What is the next step in treating a patient with a chronic cough who has not responded to Tessalon (benzocaine) and albuterol?

Next Steps After Failed Tessalon and Albuterol for Chronic Cough

You should initiate a sequential diagnostic and therapeutic approach targeting the three most common causes of chronic cough: upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD), starting with a first-generation antihistamine-decongestant combination for UACS. 1, 2

Immediate Actions

Step 1: Rule Out ACE Inhibitor Use

• If the patient is taking an ACE inhibitor, discontinue it immediately and switch to an alternative antihypertensive medication, as ACE inhibitors are a common reversible cause of chronic cough 1, 3
• Cough may resolve within 1-4 weeks after discontinuation 3

Step 2: Obtain Chest Radiograph (if not already done)

• A chest X-ray is essential to rule out serious pathology such as malignancy, interstitial lung disease, or infection before proceeding with empiric therapy 1, 3
• If abnormal findings are present, pursue directed diagnostic workup rather than empiric treatment 4

Sequential Treatment Algorithm

First-Line: Treat Upper Airway Cough Syndrome (UACS)

Begin with a first-generation antihistamine-decongestant combination (such as brompheniramine with sustained-release pseudoephedrine), as UACS is the most common cause of chronic cough 4, 1

• Expect some improvement within 1-2 weeks, though complete resolution may take several weeks 1, 2
• Continue treatment for adequate duration before concluding it has failed 4
• If partial response occurs, continue UACS treatment while adding therapy for other causes 1

Important caveat: If no response to first-generation antihistamine-decongestant therapy, obtain sinus imaging (CT or plain films) to evaluate for chronic sinusitis, which may be clinically silent 4, 2

Second-Line: Treat Asthma (Even Without Typical Symptoms)

If UACS treatment fails or provides incomplete relief, initiate asthma therapy with inhaled corticosteroids (ICS) combined with long-acting beta-agonists (LABA) such as fluticasone/salmeterol 4, 1, 2

• Asthma can present as isolated cough without wheezing or dyspnea ("cough variant asthma") 4
• Expect some improvement within 1 week, but complete resolution may require up to 8 weeks of ICS therapy 2
• If spirometry is available and normal, perform methacholine challenge testing to confirm bronchial hyperresponsiveness 2

Critical consideration: If inhaled corticosteroids alone fail, consider a short course of oral corticosteroids (prednisone 40 mg daily for 5-10 days) before concluding asthma is not the cause, as some patients require systemic steroids for diagnosis 2

• Before escalating to oral steroids, consider adding a leukotriene receptor antagonist (montelukast) 4, 2
• Ensure proper inhaler technique before concluding treatment failure 2

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

If asthma treatment with systemic steroids fails, consider NAEB, which presents similarly to asthma but without airway hyperresponsiveness 4

• If available, perform induced sputum testing for eosinophils 2
• Treat with inhaled corticosteroids as first-line therapy 4
• If testing unavailable, an empiric trial of oral corticosteroids (prednisone 40 mg daily for 1-2 weeks) is appropriate 2

Fourth-Line: Treat Gastroesophageal Reflux Disease (GERD)

If cough persists after addressing UACS and asthma/NAEB, initiate empiric GERD therapy even without typical reflux symptoms ("silent GERD") 4, 1

Treatment includes:

• Proton pump inhibitor (PPI) therapy (high-dose, such as omeprazole 40 mg twice daily) 4
• Dietary and lifestyle modifications 4
• Consider adding prokinetic therapy (metoclopramide) if no response to PPI alone 4

Important timing: Response to GERD therapy is more variable than for UACS or asthma—some patients respond within 2 weeks, while others may require 2-3 months 4, 2

Key Principles

Multifactorial Nature of Chronic Cough

• Chronic cough is often caused by multiple conditions simultaneously (e.g., UACS + asthma + GERD) 4
• Continue effective treatments while adding therapy for additional causes 1
• Cough will not resolve until all contributing factors are adequately treated 4

Common Pitfalls to Avoid

• Do not use newer-generation non-sedating antihistamines for UACS, as they are ineffective for cough 4
• Do not assume a diagnosis is ruled out based on lack of typical symptoms—all three common causes can present with cough alone 4
• Do not discontinue partially effective treatments when adding therapy for additional causes 1

When to Refer or Pursue Advanced Testing

If sequential trials of therapy for UACS, asthma/NAEB, and GERD all fail, consider:

• High-resolution CT (HRCT) scan to evaluate for bronchiectasis, interstitial lung disease, or occult pathology 4
• Bronchoscopy to evaluate for endobronchial lesions, eosinophilic bronchitis, or infection 4
• 24-hour esophageal pH monitoring if GERD remains suspected despite failed empiric therapy 4
• Referral to a pulmonologist or cough specialist 4, 2

Symptomatic Cough Suppressants (Last Resort)

If all specific therapies fail and cough remains refractory:

• Gabapentin is the first-choice neuromodulator for chronic refractory cough 5
• Alternatives include low-dose morphine (slow-release preparation), amitriptyline, or other neuromodulators 6, 7, 5
• Speech pathology treatment can be combined with neuromodulators for enhanced response 5

These symptomatic treatments should only be used after exhausting specific therapies, as they suppress symptoms rather than address underlying causes 8