How should I initially treat a stable adult with chronic morning‑predominant cough and wheeze?

Initial Management of Chronic Morning Cough with Wheeze

Focus first on smoking cessation if the patient smokes, then initiate a systematic diagnostic-therapeutic approach targeting the three most common causes: upper airway cough syndrome, asthma/eosinophilic airway disease, and gastroesophageal reflux disease—treating them sequentially and additively rather than switching between therapies.

Immediate Actions

Mandatory Baseline Assessment

• Obtain a chest radiograph and spirometry in all patients with chronic cough to exclude structural lung disease, malignancy, and to assess for airflow obstruction 1.
• Discontinue ACE inhibitors immediately if the patient is taking one, as no patient with troublesome cough should continue these medications 1.
• Strongly counsel smoking cessation if applicable, as smoking is the most significant risk factor for chronic bronchitis and is accompanied by significant symptom remission when stopped 2.

Clinical History Priorities

• Assess for environmental exposures including dusty environments, irritating inhalants, and pollutants, as these are risk factors for chronic bronchitis 2.
• Identify reflux symptoms, recognizing that cough may be the only manifestation without typical gastrointestinal complaints ("silent GERD") 2, 1.
• Document upper airway symptoms such as post-nasal drip, throat clearing, or rhinosinusitis 2, 1.
• Determine if wheeze is fixed or variable, as morning-predominant symptoms with wheeze suggest either asthma or COPD spectrum disease 3, 4.

First-Line Treatment Algorithm

Step 1: Address Upper Airway (Days to 1-2 Weeks)

• Prescribe a first-generation antihistamine-decongestant combination (e.g., brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine) for upper airway cough syndrome 5.
• Add an intranasal corticosteroid spray (fluticasone or mometasone) for prominent upper airway symptoms 2, 5, 1.
• Expect response within days to 1-2 weeks if upper airway disease is contributing 5.

Step 2: Trial of Corticosteroids for Eosinophilic Airway Disease (2 Weeks to 8 Weeks)

Given the presence of wheeze, eosinophilic airway inflammation is highly likely and must be addressed.

• Initiate a 2-week oral corticosteroid trial (prednisone 30-40 mg daily) to exclude corticosteroid-responsive cough, as no currently available test can reliably exclude eosinophilic inflammation 2, 1.
• If cough improves with oral steroids, transition to inhaled corticosteroids (fluticasone 220 mcg or budesonide 360 mcg twice daily) as first-line maintenance therapy 5, 3, 4.
• Add a long-acting beta-agonist if wheeze persists or if spirometry demonstrates reversible airflow obstruction 6.
• Allow up to 8 weeks for full therapeutic response to inhaled corticosteroids 5, 1.

Important caveat: Cough variant asthma and non-asthmatic eosinophilic bronchitis account for 14-32% of chronic cough cases and may present with wheeze as the only additional symptom 3, 6, 4. Morning-predominant symptoms are characteristic of asthma due to circadian variation in airway inflammation 3.

Step 3: Intensive Acid Suppression for GERD (Minimum 3 Months)

• Prescribe high-dose proton pump inhibitor therapy (omeprazole 40 mg twice daily or equivalent) with alginates for a minimum of 3 months 2, 5, 1.
• Initiate this even without typical reflux symptoms, as failure to consider GERD is a common reason for treatment failure 2, 1.
• Counsel dietary modifications: avoid late meals, elevate head of bed, reduce caffeine and alcohol 5.
• Response may require 2 weeks to several months, so do not discontinue prematurely 5, 1.

Critical Management Principles

Sequential and Additive Approach

• Treat causes sequentially but additively, meaning if partial improvement occurs with one intervention, continue that therapy and add the next rather than stopping and switching 5, 1.
• Multiple causes frequently coexist in chronic cough (up to 62% of cases), so complete resolution often requires addressing all contributing factors 1, 6.

What NOT to Do in Stable Chronic Bronchitis

The 2020 CHEST guidelines are explicit about the lack of evidence for pharmacologic treatment of stable chronic bronchitis:

• Do not routinely prescribe antibiotics, bronchodilators, or mucolytics specifically to relieve cough in stable chronic bronchitis, as there is insufficient evidence these treatments are safe and effective for cough relief 2.
• Do not use non-pharmacologic treatments such as positive end-expiratory pressure routinely for cough relief 2.

However, if the patient has COPD with chronic bronchitis, ensure they are on appropriate maintenance therapy with long-acting bronchodilators and inhaled corticosteroids as indicated for their underlying COPD, not specifically for cough 5.

Monitoring and Reassessment

Quantify Treatment Response

• Use validated cough-specific quality of life questionnaires or visual analog scales to formally assess treatment efficacy rather than relying solely on subjective reports 1.

Timeframe for Re-evaluation

• Reassess at 3-4 weeks after initiating each therapeutic intervention 5.
• If cough persists beyond 8 weeks of comprehensive treatment, consider referral to a specialist cough clinic 2, 1.

Red Flags Requiring Urgent Evaluation

• Hemoptysis 2, 5
• Significant breathlessness or hypoxemia 2
• Prolonged fever or constitutional symptoms 2
• Unintentional weight loss 5
• Abnormal chest radiograph 1, 6

Refractory Cases

Advanced Investigations

• High-resolution CT chest to evaluate for bronchiectasis, interstitial lung disease, or occult masses if empiric therapies fail 5, 1.
• Fibreoptic laryngoscopy for persistent upper airway symptoms despite treatment 1.
• Consider bronchoscopy to evaluate for endobronchial lesions, sarcoidosis, or eosinophilic bronchitis 5.

Specialist Referral

• Refer to a specialist cough clinic after thorough evaluation if cough remains unexplained, as treatment success is considerably higher in specialist settings than general respiratory clinics 2, 1.
• Consider idiopathic cough only after complete specialist assessment, not prematurely in primary care 1.

Common Pitfalls to Avoid

• Never continue ACE inhibitors in a patient with troublesome cough 1.
• Do not undertreat GERD—a full 3-month trial of intensive acid suppression is required before concluding it is not contributory 1.
• Do not diagnose idiopathic cough prematurely—ensure adequate treatment duration and specialist evaluation first 1.
• Do not stop the first effective therapy when adding a second—use additive sequential treatment 5, 1.
• Do not prescribe antibiotics for stable chronic bronchitis cough unless there is documented bacterial infection 2.