MKSAP Quiz: daily cough without specific triggers
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A 52-year-old man is evaluated for a daily cough for the past 6 months. It occurs throughout the day and occasionally at night, but he does not notice any specific triggers. There is occasional production of small amounts of white sputum but no hemoptysis. He does not have any known allergies, has no new pets or exposures, and does not smoke. He does have nasal discharge. He has not noticed any wheezing and has no history of asthma. He has no symptoms of heartburn. He has had no fever, weight loss, or foreign travel, and takes no medications.
Vital signs are normal. There is no cobblestone appearance of the oropharyngeal mucosa or mucus dripping down the oropharynx. Lungs are clear to auscultation. A chest radiograph is normal.
Which of the following is the most appropriate management for this patient?
A. Antihistamine/decongestant combination
B. CT scan of chest
C. Inhaled fluticasone
D. Proton-pump inhibitor
E. Pulmonary function testing
MKSAP Answer and Critique
The correct answer is A) Antihistamine/decongestant combination. This item is available to MKSAP 15 subscribers as item 9 in the General Internal Medicine section.
The most appropriate treatment for this patient is a trial of an antihistamine/decongestant combination. The initial approach in patients with chronic cough (>8 weeks in duration) is to conduct a history and physical examination looking for identifiable causes, determine whether the patient is taking an angiotensin-converting enzyme (ACE) inhibitor, and obtain a chest radiograph. In the population of patients who do not smoke, do not take an ACE inhibitor, and have a normal chest radiograph, upper airway cough syndrome (UACS) (previously termed postnasal drip), asthma, and gastroesophageal reflux disease (GERD) are responsible for approximately 99% of cases of chronic cough. When the etiology of a chronic cough is unclear, the American College of Chest Physicians recommends initial treatment with a first-generation antihistamine/decongestant combination to treat UACS. This is true even in the absence of evidence of a postnasal drip. The diagnosis of chronic cough is often based upon the patient's response to empiric therapy, and it may take weeks or even months for the cough to resolve with appropriate therapy.
In a nonsmoking patient with a normal chest radiograph and no systemic symptoms, CT scan of the chest is not indicated.
Asthma is a common cause for a chronic cough and may present only with a cough (cough-variant asthma). However, pursuing pulmonary function testing or initiating empiric β-agonist therapy for asthma is premature unless the patient fails to respond to empiric treatment of UACS.
In the absence of GERD symptoms, proton-pump inhibitors should be reserved for patients with chronic cough who have a normal chest radiograph, are not taking an ACE inhibitor, do not smoke, and have failed to improve with treatment for UACS, asthma, and nonallergic eosinophilic bronchitis.
Key Point
- Empiric treatment of chronic cough in a nonsmoking patient not taking an angiotensin-converting enzyme inhibitor who has a normal chest radiograph begins with treatment for upper airway cough syndrome.