What is the recommended medical management for Upper Airway Cough Syndrome (UACS)?

Medical Management for Upper Airway Cough Syndrome (UACS)

Start immediately with a first-generation antihistamine/decongestant combination (e.g., dexbrompheniramine 6 mg + sustained-release pseudoephedrine 120 mg twice daily) as the most effective evidence-based first-line treatment for UACS. 1

First-Line Treatment Algorithm

Initial Empiric Therapy

• Prescribe a first-generation antihistamine/decongestant combination as the cornerstone of UACS treatment, with specific effective regimens including dexbrompheniramine 6 mg + pseudoephedrine 120 mg (sustained-release) twice daily, azatadine 1 mg + pseudoephedrine 120 mg (sustained-release) twice daily, or brompheniramine 12 mg twice daily. 1, 2

• First-generation antihistamines work primarily through their anticholinergic properties, not their antihistamine effects, which is why they are superior to newer agents for UACS. 1, 2

• Never use second-generation antihistamines (loratadine, fexofenadine, cetirizine) for UACS—they are completely ineffective because they lack anticholinergic activity and have been proven ineffective in clinical trials. 3, 1, 2

• Most patients will see improvement within days to 2 weeks of initiating therapy. 1

Minimizing Side Effects

• To reduce sedation from first-generation antihistamines, start with once-daily dosing at bedtime for a few days before increasing to twice-daily therapy. 1

• Monitor for common side effects including dry mouth and transient dizziness, as well as more serious effects such as insomnia, urinary retention, jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients. 1

• Check blood pressure after initiating decongestant therapy, as decongestants can worsen hypertension and cause tachycardia. 1

Treatment Based on Underlying Etiology

For Allergic Rhinitis-Related UACS

• Add intranasal corticosteroids immediately alongside the antihistamine/decongestant combination for confirmed allergic rhinitis, using fluticasone 100-200 mcg daily for a 1-month trial. 1, 4

• Intranasal corticosteroids are the most effective monotherapy for allergic rhinitis and work synergistically with antihistamines. 1, 4

• For moderate-to-severe allergic rhinitis, the combination of intranasal fluticasone plus intranasal azelastine provides 40% superior symptom reduction compared to either agent alone. 4

• Oral leukotriene inhibitors (e.g., montelukast 10 mg daily) may be added to decrease symptoms of allergic rhinitis, though they are less effective than intranasal corticosteroids. 1, 4

For Non-Allergic Rhinitis-Related UACS

• First-line therapy is the older-generation antihistamine plus decongestant combination alone—do not add intranasal corticosteroids initially. 1

• If patients don't respond to antihistamine/decongestant combinations or have contraindications (e.g., uncontrolled hypertension, cardiovascular disease), use ipratropium bromide nasal spray (42 mcg per spray, 2 sprays per nostril 4 times daily) as an alternative, which provides anticholinergic drying effects without systemic cardiovascular side effects. 1

For Chronic Sinusitis-Related UACS

• Chronic sinusitis may cause a productive cough but can also be "clinically silent" with a relatively or completely nonproductive cough. 3, 1

• If the patient has purulent nasal discharge, facial pain, or symptoms persisting beyond 10 days, consider bacterial sinusitis and prescribe antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae for a minimum of 3 weeks. 1

• Add intranasal corticosteroids to decrease inflammation and continue for 3 months after cough resolution as maintenance therapy. 4

Adjunctive Therapies

Nasal Saline Irrigation

• Recommend high-volume saline nasal irrigation (150 mL) to mechanically remove mucus, enhance ciliary activity, and disrupt inflammatory mediators—this is more effective than saline spray because irrigation better expels secretions. 1

• Longer treatment duration (mean 7.5 months) shows better results than shorter courses. 1

Topical Nasal Decongestants (Short-Term Only)

• Never use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 consecutive days due to the risk of rhinitis medicamentosa (rebound congestion). 1

When Initial Treatment Fails

After 1-2 Weeks Without Response

• If cough persists after 1-2 weeks of adequate antihistamine/decongestant therapy, obtain sinus imaging (CT scan) to evaluate for chronic sinusitis. 3, 1, 2

• Air-fluid levels on imaging indicate acute bacterial sinusitis requiring antibiotics. 1

After 2 Weeks Without Response

• Proceed with sequential evaluation for other common causes of chronic cough, specifically asthma/non-asthmatic eosinophilic bronchitis (NAEB) and gastroesophageal reflux disease (GERD), as these conditions frequently coexist with UACS. 3, 1

• UACS, asthma, and GERD together account for approximately 90% of chronic cough cases in nonsmokers with normal chest radiographs who are not taking ACE inhibitors. 3, 1, 5

Evaluating for Asthma/NAEB

• Perform bronchoprovocation testing (methacholine challenge) if spirometry is normal, or initiate an empiric trial of inhaled corticosteroids plus bronchodilators if testing is unavailable. 1, 2

Evaluating for GERD

• Initiate empiric proton pump inhibitor therapy (omeprazole 20-40 mg twice daily before meals) for at least 8 weeks plus dietary modifications if the clinical profile suggests GERD. 1

• Improvement in cough from GERD treatment may take up to 3 months. 1

• GERD frequently mimics UACS with upper respiratory symptoms and can coexist with true postnasal drip. 1

Critical Diagnostic Considerations

"Silent" UACS

• Approximately 20% of patients have "silent" postnasal drip with no obvious symptoms (no visible drainage, throat clearing, or pharyngeal cobblestoning) yet still respond to UACS-directed treatment. 1, 2

• The absence of typical findings does not rule out UACS—always give an empiric trial of first-generation antihistamine/decongestant therapy before looking for less common causes of chronic cough. 1

Confirming the Diagnosis

• The diagnosis of UACS is confirmed by response to specific therapy, not by symptoms or physical findings alone. 3, 1, 2

• Symptoms and clinical findings (cobblestoning, visible mucus) are not reliable discriminators for establishing UACS as the cause of cough. 1

• Do not rely on cough characteristics (productive vs. non-productive, timing, or quality) to differentiate UACS from other causes—these features are unreliable. 3, 2

Common Pitfalls to Avoid

• Do not use second-generation antihistamines for UACS—they are ineffective for non-allergic causes of postnasal drip cough. 3, 1, 2

• Do not prescribe antibiotics during the first week of symptoms, even with purulent discharge and sinus imaging abnormalities, as these findings are indistinguishable from viral rhinosinusitis. 3, 1

• Do not discontinue partially effective treatments prematurely—maintain all therapies that provide some benefit, as multiple causes of chronic cough frequently coexist. 1

• Do not overlook "silent" UACS as a potential cause of chronic cough before investigating less common etiologies. 1

• Do not confuse GERD with UACS—both conditions can coexist and produce similar pharyngeal irritation and throat symptoms. 1

• Do not use intranasal corticosteroids as monotherapy initially for non-allergic UACS—they should follow or accompany combination therapy with antihistamine/decongestant. 4

Long-Term Management

• For chronic rhinitis conditions, longer treatment courses may be necessary beyond the initial 1-2 week trial. 1

• Once cough resolves with treatment for chronic sinusitis-related UACS, continue intranasal corticosteroids for 3 months to maintain symptom control and prevent recurrence. 4

• Complete resolution of UACS may take several weeks to a few months. 1