What is the recommended treatment with steroids for a patient with a chronic bronchial cough lasting more than 2 months?

Steroid Treatment for Chronic Bronchial Cough (>2 Months)

For chronic cough lasting more than 2 months, steroids should NOT be routinely prescribed unless specific underlying conditions are identified through systematic evaluation, including testing for bronchial hyperresponsiveness and eosinophilic inflammation. 1

Initial Diagnostic Approach

Before considering steroid therapy, you must systematically exclude or identify specific treatable causes:

• Rule out common causes first: upper airway cough syndrome (postnasal drip), asthma, and gastroesophageal reflux disease must be evaluated and treated before attributing cough to other causes 1

• Obtain objective testing: Perform testing for bronchial hyperresponsiveness and eosinophilic bronchitis (sputum eosinophils or exhaled nitric oxide), or conduct a therapeutic corticosteroid trial to guide diagnosis 1

• Check chest imaging: Obtain chest radiography to exclude interstitial lung disease, sarcoidosis, or other structural abnormalities 1

When Steroids ARE Indicated

Postinfectious Cough (3-8 weeks duration)

• First-line: Trial of inhaled ipratropium bromide 1
• Second-line: If cough persists despite ipratropium and adversely affects quality of life, consider inhaled corticosteroids 1
• For severe paroxysms: Prescribe prednisone 30-40 mg daily for a short, finite period only after ruling out upper airway cough syndrome, asthma, and GERD 1

Cough Variant Asthma

• Diagnostic trial: Prednisone 30 mg daily for 1-2 weeks establishes diagnosis; cough should improve within 3 days to 2 weeks 2, 3
• Long-term management: Transition to inhaled corticosteroids (e.g., fluticasone 500 mcg twice daily) for maintenance therapy 2, 3
• This diagnosis requires: Evidence of bronchial hyperresponsiveness or response to bronchodilators 1

Eosinophilic Bronchitis

• Sputum eosinophilia is the key predictor: Patients with sputum eosinophils (not just blood eosinophils) respond favorably to corticosteroids 4
• Treatment: Inhaled corticosteroids are first-line; if symptoms persist despite high-dose inhaled steroids, add oral corticosteroids 5

Specific Interstitial Lung Diseases

• Hypersensitivity pneumonitis: Remove offending exposure plus systemic corticosteroids for those with physiologic impairment 1
• Sarcoidosis: Oral corticosteroids may improve symptoms, but require individualized risk-benefit analysis given lack of proven long-term benefit and significant side effects 1
• Toxic/antigenic exposure bronchiolitis: Cessation of exposure plus corticosteroids for those with physiologic impairment 1

When Steroids Are NOT Indicated

Unexplained Chronic Cough (>8 weeks)

If testing for bronchial hyperresponsiveness and eosinophilia is negative, do NOT prescribe inhaled corticosteroids 1. This is a Grade 2B recommendation from the American College of Chest Physicians.

• Alternative treatments: Consider multimodality speech pathology therapy (Grade 2C) or gabapentin trial (Grade 2C) after discussing risks and benefits 1

Acute Bronchitis

Systemic corticosteroids are explicitly NOT justified for acute bronchitis in healthy adults 6. The clinical course is self-limited after approximately 10 days, and steroids provide no benefit while exposing patients to unnecessary risks including hyperglycemia, weight gain, insomnia, and immunosuppression 6.

Chronic Cough Without Eosinophilia

Research demonstrates that budesonide 400 mcg twice daily for 4 weeks does not improve cough in patients without sputum eosinophilia 7. Similarly, inhaled fluticasone modestly reduces cough severity but does not alter key inflammatory mediators (LTB4, cysteinyl leukotrienes, PGE2) 8.

Critical Pitfalls to Avoid

• Do not prescribe steroids based on purulent sputum alone: This does not indicate bacterial superinfection or justify steroid treatment in acute bronchitis 6

• Do not confuse acute bronchitis with acute exacerbations of chronic bronchitis: The latter benefits from short-course systemic steroids (prednisone 40 mg daily for 5-7 days), while the former does not 6

• Blood eosinophilia is NOT a reliable predictor: Sputum eosinophilia, not peripheral blood eosinophil count, predicts steroid responsiveness 4

• Avoid long-term oral corticosteroids: For stable chronic bronchitis, long-term maintenance with oral prednisone should NOT be used due to lack of efficacy evidence and significant side effects 6, 5

Practical Treatment Algorithm

1. Duration 2-8 weeks (postinfectious): Trial inhaled ipratropium → if persistent, trial inhaled corticosteroids → if severe paroxysms, short course prednisone 30-40 mg daily 1

2. Duration >8 weeks: Obtain sputum eosinophils or exhaled nitric oxide + bronchial hyperresponsiveness testing 1

   • If eosinophilia present: Inhaled corticosteroids 5, 4
   • If negative: Do NOT use inhaled corticosteroids; consider speech pathology or gabapentin 1

3. Suspected cough variant asthma: Diagnostic trial prednisone 30 mg daily for 1-2 weeks → if responsive, transition to inhaled corticosteroids 2, 3

4. Interstitial lung disease identified: Address specific etiology (remove exposure, treat underlying condition) plus corticosteroids if physiologic impairment present 1