What is the best course of treatment for a former smoker with a 3-month history of dry cough, wheezing, and worsening symptoms at night?

Management of Chronic Cough with Wheezing in a Former Smoker

This patient most likely has cough-variant asthma or undiagnosed COPD, and should be started on an inhaled bronchodilator after obtaining a chest radiograph and spirometry to confirm the diagnosis and rule out lung cancer.

Immediate Diagnostic Workup

Essential First Steps

• Obtain a chest radiograph immediately to rule out lung cancer, given the smoking history and 3-month duration of symptoms 1.
• Perform spirometry to confirm airflow obstruction and differentiate between asthma and COPD, as this is mandatory for diagnosis 1, 2.
• Measure oxygen saturation with pulse oximetry to assess for hypoxemia 3.

The combination of chronic cough, wheezing, nocturnal worsening, and former smoking status creates significant concern for both asthma and COPD. In former smokers with persistent cough, COPD must be strongly considered, as they are at risk of developing airflow obstruction 1, 2. However, the nocturnal predominance and wheezing pattern also suggests cough-variant asthma 1.

Critical Red Flags to Assess

• Hemoptysis requires urgent bronchoscopy even if chest radiograph is normal 1, 3.
• Constitutional symptoms (weight loss, night sweats, persistent fever) suggest malignancy or tuberculosis 1, 3.
• Progressive dyspnea beyond what cough alone would explain 3.

Diagnostic Interpretation

Spirometry Findings Will Guide Treatment

• If FEV1 <80% predicted with FEV1/FVC ratio <70% and minimal bronchodilator reversibility: This confirms COPD 1, 2.
• If significant bronchodilator reversibility (>12% and >200mL improvement in FEV1): This suggests asthma 1, 2.
• If spirometry is normal but symptoms persist: Consider bronchial provocation testing for cough-variant asthma, as airway hyperresponsiveness testing is indicated for unexplained chronic cough with normal lung function 1.

Chest Radiograph Interpretation

• If abnormal: Immediate specialist referral is required, particularly if mass, nodule, or infiltrate is present 1, 4.
• If normal: Proceed with empiric treatment trial based on spirometry results 1.

Initial Treatment Strategy

For Confirmed or Suspected Asthma (Normal or Reversible Spirometry)

Start with an inhaled short-acting beta-agonist (SABA) as needed, then add an inhaled corticosteroid (ICS) if symptoms persist 1.

• Begin with albuterol 2 puffs every 4-6 hours as needed for symptom relief 1.
• If symptoms continue after 1-2 weeks, add an ICS such as fluticasone 88-220 mcg twice daily 5.
• Reassess in 2-4 weeks; if no improvement, consider stepping up to combination ICS/LABA therapy 5, 2.

The nocturnal worsening strongly suggests asthma, as this is a classic pattern of airway hyperresponsiveness 1, 6.

For Confirmed COPD (Fixed Airflow Obstruction)

Start with a long-acting bronchodilator (LABA or LAMA) as monotherapy 1, 2.

• Initiate either a long-acting beta-agonist (salmeterol 50 mcg twice daily) or long-acting muscarinic antagonist 1, 5, 2.
• Current guidelines recommend starting with monotherapy and stepping up to combination therapy as needed 2.
• Add inhaled corticosteroids only if symptoms progress or frequent exacerbations occur 5, 2.

Smoking Cessation Counseling

Smoking cessation is mandatory and should be addressed at every visit, as continued smoking worsens both asthma and COPD outcomes 1, 2.

Common Pitfalls to Avoid

• Do not dismiss this as a simple "smoker's cough" without objective testing, as lung cancer presents with cough in over 65% of cases at diagnosis 4.
• Do not start inhaled corticosteroids without confirming the diagnosis with spirometry, as inappropriate prescribing is common with diagnostic uncertainty 1.
• Do not assume wheezing always means asthma in a former smoker; COPD commonly presents with wheeze, and the FEV1/FVC ratio is essential for differentiation 1, 2.
• Do not overlook pertussis in adults with persistent paroxysmal cough, though the 3-month duration makes this less likely unless there was an epidemiologic link 1, 3.
• Do not prescribe antibiotics empirically without evidence of bacterial infection, as chronic cough in this setting is not infectious 1.

Follow-Up and Reassessment

• Reassess in 2-4 weeks after initiating bronchodilator therapy to evaluate treatment response 1, 7.
• If no improvement after 3-4 weeks of appropriate therapy, consider alternative diagnoses including gastroesophageal reflux disease (GERD), upper airway cough syndrome, or non-asthmatic eosinophilic bronchitis 1, 7.
• If symptoms worsen or new symptoms develop, repeat chest radiograph and consider specialist referral 1.