Upper airway cough syndrome
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
suspected upper airway cough syndrome (UACS)
empiric trial of therapy
Empiric therapy with a first-generation antihistamine (e.g., chlorpheniramine) plus a decongestant (e.g., pseudoephedrine) should be started when the etiology of cough is not apparent. Improvement or resolution of the cough in response to treatment is the pivotal factor in confirming a diagnosis of UACS.[1]American College of Chest Physicians. Diagnosis and Management of Cough. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Jan 2006 [internet publication]. https://www.chestnet.org/Guidelines/Clinical-Pulmonary
Open studies have shown therapeutic benefit with this combination regimen, and it is the recommended first-line treatment option.[1]American College of Chest Physicians. Diagnosis and Management of Cough. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Jan 2006 [internet publication]. https://www.chestnet.org/Guidelines/Clinical-Pulmonary
Approximately 60% of patients improved with this approach, and improvement is usually seen within 2 weeks.[1]American College of Chest Physicians. Diagnosis and Management of Cough. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Jan 2006 [internet publication]. https://www.chestnet.org/Guidelines/Clinical-Pulmonary [27]Pratter MR, Bartter T, Akers S, et al. An algorithmic approach to chronic cough. Ann Intern Med. 1993 Nov 15;119(10):977-83. http://www.ncbi.nlm.nih.gov/pubmed/8214994?tool=bestpractice.com Patients who have benefited from an empiric trial of this therapy should continue with it.
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]European Medicines Agency. Pseudoephedrine-containing medicinal products - referral. Jan 2024 [internet publication]. https://www.ema.europa.eu/en/medicines/human/referrals/pseudoephedrine-containing-medicinal-products
As sedation is a potential adverse effect of this regimen, it is recommended that treatment is commenced once daily in the evening prior to sleep for the first few days before increasing to the recommended dose.[1]American College of Chest Physicians. Diagnosis and Management of Cough. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Jan 2006 [internet publication]. https://www.chestnet.org/Guidelines/Clinical-Pulmonary
Primary options
chlorpheniramine: 4 mg orally (immediate-release) every 4-6 hours, maximum 24 mg/day
and
pseudoephedrine: 60 mg orally (immediate-release) every 4-6 hours, maximum 240 mg/day; 120 mg orally (extended-release) twice daily
trigger identification and avoidance
Treatment recommended for ALL patients in selected patient group
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]American College of Chest Physicians. Diagnosis and Management of Cough. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Jan 2006 [internet publication]. https://www.chestnet.org/Guidelines/Clinical-Pulmonary
avoidance of nasal decongestant overuse
Treatment recommended for SOME patients in selected patient group
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).
confirmed upper airway cough syndrome (UACS)
first-generation antihistamine + decongestant
Patients who have benefited from an empiric trial of this therapy should continue with it. Open studies have shown therapeutic benefit with this combination regimen, and it is the recommended first-line treatment option.[1]American College of Chest Physicians. Diagnosis and Management of Cough. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Jan 2006 [internet publication]. https://www.chestnet.org/Guidelines/Clinical-Pulmonary
Approximately 60% of patients improved with this approach, and improvement is usually seen within 2 weeks.[1]American College of Chest Physicians. Diagnosis and Management of Cough. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Jan 2006 [internet publication]. https://www.chestnet.org/Guidelines/Clinical-Pulmonary [27]Pratter MR, Bartter T, Akers S, et al. An algorithmic approach to chronic cough. Ann Intern Med. 1993 Nov 15;119(10):977-83. http://www.ncbi.nlm.nih.gov/pubmed/8214994?tool=bestpractice.com
As sedation is a potential adverse effect of this regimen, it is recommended that treatment is commenced once daily in the evening prior to sleep for the first few days before increasing to the recommended dose.[1]American College of Chest Physicians. Diagnosis and Management of Cough. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Jan 2006 [internet publication]. https://www.chestnet.org/Guidelines/Clinical-Pulmonary
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]European Medicines Agency. Pseudoephedrine-containing medicinal products - referral. Jan 2024 [internet publication]. https://www.ema.europa.eu/en/medicines/human/referrals/pseudoephedrine-containing-medicinal-products
Primary options
chlorpheniramine: 4 mg orally (immediate-release) every 4-6 hours, maximum 24 mg/day
and
pseudoephedrine: 60 mg orally (immediate-release) every 4-6 hours, maximum 240 mg/day; 120 mg orally (extended-release) twice daily
continued trigger avoidance
Treatment recommended for SOME patients in selected patient group
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]American College of Chest Physicians. Diagnosis and Management of Cough. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Jan 2006 [internet publication]. https://www.chestnet.org/Guidelines/Clinical-Pulmonary
avoidance of nasal decongestant overuse
Treatment recommended for SOME patients in selected patient group
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).
specialist management of structural upper airway abnormalities
Treatment recommended for SOME patients in selected patient group
Management of structural upper airway abnormalities should be guided by an ENT specialist. For example, significant nasal septal deviation may require surgical correction.
