Management of Persistent Cough

Initial Assessment and Optimization

The American Thoracic Society recommends that complete resolution of cough may require up to 8 weeks of treatment with inhaled corticosteroids, even though partial improvement often occurs after 1 week 1, 2
Proper inhaler technique should be confirmed, as improper use is a common cause of treatment failure that must be excluded before escalating therapy 1, 2
Inhaled steroid-induced cough itself should be ruled out, as the aerosol constituents can paradoxically trigger cough 1, 2

The American College of Chest Physicians suggests that upper airway cough syndrome (UACS) should be addressed first, as it is one of the three most common causes of chronic cough 4, 5
A first-generation antihistamine/decongestant combination and intranasal corticosteroid spray may be prescribed to treat UACS 4, 5
If cough persists despite optimized UACS treatment, inhaled corticosteroid dose should be stepped up and a leukotriene inhibitor considered 3
The American Thoracic Society recommends assessing airway inflammation through induced sputum or bronchoalveolar lavage to identify persistent eosinophilia 1, 2

The American College of Chest Physicians suggests that central-acting antitussives may be considered when other measures fail 8, 4, 5
Inhaled ipratropium bromide may be added to attenuate post-infectious and chronic cough 8, 4, 5

The American Thoracic Society recommends not assuming treatment failure after only 1-2 weeks of inhaled corticosteroids, as complete cough resolution requires up to 8 weeks 1, 2
The American College of Chest Physicians suggests not diagnosing "unexplained cough" until completing systematic evaluation of UACS, asthma/NAEB, and GERD with adequate treatment trials of appropriate duration 4, 7