 1
• If nasal symptoms persist despite oral therapy, add a topical nasal corticosteroid. 1
• If symptoms remain refractory, obtain sinus imaging (CT or plain films) to evaluate for acute or chronic sinusitis. 1

Second-Line: Evaluate and Treat for Asthma

• If spirometry shows reversible airflow obstruction (FEV1/FVC <0.70 with >12% and 200mL improvement post-bronchodilator), diagnose asthma and initiate inhaled corticosteroids as first-line therapy. 1
• If spirometry is normal but asthma is still suspected based on symptoms, perform bronchoprovocation challenge testing (methacholine challenge) to assess for airway hyperresponsiveness. 1
• For confirmed asthma with persistent cough, step up inhaled corticosteroid dose and consider adding a leukotriene inhibitor if response is incomplete. 1
• Beta-agonists should be used in combination with inhaled corticosteroids, not as monotherapy. 1

Third-Line: Consider Non-Asthmatic Eosinophilic Bronchitis (NAEB)

• NAEB presents with chronic cough and eosinophilic airway inflammation but without airflow obstruction or airway hyperresponsiveness on testing. 1
• If available, obtain induced sputum for eosinophil count or measure fractional exhaled nitric oxide (FeNO). 1
• Treat empirically with inhaled corticosteroids if testing is unavailable but clinical suspicion is high. 1

Fourth-Line: Empiric GERD Treatment

• Initiate intensive acid suppression with proton pump inhibitors for a minimum of 2 months (may require 8-12 weeks for response). 2, 3
• GERD therapy should be tried even without typical reflux symptoms, as it can present with isolated cough. 1

Common Pitfalls to Avoid

• Do not rely on cough characteristics (timing, quality, sputum production) to rule in or rule out specific diagnoses—these have little diagnostic value. 1, 2
• Do not treat only one cause—chronic cough is frequently multifactorial, with patients having two or all three of UACS, asthma, and GERD simultaneously requiring additive therapy. 1
• Do not use single peak expiratory flow measurements for diagnosis, as they are less accurate than FEV1 for identifying airflow obstruction. 1, 3
• Do not abandon GERD therapy prematurely—it may require 8-12 weeks for response. 3

When Spirometry Suggests COPD

If post-bronchodilator FEV1/FVC is <0.70, COPD should be diagnosed even without a prior history, particularly in smokers or those with occupational exposures. 1

• Wheezing, cough, and sputum production are classic COPD symptoms, though they are poor predictors of severity. 1
• Sinusitis and upper airway symptoms coexist in up to 75% of COPD patients, so treating both upper and lower airway disease is essential. 4
• Normal spirometry effectively excludes COPD as a diagnosis. 1

Refractory Cases

• If cough persists after 4-6 weeks of sequential empiric treatment for UACS, asthma, and GERD, consider high-resolution CT chest or bronchoscopy to evaluate for uncommon causes including bronchiectasis, interstitial lung disease, or occult malignancy. 2, 3
• Referral to a specialist cough clinic is appropriate when diagnosis remains unclear despite thorough evaluation. 2