speech and language therapy
Treatment recommended for SOME patients in selected patient group
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]European Respiratory Society. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. 2020 [internet publication]. https://erj.ersjournals.com/content/55/1/1901136 [32]American College of Chest Physicians. Treatment of unexplained chronic cough: CHEST guideline and expert panel report. 2016 [internet publication]. https://www.chestnet.org/Guidelines/Clinical-Pulmonary [33]Vertigan AE, Theodoros DG, Gibson PG, et al. Efficacy of speech pathology management for chronic cough: a randomised placebo controlled trial of treatment efficacy. Thorax. 2006 Dec;61(12):1065-9. https://thorax.bmj.com/content/61/12/1065.long http://www.ncbi.nlm.nih.gov/pubmed/16844725?tool=bestpractice.com [34]Ryan NM, Vertigan AE, Bone S, et al. Cough reflex sensitivity improves with speech language pathology management of refractory chronic cough. Cough. 2010 Jul 28;6:5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921346 http://www.ncbi.nlm.nih.gov/pubmed/20663225?tool=bestpractice.com [35]Chamberlain S, Birring SS, Garrod R. Nonpharmacological interventions for refractory chronic cough patients: systematic review. Lung. 2014 Feb;192(1):75-85. http://www.ncbi.nlm.nih.gov/pubmed/24121952?tool=bestpractice.com
One randomized, placebo-controlled trial in patients with chronic cough demonstrated that 4 treatment sessions significantly improved cough and upper airway scores.[33]Vertigan AE, Theodoros DG, Gibson PG, et al. Efficacy of speech pathology management for chronic cough: a randomised placebo controlled trial of treatment efficacy. Thorax. 2006 Dec;61(12):1065-9. https://thorax.bmj.com/content/61/12/1065.long http://www.ncbi.nlm.nih.gov/pubmed/16844725?tool=bestpractice.com
Treatment modalities include educational information, strategies to reduce cough, improved laryngeal hygiene (e.g., increased hydration), and psychoeducational counseling.
intranasal corticosteroid, antihistamine, cromolyn, or leukotriene receptor antagonist
Treatment recommended for ALL patients in selected patient group
First-line treatments for rhinitis include intranasal corticosteroids (e.g., mometasone), antihistamines (e.g., azelastine), or cromolyn sodium.[1]American College of Chest Physicians. Diagnosis and Management of Cough. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Jan 2006 [internet publication]. https://www.chestnet.org/Guidelines/Clinical-Pulmonary
Leukotriene receptor antagonists (e.g., montelukast) also appear to improve symptoms in patients with allergic rhinitis.[1]American College of Chest Physicians. Diagnosis and Management of Cough. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Jan 2006 [internet publication]. https://www.chestnet.org/Guidelines/Clinical-Pulmonary 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]US Food & Drug Administration. FDA requires Boxed Warning about serious mental health side effects for asthma and allergy drug montelukast (Singulair); advises restricting use for allergic rhinitis. 4 March 2020 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-boxed-warning-about-serious-mental-health-side-effects-asthma-and-allergy-drug
Primary options
mometasone nasal: 100 micrograms (2 sprays) in each nostril once daily
OR
azelastine nasal: 137-274 micrograms (1-2 sprays) in each nostril twice daily
OR
cromolyn: 5.2 mg (1 spray) into both nostrils four to six times daily
Secondary options
montelukast: 10 mg orally once daily
antibiotic or antifungal
Treatment recommended for ALL patients in selected patient group
Excess sputum production may indicate bacterial or fungal sinusitis.
Common pathogens include Streptococcus pneumoniae and Haemophilus influenzae.
Appropriate antibiotic therapy (or antifungal therapy depending on the etiology) should be initiated after CT imaging and an ENT assessment if warranted.[29]Fokkens WJ, Lund VJ, Mullol J, et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology. 2012 Mar;50(1):1-12. http://www.ncbi.nlm.nih.gov/pubmed/22469599?tool=bestpractice.com
proton-pump inhibitor
Treatment recommended for ALL patients in selected patient group
Treatment of co-existing gastroesophageal 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]Pawar S, Lim HJ, Gill M, et al. Treatment of postnasal drip with proton pump inhibitors: a prospective, randomized, placebo-controlled study. Am J Rhinol. 2007 Nov-Dec;21(6):695-701. http://www.ncbi.nlm.nih.gov/pubmed/18201449?tool=bestpractice.com
Omeprazole or lansoprazole may also be used.
Primary options
rabeprazole: 20-40 mg/day orally
OR
omeprazole: 20-40 mg/day orally
OR
lansoprazole: 15-30 mg/day orally
sinus imaging
Treatment recommended for SOME patients in selected patient group
Patients who do not respond to targeted treatment with a first-generation antihistamine plus decongestant should undergo sinus imaging, as chronic sinusitis may be clinically silent.
If the diagnosis is confirmed, additional targeted treatment for chronic sinusitis is recommended (e.g., antibiotics, intranasal corticosteroids).
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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