What are the next steps for an elderly female patient with hypertension and asthma presenting with a 2-day history of dry cough?

Management of Elderly Female with Hypertension, Asthma, and 2-Day Dry Cough

This is acute cough (< 3 weeks duration), not chronic cough, and should be managed as acute bronchitis with optimization of asthma therapy—antibiotics are not indicated unless pneumonia is confirmed. 1

Immediate Clinical Assessment

Rule out pneumonia first by checking for these four vital sign and examination findings 1:

• Heart rate > 100 beats/min
• Respiratory rate > 24 breaths/min
• Oral temperature > 38°C
• Chest examination findings of focal consolidation, egophony, or fremitus

If all four findings are absent, chest radiograph is not needed and pneumonia is effectively ruled out. 1 This patient can be managed as acute bronchitis without imaging.

Primary Management Strategy

Optimize Asthma Control Immediately

Start or intensify inhaled corticosteroids plus short-acting bronchodilators 1, 2:

• Albuterol 2-4 puffs every 4-6 hours as needed for acute symptom control 3
• Inhaled corticosteroid (e.g., beclomethasone or fluticasone) twice daily 1
• Improvement typically occurs within 1 week, but complete resolution may require up to 8 weeks 1, 2

Critical precaution: Use albuterol with caution given her hypertension—monitor blood pressure as sympathomimetic amines can exacerbate cardiovascular conditions 3

Address Upper Airway Symptoms

Add first-generation antihistamine-decongestant combination plus intranasal corticosteroid if she reports throat clearing, postnasal drip sensation, or nasal symptoms 2:

• This addresses upper airway cough syndrome (UACS), which commonly coexists with asthma 2
• Improvement expected within days to 1-2 weeks 2
• Monitor blood pressure closely when using decongestants in hypertensive patients 4

What NOT to Do

Do not prescribe antibiotics 1, 4:

• Acute bronchitis is primarily viral and routine antibiotic use is not justified 1
• Purulent sputum (if it develops) does not indicate bacterial infection—it reflects inflammatory cells common in viral infections and asthma exacerbations 4
• Antibiotics should only be used if pneumonia is documented by chest radiograph 1, 4

Do not stop therapy prematurely 2:

• Complete resolution may take up to 8 weeks of inhaled corticosteroid treatment 2
• Abandoning therapy after only 1-2 weeks is a common pitfall 2

Expected Timeline and Follow-Up

Reassess at 3 weeks 4:

• If cough persists beyond 3 weeks despite treatment, mandatory reassessment is required 4
• At that point, the cough transitions from acute to subacute, requiring systematic evaluation for chronic causes 1
• Consider chest radiograph at that time if not already obtained 1

If Initial Treatment Fails After 3 Weeks

Evaluate for the three most common causes of persistent cough in this population 2, 5:

1. Upper airway cough syndrome (UACS) - ensure adequate treatment duration 2
2. Asthma - consider spirometry or methacholine challenge if not already done 1, 2
3. Gastroesophageal reflux disease (GERD) - start proton pump inhibitor for at least 3 months, even without GI symptoms 2, 5

These three conditions account for 85-100% of chronic cough in elderly patients with normal chest radiographs who are nonsmokers and not taking ACE inhibitors. 5, 6