The most appropriate management of this patient with chronic cough is an empiric trial of a proton pump inhibitor. In general, an algorithmic approach to chronic cough (cough of greater than 8 weeks' duration) leads to successful outcomes in more than 90% of patients. Patients with chronic cough, especially smokers, should undergo chest radiography. If the chest radiograph does not reveal a potential cause of cough, the physician should consider upper airway cough syndrome, asthma, nonasthmatic eosinophilic bronchitis, and gastroesophageal reflux disease (GERD) and begin a stepwise approach for evaluation and treatment. The definitive diagnosis may be suggested by history and physical examination findings and confirmed by successful empiric treatment. This obese patient with a 15-pack-year history has chronic cough and symptoms typical of GERD (heartburn, cough that is worsened after a large meal). Additionally, his tobacco use, alcohol use, and caffeine intake are risk factors for GERD. Initiating a proton pump inhibitor such as omeprazole is the next most appropriate step and can be started without 24-hour esophageal pH monitoring. All patients with chronic cough who smoke should also receive tobacco cessation counseling.

A combination antihistamine and decongestant is helpful in patients with cough due to upper airway cough syndrome; however, this patient does not present with symptoms or signs of upper airway cough syndrome (allergic symptoms or postnasal drip).

In the presence of a normal chest radiograph, bronchoscopy is unlikely to be of benefit and should be reserved for second-line testing if the patient's symptoms fail to improve after several months of optimized therapy with a proton pump inhibitor.

Echocardiography is helpful in evaluating left ventricular function or valvular heart disease as a cause of cough; however, in the absence of symptoms (shortness of breath, paroxysmal nocturnal dyspnea) or physical examination findings (crackles, S₃, edema, murmur), an echocardiogram is unnecessary and represents low value care.