What are the recommended treatments for a patient with a persistent deep cough following bronchitis treatment, considering official guidelines?

Treatment of Persistent Deep Cough Following Bronchitis

For a persistent deep cough following bronchitis (postinfectious cough lasting 3-8 weeks), start with inhaled ipratropium bromide 36 μg (2 inhalations) four times daily, and if the cough persists and adversely affects quality of life, add inhaled corticosteroids. 1

Initial Assessment and Diagnosis

• Confirm the diagnosis of postinfectious cough if the cough has been present for at least 3 weeks but not more than 8 weeks following an acute respiratory infection 1
• If cough persists beyond 8 weeks, consider diagnoses other than postinfectious cough, such as upper airway cough syndrome, asthma, or gastroesophageal reflux disease 1
• Identify contributing pathogenetic factors including postviral airway inflammation, bronchial hyper-responsiveness, mucus hypersecretion, and impaired mucociliary clearance before initiating therapy 1

First-Line Treatment Algorithm

Step 1: Inhaled Ipratropium Bromide

• Initiate inhaled ipratropium bromide as it may attenuate the cough (Grade B recommendation) 1
• Standard dosing is 36 μg (2 inhalations) four times daily 2
• This reduces cough frequency, cough severity, and volume of sputum expectorated 2, 3

Step 2: Add Inhaled Corticosteroids if Needed

• If cough persists despite ipratropium and adversely affects quality of life, add inhaled corticosteroids (Grade E/B recommendation) 1
• This addresses the underlying postviral airway inflammation and bronchial hyper-responsiveness 1

Step 3: Short Course of Oral Corticosteroids for Severe Cases

• For severe paroxysms of postinfectious cough, consider prescribing 30-40 mg of prednisone per day for a short, finite period after ruling out other common causes like upper airway cough syndrome, asthma, or gastroesophageal reflux disease (Grade C recommendation) 1

What NOT to Do

• Do NOT prescribe antibiotics for postinfectious cough, as the cause is not bacterial infection (Grade I recommendation) 1
• Do NOT use mucokinetic agents (expectorants and mucolytics) as there is no consistent favorable effect on cough in acute bronchitis (Grade I recommendation) 1
• Antitussive agents (codeine, dextromethorphan) may be offered for short-term symptomatic relief but provide only modest benefit (Grade C recommendation) 1, 3

Special Considerations

If Bacterial Sinusitis or Pertussis is Suspected

• The above recommendations apply specifically to postinfectious cough not due to bacterial sinusitis or early Bordetella pertussis infection 1
• If these conditions are suspected, appropriate antibiotic therapy is indicated 1

Monitoring Response

• Reassess after 2 weeks of ipratropium therapy to determine if additional treatment is needed 2
• If inadequate response to ipratropium, consider adding a short-acting β-agonist for additional bronchodilation and potential cough relief 2

Common Pitfalls to Avoid

• Avoid prescribing antibiotics reflexively - they reduce cough duration by only 0.5 days while exposing patients to adverse effects and contributing to antibiotic resistance 3
• Do not use long-term prophylactic antibiotics in stable patients with chronic bronchitis due to concerns about antibiotic resistance (Grade I recommendation) 1, 2
• Set realistic expectations - inform patients that postinfectious cough typically resolves within 3-8 weeks, and complete resolution may take up to 8 weeks 3, 4