Emetic cough in adults

Specialty: Respiratory.

• cough that causes vomiting
• posttussive emesis in adults

Why it occurs

• Whooping cough in adults (infection with Bordetella pertussis, characterized by paroxysms of extreme dry cough that end with a deep inspiration or "rooster" and reactive vomiting due to stimulation of the gag reflex)
• Severe gastroesophageal reflux (GER) with microaspirations (irritant cough stimulates the lower esophageal sphincter, facilitating regurgitation and vomiting, establishing a vicious cycle of laryngopharyngeal irritation)
• Reacerbated chronic bronchitis with retention of very thick mucus plugs in the hypopharynx (persistent cough attempts to mobilize mucus, mechanically stimulating the pharyngeal vomit reflex receptors)
• Severe chronic postnasal drip due to purulent or allergic rhinosinusitis (the mucus accumulated on the posterior wall of the pharynx triggers an irritative cough predominantly at night that induces vomiting upon awakening)

Initial workup

Determination of IgM/IgG antibodies or PCR for Bordetella pertussis in nasopharyngeal swab; 24-hour esophageal pH-metry with impedanciometry (for GER); Computed tomography (CT) of paranasal sinuses; Upper gastrointestinal endoscopy (to rule out esophagitis or hiatal hernia that facilitates reflux); Spirometry with bronchodilator test.

Standard management

• Azithromycin — 500 mg orally on the first day, followed by 250 mg once daily for 4 more days to eradicate Bordetella pertussis and reduce transmission
• Omeprazole — 20-40 mg orally every 12 hours if severe esophageal reflux is confirmed
• Metoclopramide (10 mg orally or intravenously every 8 hours as a prokinetic to accelerate gastric emptying and raise the tone of the lower esophageal sphincter).