What's the next step in managing an elderly female patient with asthma, hypertension, and supraventricular tachycardia, who has a persistent cough despite recent treatments with doxycycline, methylprednisolone, albuterol, and beclomethasone, and negative chest X-rays?

Management of Persistent Cough in an Elderly Female with Asthma

Perform spirometry in clinic today and initiate treatment for upper airway cough syndrome (UACS) with a first-generation antihistamine-decongestant combination plus intranasal corticosteroid spray while optimizing her asthma controller therapy. 1, 2

Immediate Clinical Assessment

This patient's persistent cough despite multiple treatments warrants systematic evaluation following established chronic cough protocols, as she has now exceeded the typical 3-8 week timeframe for post-infectious cough. 1

Key Historical Details to Obtain

• Cough characteristics: Inquire specifically about throat clearing, sensation of post-nasal drip, timing relative to meals, worsening with exercise or cold air, and nocturnal patterns 1
• Diurnal variation: A cough that abates overnight may suggest gastroesophageal reflux disease (GERD), while nocturnal cough suggests asthma, infection, or heart failure 1
• ACE inhibitor use: Although not mentioned in her medication list, verify she is not on any ACE inhibitors for hypertension, as these can cause persistent cough that may take up to 26 days to resolve after discontinuation 1
• Smoking status: Confirm she is a non-smoker, as this significantly narrows the differential diagnosis 1, 3

Essential Testing in Clinic Today

Spirometry is Mandatory

Spirometry should be performed in all patients with chronic cough and is more accurate than peak flow measurements for diagnosing airflow obstruction. 1 This is critical because:

• Normal spirometry does not exclude asthma as a cause of chronic cough 1
• Many asthmatic patients may not demonstrate sufficient reversibility to meet traditional diagnostic criteria 1
• It helps identify chronic airways obstruction that may be contributing to her symptoms 1

Additional Baseline Assessment

• Verify proper inhaler technique, as improper use is a common cause of treatment failure 2
• Confirm the inhaled corticosteroid (Qvar) itself is not paradoxically triggering cough from aerosol constituents 2

Primary Treatment Strategy

Based on the evidence, the most likely diagnoses in elderly females with chronic cough and normal chest radiographs are: post-nasal drip syndrome (UACS), gastroesophageal reflux disease, and asthma, which account for 100% of causes in non-smoking patients not taking ACE inhibitors with normal chest X-rays. 3

First-Line: Treat UACS Immediately

Start a first-generation antihistamine-decongestant combination (such as chlorpheniramine with pseudoephedrine or phenylephrine) plus intranasal corticosteroid spray while optimizing asthma therapy. 2 This approach is recommended because:

• A one-week duration of symptoms with congestion and runny nose strongly suggests UACS 2
• Improvement is often seen within days to 1-2 weeks, though complete resolution may take several weeks to a few months 2
• The absence of dyspepsia does not rule out reflux as a cause, but UACS should be addressed first 1

Second-Line: Optimize Asthma Control

• Step up the inhaled corticosteroid dose if cough persists after addressing UACS 2
• Add a leukotriene receptor antagonist (montelukast or zafirlukast) if response remains incomplete after optimizing UACS treatment 2
• Complete resolution may require up to 8 weeks of inhaled corticosteroid treatment, even though partial improvement often occurs after 1 week 2

Critical Pitfall to Avoid

Do not abandon therapy after only 1-2 weeks. 2 The patient has already received doxycycline (unnecessary unless bacterial infection documented 2), a Medrol pak (which may have provided temporary relief), and bronchodilators. The systematic approach was not followed, which is why she continues to have symptoms.

If Initial Treatment Fails

For Persistent UACS Symptoms

• Increase or add intranasal corticosteroid, nasal anticholinergic, or nasal antihistamine 2
• Obtain sinus imaging to evaluate for acute or chronic sinusitis 2

For Persistent Cough Despite Optimized UACS and Asthma Treatment

• Consider GERD: Assess for gastroesophageal reflux disease and consider intensive acid suppression with proton pump inhibitors for at least 3 months 4, 3
• Note that reflux-associated cough may occur without gastrointestinal symptoms 4
• The clinical profile predicting GERD-related cough includes: persistently troublesome cough for at least 3 weeks, non-smoker, not on ACE inhibitor, no response to UACS/asthma therapy, and normal chest radiograph 3

When to Consider Additional Testing

Chest CT should only be performed if there is clinical suspicion of underlying pulmonary disease or abnormal chest radiograph, not as part of routine chronic cough evaluation. 1 Given her two negative chest X-rays and normal vitals, CT is not indicated at this time.

Special Considerations for This Elderly Patient

• Her history of SVT requires caution with decongestants; monitor for cardiac effects 5
• Beta-2 agonists (albuterol) can cause chronotropic effects and hypokalaemia, which may be life-threatening in susceptible patients, particularly when combined with other medications 5
• Chronic cough significantly impairs quality of life in elderly women, with particular impact on psychological aspects 1
• In older adults, post-nasal drip syndrome, GERD, and asthma account for 85% of chronic cough causes 3

What NOT to Do

• Do not use antibiotics unless bacterial infection is documented 2, 4
• Do not diagnose "unexplained cough" until completing systematic evaluation of UACS, asthma, and GERD with adequate treatment trials of appropriate duration 2
• Do not add nebulized ipratropium to routine asthma management unless treating acute severe asthma unresponsive to beta-agonists alone 2