Treatment algorithm

Your Organizational Guidance

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Aanhoudende hoest bij kinderen in de eerste lijnPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2017La toux prolongée chez l’enfant en première ligne de soinsPublished by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2017

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

INITIAL

suspected upper airway cough syndrome (UACS)

1st line – empiric trial of therapy

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INITIAL
|
suspected upper airway cough syndrome (UACS)
1st line – 

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]​​​

Open studies have shown therapeutic benefit with this combination regimen, and it is the recommended first-line treatment option.[1]​​​

In a prospective trial of antihistamine plus decongestant therapy in 45 patients, 55% of patients showed at least marked improvement after one week, and improvement is usually seen within 2 weeks.[1]​​​[46]​​ 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.[48]

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]​​​

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

Plus – trigger identification and avoidance

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INITIAL
|
suspected upper airway cough syndrome (UACS)
Plus – 

trigger identification and avoidance

Treatment recommended for ALL patients in selected patient group

Establishing and avoiding the trigger 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.

In addition to avoiding exposure, avoidance strategies include improving ventilation, filters, and personal protective devices (e.g., masks).[1]​​​

Consider – avoidance of nasal decongestant overuse

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INITIAL
|
suspected upper airway cough syndrome (UACS)
Consider – 

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).

ACUTE

confirmed upper airway cough syndrome (UACS)

1st line – first-generation antihistamine + decongestant

Back
ACUTE
|
confirmed upper airway cough syndrome (UACS)
1st line – 

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]​​​

In a prospective trial of antihistamine plus decongestant therapy in 45 patients, 55% of patients showed at least marked improvement after 1 week, and improvement is usually seen within 2 weeks.[1]​​​[46]​​

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]​​​

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 with chronic or severe acute kidney disease.[48]

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

Consider – continued trigger avoidance

Back
ACUTE
|
confirmed upper airway cough syndrome (UACS)
Consider – 

continued trigger avoidance

Treatment recommended for SOME patients in selected patient group

Establishing and avoiding the trigger 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.

In addition to avoiding exposure, avoidance strategies include improving ventilation, filters, and personal protective devices (e.g., masks).[1]​​​

Consider – avoidance of nasal decongestant overuse

Back
ACUTE
|
confirmed upper airway cough syndrome (UACS)
Consider – 

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).

Consider – specialist management of structural upper airway abnormalities

Back
ACUTE
|
confirmed upper airway cough syndrome (UACS)
Consider – 

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.

Consider – speech and language therapy

Back
ACUTE
|
confirmed upper airway cough syndrome (UACS)
Consider – 

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.[3][52]​​​​[53][54][55]

One randomized, placebo-controlled trial in patients with chronic cough demonstrated that 4 treatment sessions significantly improved cough and upper airway scores.[53]

Treatment modalities include educational information, strategies to reduce cough, improved laryngeal hygiene (e.g., increased hydration), and psychoeducational counseling.

Plus – intranasal corticosteroid, antihistamine, cromolyn, or leukotriene receptor antagonist

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ACUTE
|
confirmed upper airway cough syndrome (UACS)
|
with coexisting rhinitis
Plus – 

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]​​​

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 drugs.[50]

See Non-allergic rhinitis and Allergic rhinitis.

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

Plus – intranasal corticosteroid

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ACUTE
|
confirmed upper airway cough syndrome (UACS)
|
with coexisting chronic rhinosinusitis with nasal polyps
Plus – 

intranasal corticosteroid

Treatment recommended for ALL patients in selected patient group

Intranasal corticosteroids (e.g., mometasone) are the first-line treatment for patients with chronic rhinosinusitis with nasal polyps. They are well tolerated and effectively reduce nasal polyp size, reduce symptoms and improve quality of life.[56]

See Nasal polyps.

Primary options

mometasone nasal: 100 micrograms (2 sprays) in each nostril once or twice daily

Plus – antibiotic or antifungal

Back
ACUTE
|
confirmed upper airway cough syndrome (UACS)
|
with coexisting infective rhinosinusitis
Plus – 

antibiotic or antifungal

Treatment recommended for ALL patients in selected patient group

Excess sputum production may indicate bacterial or fungal rhinosinusitis.

Common pathogens include Streptococcus pneumoniae and Haemophilus influenzae. 

Appropriate antibiotic therapy (or antifungal therapy depending on the etiology) may be initiated after CT imaging with microbiological testing and an ENT assessment if warranted.[49]

See Acute rhinosinusitis.

Plus – proton-pump inhibitor

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ACUTE
|
confirmed upper airway cough syndrome (UACS)
|
with coexisting gastroesophageal reflux
Plus – 

proton-pump inhibitor

Treatment recommended for ALL patients in selected patient group

Treatment of coexisting gastroesophageal reflux is an important consideration.

One randomized, placebo-controlled study found that treatment with a proton-pump inhibitor (rabeprazole) for 90 days resulted in a significantly greater reduction in UACS symptom frequency and chronic cough compared with placebo.[51]

Omeprazole or lansoprazole may also be used.

See Gastroesophageal reflux disease.

Primary options

rabeprazole: 20-40 mg/day orally

OR

omeprazole: 20-40 mg/day orally

OR

lansoprazole: 15-30 mg/day orally

Consider – sinus imaging

Back
ACUTE
|
confirmed upper airway cough syndrome (UACS)
|
with no response to targeted treatment
Consider – 

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 rhinosinusitis may be clinically silent.

If the diagnosis is confirmed, additional targeted treatment for chronic rhinosinusitis is recommended (e.g., antibiotics, intranasal corticosteroids).

See Chronic rhinosinusitis without nasal polyps.

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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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