What is the appropriate management for a patient presenting with a cough?

Management of Cough

Begin by classifying cough duration—acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks)—as this determines your diagnostic and therapeutic pathway. 1, 2, 3

Immediate Actions

• Discontinue ACE inhibitors immediately if the patient is taking them, as they are a common reversible cause of cough 2, 3, 4
• Counsel smokers on cessation, as 90-94% experience cough resolution within the first year of quitting 3
• Assess for life-threatening conditions including pneumonia (tachypnea, tachycardia, abnormal lung findings), pulmonary embolism, or systemic illness requiring urgent intervention 1, 2
• Evaluate for respiratory distress: markedly elevated respiratory rate, intercostal retractions, grunting, cyanosis, severe dehydration, or altered mental status 2, 4

Initial Diagnostic Workup

• Obtain chest radiograph if pneumonia is suspected based on tachypnea, tachycardia, dyspnea, or abnormal lung findings 2, 4
• Perform spirometry as part of basic evaluation for chronic cough, though its utility is not clearly established 3
• History should identify: ACE inhibitor use, smoking status, environmental exposures, and signs of serious systemic disease 1, 2, 4

Management by Duration

Acute Cough (<3 weeks)

For common cold-related cough:

• Use first-generation antihistamine/decongestant combination plus naproxen to decrease cough severity and hasten resolution 1, 2, 3
• Do not use newer non-sedating antihistamines as they are ineffective for cough 2

For acute exacerbation of chronic bronchitis:

• Prescribe short course (10-15 days) of systemic corticosteroids 2, 3

Subacute Cough (3-8 weeks)

• Determine if postinfectious or non-infectious in origin, as this guides treatment 1, 4
• If postinfectious, consider inhaled ipratropium as it may attenuate cough 1
• If non-infectious, manage as chronic cough using the algorithm below 1, 4

Chronic Cough (>8 weeks)

Use a sequential and additive treatment approach targeting the three most common causes, which frequently coexist: 1, 2, 3

1. Upper Airway Cough Syndrome (UACS)

• Prescribe oral first-generation antihistamine/decongestant combination as initial treatment 2, 3, 4
• Add topical nasal corticosteroid if prominent upper airway symptoms are present 3

2. Asthma

• Treat with inhaled bronchodilators and inhaled corticosteroids if spirometry shows reversible airflow obstruction 2, 3, 4
• Perform bronchoprovocation challenge if spirometry is normal but asthma is suspected 3, 4
• If testing unavailable, initiate empiric trial of inhaled corticosteroids and bronchodilators 3, 4
• For refractory cases, add leukotriene receptor antagonist before escalating to systemic corticosteroids 2

3. Gastroesophageal Reflux Disease (GERD)

• Initiate empiric proton pump inhibitor therapy for patients with typical reflux symptoms before performing esophageal testing 3
• Add prokinetic agent (metoclopramide) and rigorous dietary measures if initial therapy fails 1
• Consider 24-hour esophageal pH monitoring if cough persists despite optimal medical therapy 1

4. Non-Asthmatic Eosinophilic Bronchitis (NAEB)

• Perform induced sputum test for eosinophils if available 3, 4
• Use empiric inhaled corticosteroids if testing is unavailable 2, 3, 4
• Identify and avoid causal allergen or occupational sensitizer if present 2

Critical Treatment Principles

• Maintain all partially effective treatments as multiple causes often coexist simultaneously 1, 2, 3
• Continue empiric therapy for 4-6 weeks before declaring treatment failure 3
• Do not rely on cough characteristics (productive vs. dry, timing) for diagnosis, as they lack diagnostic sensitivity and specificity 1, 3

Advanced Evaluation for Refractory Cough

If cough persists after 4-6 weeks of appropriate empiric treatment: 3

• Obtain high-resolution CT scan to evaluate for bronchiectasis, interstitial lung disease, or occult airway disease 1
• Perform bronchoscopy to look for endobronchial tumor, sarcoidosis, suppurative infection, or eosinophilic/lymphocytic bronchitis 1
• Consider uncommon causes: nonacid reflux disease, swallowing disorder, congestive heart failure, or habit cough 1
• Refer to specialist cough clinic when diagnosis remains unclear 3

Special Populations

Immunocompromised patients:

• Use same initial algorithm but expand differential diagnosis based on immune defect type and severity 2, 3
• In HIV patients with CD4+ <200 cells/μL, suspect Pneumocystis pneumonia, tuberculosis, and opportunistic infections 3

High tuberculosis prevalence areas:

• Obtain sputum smears, acid-fast bacilli cultures, and chest radiograph if evaluation fails to yield diagnosis 1, 3

Common Pitfalls to Avoid

• Do not treat only one cause—multiple factors often contribute simultaneously, requiring additive therapy 2, 3
• Do not label as idiopathic until thorough assessment at specialist clinic excludes uncommon causes 3
• Do not use routine cough suppressants when cough clearance is important for secretion management 3
• Do not perform chest CT in initial workup unless chest radiograph is abnormal or clinical suspicion warrants it, as CT is noncontributory in 48% of cases with normal chest radiographs 1