Should Bilasure M Be Continued After Tracheostomy Decannulation in a Patient With Cough?
Discontinue Bilasure M (bilastine + montelukast) immediately, as this combination has no established role in managing post-decannulation cough and does not address the underlying causes of cough in this clinical context.
Understanding Post-Decannulation Cough
Post-tracheostomy decannulation cough is a distinct clinical entity that requires evaluation for specific etiologies rather than empiric antihistamine-leukotriene therapy:
Cough following decannulation typically results from tracheal irritation, retained secretions, upper airway inflammation, or aspiration—none of which respond to antihistamine or leukotriene receptor antagonist therapy. 1
The duration of cough determines the diagnostic approach: acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks), with post-decannulation cough usually falling into the acute or subacute category. 2
Why Bilasure M Is Not Indicated
Bilastine Component
Bilastine is a second-generation H1-antihistamine approved only for allergic rhinoconjunctivitis and urticaria—conditions unrelated to post-tracheostomy cough. 3, 4
No evidence supports antihistamine use for post-procedural airway cough, and the mechanism of post-decannulation cough does not involve histamine-mediated pathways. 1, 2
Montelukast Component
Montelukast is a leukotriene receptor antagonist indicated for asthma and allergic rhinitis, not for acute or subacute cough following airway procedures. 5
The fixed-dose combination of bilastine-montelukast has been studied only in allergic rhinitis and mild asthma—not in post-procedural or post-intubation cough. 6, 7, 5
Appropriate Management of Post-Decannulation Cough
Immediate Assessment
Obtain chest radiograph to exclude pneumonia, atelectasis, or aspiration, which are common complications after prolonged intubation and tracheostomy. 2
Perform spirometry if the patient can cooperate to assess for airflow obstruction or restrictive defects. 2
Evaluate for retained secretions and impaired cough clearance, particularly if the patient has neuromuscular weakness or bulbar dysfunction. 1
Targeted Interventions
Use manually assisted cough techniques and mechanical insufflation-exsufflation (MI-E) if peak cough flow is <270 L/min or maximal expiratory pressure is <60 cm H₂O, as impaired cough clearance is common after prolonged tracheostomy. 1
Consider inhaled ipratropium bromide (250-500 mcg four times daily) for post-infectious or post-procedural cough, as it has demonstrated benefit in reducing cough frequency in subacute cough. 1
If cough persists beyond 3 weeks with significant quality-of-life impact, consider a short course of oral corticosteroids (30-40 mg prednisone daily for 5-7 days) after excluding infection, as post-inflammatory airway hyperresponsiveness may contribute. 1
Red-Flag Symptoms Requiring Urgent Evaluation
Hemoptysis, fever, purulent sputum, or worsening dyspnea mandate immediate investigation for pneumonia, tracheal stenosis, or tracheoesophageal fistula. 1, 2
Stridor or progressive dyspnea may indicate tracheal stenosis or granulation tissue requiring bronchoscopy. 1
Common Pitfalls to Avoid
Do not continue medications prescribed for allergic conditions when the clinical context is post-procedural airway management—this represents inappropriate polypharmacy. 2
Do not assume cough is "allergic" without objective evidence (elevated IgE, eosinophilia, or clear temporal relationship to allergen exposure). 5
Do not delay evaluation for serious complications (aspiration, stenosis, infection) by empirically treating with antihistamines or leukotriene antagonists. 1, 2