Combatting the cough that won’t quit
By the time patients come to see you, they’ve often tried a host of OTC remedies. This review and handy algorithm will help you detect and treat the cause of persistent cough without delay.
Patients with NAEB respond well to inhaled corticosteroids, and budesonide 400 mcg twice a day or prednisolone 30 mg daily may be prescribed. It is also important to remove airway irritants. Long-term follow-up studies of patients with NAEB have had conflicting results. One study found that most cases resolve completely;23 another showed a need for long-term treatment, and suggested that patients with NAEB may be at increased risk for asthma and chronic obstructive pulmonary disease. 25
Paroxysmal cough, whoops point to pertussis
When a patient has paroxysms of cough, posttussive vomiting, and/or an inspiratory whooping sound, B pertussis infection is the likely culprit.26-28 A definitive diagnosis of pertussis, or whooping cough, may be based on a positive culture from a nasopharyngeal aspirate swab.29 Suspected cases can be confirmed with a polymerase chain reaction test, and a presumptive diagnosis may be made as a result of a 4-fold increase in immunoglobulin G or immunoglobulin A antibodies for B pertussis.4
A macrolide antibiotic, usually azithromycin, is the standard treatment for pertussis.30-32 Patients should be isolated for 5 days from the start of treatment. Antibiotic therapy will reduce the risk of transmission, but will not affect the duration of the cough, which may be 6 to 8 weeks. Long-acting beta-agonists, antihistamines, and corticosteroids should not be used to treat pertussis.4
CASE After a 2-week course of omeprazole 20 mg daily, Margaret was coughing much less. We extended the prescription, and by the end of the next 4 weeks, she was no longer coughing. After 2 months, both the PPI and the antihistamine/decongestant were discontinued. We advised her to institute antireflux measures, such as elevating her head at night and not eating after 6 pm, and she has not had a relapse.
CORRESPONDENCE Rebecca H. Gladu, MD, FAAFP, San Jacinto Methodist Hospital, 4401 Garth Road, Baytown, TX 77521; Rgladu@tmhs.org
