How should I evaluate and manage a 60-year-old woman with an 18-month daily productive cough of thick pale‑yellow sputum, no fever, no upper‑respiratory infection symptoms, negative tuberculosis test, and no smoking history?

Evaluation and Management of Chronic Productive Cough in a 60-Year-Old Non-Smoker

Order a chest radiograph and spirometry immediately, then proceed with high-resolution CT of the chest to evaluate for bronchiectasis, which is the most likely diagnosis given the 18-month history of daily thick pale-yellow sputum production in a healthy non-smoking woman. 1, 2

Initial Mandatory Investigations

• Obtain a chest radiograph to exclude mass lesions, infiltrates, bronchiectasis, interstitial lung disease, and cardiac abnormalities in any adult with chronic cough lasting > 8 weeks. 1, 2

• Perform spirometry with bronchodilator testing to detect airflow obstruction and assess reversibility; this is non-negotiable baseline testing for chronic cough. 1, 2

• Quantify cough severity using visual-analog scales or validated quality-of-life questionnaires to objectively monitor treatment response. 1, 2

Medication and Exposure Review

• Review all current medications and discontinue any ACE-inhibitor, as drug-induced cough typically resolves within a median of 26 days after cessation. 2

• Verify smoking status and environmental exposures; although this patient is a non-smoker with no exposure history, systematic assessment for occupational or environmental irritants remains essential. 1, 2

Most Likely Diagnosis: Bronchiectasis

The 18-month history of daily thick pale-yellow to white sputum production in an otherwise healthy non-smoking woman strongly suggests bronchiectasis as the primary diagnosis. 2, 3

• Bronchiectasis is characterized by persistent mucopurulent sputum production and should be evaluated regardless of overt risk factors when this clinical pattern is present. 2

• High-resolution CT (HRCT) of the chest is the definitive diagnostic test for bronchiectasis and should be obtained when chest radiograph and empiric therapies fail to identify the cause of chronic productive cough. 1, 2

• If HRCT confirms bronchiectasis, refer to pulmonology for airway-clearance training, consider long-term macrolide therapy, and obtain regular sputum cultures. 2

Alternative Diagnoses to Consider

Upper Airway Cough Syndrome (UACS)

• UACS accounts for 18.6%–81.8% of chronic cough cases and can present as "silent post-nasal drip syndrome" where cough is the only symptom despite absence of overt nasal complaints. 2, 4

• Chronic rhinosinusitis is a very common cause of chronic productive cough in young adults, accounting for 27%–41% of cases in some series, and is more frequent in females. 5

• Initiate empiric therapy with a first-generation antihistamine-decongestant combination (e.g., brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine) plus an intranasal corticosteroid spray (fluticasone or mometasone), with improvement typically seen within days to 1–2 weeks. 2, 4

Asthma (Including Cough-Variant Asthma)

• Asthma accounts for 14.6%–41.3% of chronic cough and may present with cough as the sole manifestation without wheezing or dyspnea. 2

• Normal spirometry does not exclude asthma-related cough; methacholine bronchial provocation testing is indicated when spirometry is normal but clinical suspicion remains. 2

• Initiate inhaled corticosteroids (fluticasone 220 µg or budesonide 360 µg twice daily) according to national asthma guidelines; complete resolution may require up to 8 weeks. 2, 4

• A 2-week trial of oral prednisone (30–40 mg daily) can differentiate eosinophilic airway inflammation; lack of improvement makes an eosinophilic mechanism unlikely. 2

Gastroesophageal Reflux Disease (GERD)

• GERD contributes to 4.6%–85.4% of chronic cough and often occurs without gastrointestinal symptoms; cough can be the exclusive clinical feature of "silent GERD." 2, 4

• Initiate intensive acid suppression with omeprazole 20–40 mg twice daily before meals for ≥ 8 weeks, combined with dietary and lifestyle modifications. 2, 4

• Clinical response may require 2 weeks to 12 weeks, and prokinetic agents (metoclopramide 10 mg three times daily) may be added if response is inadequate. 1, 2

Non-Asthmatic Eosinophilic Bronchitis (NAEB)

• NAEB accounts for 6.4%–17.2% of chronic cough cases and is characterized by eosinophilic airway inflammation without airway hyper-responsiveness or variable airflow obstruction. 2, 4

• Induced sputum analysis with eosinophil count > 3% helps differentiate eosinophilic causes (asthma or NAEB) from non-eosinophilic etiologies. 4

• Inhaled corticosteroids are effective in reducing cough severity in NAEB. 2

Systematic Empiric Treatment Algorithm

Up to 67% of chronic cough patients have multiple simultaneous causes, necessitating combination therapy rather than sequential monotherapy. 2

Step 1: UACS Treatment (Days to 1–2 Weeks)

• Start first-generation antihistamine-decongestant combination plus intranasal corticosteroid spray. 2, 4

Step 2: Asthma Treatment (Up to 8 Weeks)

• If UACS treatment fails, perform bronchoprovocation testing or initiate empiric trial of inhaled corticosteroids and beta-agonists. 2, 4

Step 3: GERD Treatment (2 Weeks to Several Months)

• Initiate high-dose PPI therapy with dietary modifications if asthma treatment is inadequate. 2, 4

Step 4: Advanced Imaging

• If all empiric therapies fail after 8 weeks, obtain HRCT to evaluate for bronchiectasis, interstitial lung disease, or occult masses. 1, 2

• Consider bronchoscopy to evaluate for endobronchial lesions, sarcoidosis, eosinophilic bronchitis, or occult infection if complete workup fails. 1, 2

Red-Flag Features Requiring Urgent Evaluation

• Hemoptysis, unintentional weight loss, fever, night sweats, or recurrent pneumonia mandate urgent investigation for malignancy, tuberculosis, or serious infection. 2

• Finger clubbing together with productive cough should prompt evaluation for bronchiectasis, interstitial lung disease, or malignancy. 2

Common Pitfalls to Avoid

• Failing to consider bronchiectasis in patients with persistent mucopurulent sputum, even without overt risk factors, is a frequent diagnostic error. 2, 3

• Assuming a single etiology when up to 67% of chronic cough patients have multiple concurrent causes; retain partially effective therapies and employ additive treatment strategies. 2

• Inadequate trial duration—empiric therapeutic trials should be maintained for 4–6 weeks before deeming them ineffective. 2

• Antibiotics have no role in chronic productive cough unless there is documented acute bacterial infection (e.g., acute sinusitis, pertussis, or pneumonia). 2, 4

Follow-Up and Outcome Measurement

• Schedule a follow-up visit within 4–6 weeks to reassess cough severity using validated scales and verify treatment adherence before abandoning a therapeutic trial. 2

• Formal quantification of treatment response using validated cough-severity instruments is recommended. 1, 2

• Referral to a specialist cough clinic is appropriate when the condition remains undiagnosed after systematic evaluation of UACS, asthma, eosinophilic bronchitis, and GERD. 2