Approach

There are few well-conducted studies validating the best approach to the treatment of upper airway cough syndrome (UACS).The difficulties and uncertainties surrounding the definition of UACS and a lack of stringent diagnostic criteria underpin the current inability to recommend an optimum, stepwise approach to management.[3][13]

The American College of Chest Physicians (ACCP) recommendations are based almost entirely on expert opinion or a sparse evidence base.[1]​ Despite this, a stepwise approach to management with an emphasis on the avoidance of triggers and targeted treatment for co-existing nasal conditions is logical.[1]​​[10]

Approach to management

The ACCP guideline classifies treatment options into the following categories:[1]​​

  • Avoidance

  • Treatment to block or reduce inflammation and secretions

  • Treatment of infection

  • Correction of structural alterations.

In patients in whom the etiology of cough is apparent, specific therapy directed at this condition should be started. When the etiology of cough is not apparent, empiric therapy with a first-generation antihistamine plus a decongestant should be started. Improvement or resolution of the cough in response to treatment is the pivotal factor in confirming a diagnosis of UACS.[1]​​

Avoidance

Establishing the trigger and avoiding it is desirable but not always possible. In patients with an allergic or environmental trigger, initiating an appropriate avoidance strategy is important. This can be difficult, as many people with rhinitis are sensitized to a perennial allergen. Avoidance strategies include avoiding exposure, improved ventilation, filters, and personal protective devices (e.g., masks).[1]​ The role of allergen desensitization in this context is yet to be determined.

If rhinitis medicamentosa is suspected, it is important to discourage continuous use of topical nasal decongestants. If they have been used for some time, patients should gradually wean themselves off them (e.g., one nostril at a time).

Treatment to block or reduce inflammation and secretions

While there are no well-conducted, randomized, double-blind, placebo-controlled trials of treatment in UACS, open studies have shown therapeutic benefit with a combination of a first-generation antihistamine (e.g., chlorpheniramine) plus a decongestant (e.g., pseudoephedrine).[1]​ The combination of the two drugs is the recommended first-line treatment option.[1]​ Approximately 60% of patients improved with this approach.[27] Improvement in cough is usually seen within 2 weeks of starting therapy.[1]​ Patients who have benefited from an empiric trial of this therapy should continue with it.

While the mechanism of action in UACS is unclear, it is thought that the therapeutic effect of the antihistamine is the consequence of a central antitussive effect.[3] It should be noted that nonsedating, second-generation antihistamines appear to be less effective than first-generation antihistamines for the treatment of UACS, particularly in the context of co-existing nonallergic rhinitis or sinusitis.[1]​​

Pseudoephedrine is associated with risks of posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS); it should be avoided in patients with severe or uncontrolled hypertension or chronic or severe acute kidney disease.[28]

Patients who do not respond to targeted treatment should undergo sinus imaging, as chronic sinusitis may be clinically silent. If diagnosis is confirmed, additional targeted treatment for chronic sinusitis is recommended (e.g., antibiotics, intranasal corticosteroids).

Treatment of infection

Excess sputum production may indicate bacterial or fungal sinusitis. Common pathogens include Streptococcus pneumoniae and Haemophilus influenzae. Antibiotic therapy (or antifungal therapy depending on the etiology) should be initiated after CT imaging and an ENT assessment if warranted.[29]

Correction of structural alterations

Management of structural upper airway abnormalities should be guided by an ENT specialist. For example, significant nasal septal deviation may require surgical correction.

Treatment of co-existing conditions

Rhinitis

  • Co-existing nasal conditions should be treated[22][29]

  • First-line treatments for rhinitis include intranasal corticosteroids (e.g., mometasone), antihistamines (azelastine), or cromolyn sodium[1]​​

  • Leukotriene receptor antagonists (e.g., montelukast) also appear to improve symptoms in patients with allergic rhinitis.[1]​ The Food and Drug Administration (FDA) has strengthened its warnings for montelukast about the risk of serious behavior and mood-related changes. For allergic rhinitis, the FDA has determined that montelukast should be reserved for those who are not treated effectively with or cannot tolerate other allergy medicines.[30]

Gastroesophageal reflux

  • Treatment of co-existing reflux is an important consideration

  • One study found that treatment with a proton-pump inhibitor (rabeprazole) for 90 days reduced rhinitis symptom scores and chronic cough.[31] Omeprazole or lansoprazole may also be used.

Other therapies

There is some evidence for the use of nonpharmacologic interventions such as speech and language therapy in the management of chronic cough with upper airway features.[26][32]​​​​[33][34][35]​​ One randomized, placebo-controlled trial in patients with chronic cough demonstrated that 4 treatment sessions significantly improved cough and upper airway scores.[33] Treatment modalities included educational information, strategies to reduce cough, improved laryngeal hygiene (e.g., increased hydration), and psychoeducational counseling.

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