What is the best course of treatment for an otherwise healthy individual presenting with a post-viral upper respiratory tract infection (URTI) induced cough?

Post-Cold Cough Management

For an otherwise healthy individual with post-viral cough, reassure them that the condition is self-limited and will resolve within 3-8 weeks, and prescribe inhaled ipratropium bromide as the only evidence-based pharmacologic therapy. 1, 2, 3

Understanding the Timeline

Post-infectious cough is a subacute cough that persists for 3-8 weeks after the acute URI symptoms have resolved. 1, 2

• Most cases resolve within 3 weeks, though some persist up to 8 weeks before spontaneous resolution. 2
• The cough results from extensive disruption of airway epithelial integrity, widespread inflammation of upper and/or lower airways, mucus hypersecretion, and transient airway hyperresponsiveness. 1, 2
• This is a benign, self-limiting condition in otherwise healthy individuals. 1

First-Line Treatment Approach

What TO Prescribe

Inhaled ipratropium bromide (2 puffs four times daily) is the only medication with evidence for treating post-infectious cough, with approximately 70% response rate. 2, 3

• Response should be seen within 1-2 weeks. 3
• This is a Grade B recommendation from the American Thoracic Society. 3

What NOT to Prescribe

Antibiotics have no role in treating post-infectious cough, as the cause is not bacterial infection at this stage. 1, 3, 4

• The only exceptions are confirmed bacterial sinusitis or early pertussis infection. 1

Critical Red Flag: Rule Out Pertussis

Before assuming benign post-viral cough, actively screen for pertussis, especially if the cough has these features: 1, 2, 4

• Paroxysms of coughing
• Post-tussive vomiting
• Inspiratory whooping sound

If pertussis is suspected clinically, start azithromycin immediately without waiting for laboratory confirmation, as this is highly contagious with an 80% secondary attack rate. 4

• Obtain nasopharyngeal culture or PCR for confirmation. 4
• Pertussis responds to oral macrolide antibiotics only when administered early in the disease course. 1

When to Reassess and Consider Alternative Diagnoses

At 3 Weeks

If cough persists or worsens at the 3-week mark, begin considering: 2

• Bordetella pertussis infection
• Mycoplasma or Chlamydophila pneumoniae (mean cough duration 23-26 days) 2
• Upper airway cough syndrome (UACS) - accounts for 33% of subacute cough cases 4
• Gastroesophageal reflux disease (GERD) - may be exacerbated by vigorous coughing 1, 4

At 8 Weeks

If cough persists beyond 8 weeks, this is now chronic cough requiring full diagnostic workup for: 2, 3, 4

• Asthma or cough-variant asthma
• Chronic sinusitis
• GERD
• Other chronic pulmonary conditions

Algorithmic Approach to Treatment Failure

If ipratropium bromide fails after 1-2 weeks, proceed systematically: 3

1. For suspected UACS: Trial first-generation antihistamine-decongestant combination for 1-2 weeks 3, 4

2. For suspected asthma/cough-variant asthma:

   • Perform spirometry with bronchodilator response or bronchoprovocation challenge 3
   • Trial inhaled corticosteroids if indicated 3

3. For suspected GERD:

   • Initiate high-dose PPI therapy (omeprazole 20-40 mg twice daily before meals) for at least 8 weeks 3
   • Consider adding prokinetic agents if needed 3

Common Pitfalls to Avoid

• Do not reflexively prescribe antibiotics - they are ineffective for post-infectious cough and contribute to antimicrobial resistance. 1, 4
• Do not dismiss pertussis in vaccinated individuals - breakthrough infections occur and pose serious transmission risk. 2, 4
• Do not assume this is benign without proper assessment - always rule out pertussis and consider chest X-ray if any atypical features are present. 3, 4

Symptomatic Management

Central antitussives (codeine, dextromethorphan) should only be considered when other measures fail, and are not first-line therapy. 3

• Guaifenesin may help loosen mucus but lacks strong evidence for post-infectious cough specifically. 5

Patient Counseling

Reassure patients that post-infectious cough is self-limited and will resolve, typically within 3-8 weeks, even without specific treatment. 1, 2

• Approximately 90% of patients experience cough resolution within 3 weeks. 2
• Only 10% will continue coughing beyond 20-25 days. 2