What additional treatments can be used for a patient with a refractory cough secondary to an infective exacerbation of Obstructive Airway Disease (OAD), who is already on a mucolytic and an antihistamine?

From the Guidelines

For a patient with refractory cough due to an infective exacerbation of Obstructive Airway Disease who is already on a mucolytic and antihistamine, the most effective additional treatment option is to add a short-acting beta-agonist such as albuterol (2 puffs every 4-6 hours as needed) to help with bronchodilation and symptom relief, as recommended by the 2017 Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease report 1.

Additional Treatment Options

Other treatment options that can be considered include:

• Short-term oral corticosteroids such as prednisone 40mg daily for 5-7 days to reduce airway inflammation, as suggested by the BTS guidelines for the management of chronic obstructive pulmonary disease 1
• Inhaled corticosteroids like fluticasone (250-500mcg twice daily) or budesonide (200-400mcg twice daily) for more targeted anti-inflammatory effects, as recommended by the 2017 GOLD executive summary 1
• Long-acting bronchodilators like tiotropium (18mcg once daily) or salmeterol (50mcg twice daily) for more persistent symptoms, as suggested by the European Respiratory Journal review of national guidelines for management of COPD in Europe 1
• Codeine-based cough suppressants (15-30mg every 4-6 hours) or dextromethorphan (15-30mg every 6-8 hours) to directly suppress the cough reflex when the cough is non-productive and disruptive to sleep or daily activities
• Nebulized saline treatments to loosen secretions, and chest physiotherapy techniques to assist with clearing airways, as recommended by the 2017 GOLD executive summary 1

Rationale

These treatments work by addressing different aspects of the pathophysiology: reducing inflammation, improving bronchodilation, suppressing the cough reflex, or enhancing mucus clearance, which together can help manage the persistent cough that hasn't responded to initial therapy. The choice of treatment should be based on the individual patient's needs and response to therapy, as well as the severity of their symptoms and the presence of any comorbidities.

Key Considerations

It is essential to note that the treatment of COPD exacerbations should be tailored to the individual patient's needs, and the goal of treatment is to minimize the negative impact of the current exacerbation and to prevent subsequent events 1. The use of systemic corticosteroids, antibiotics, and non-invasive ventilation (NIV) should be considered on a case-by-case basis, as recommended by the 2017 GOLD executive summary 1.

From the FDA Drug Label

The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute bacterial exacerbations of chronic obstructive pulmonary disease is not specified, however for Acute bacterial exacerbations of chronic obstructive pulmonary disease (mild to moderate) in adults, the dose is 500 mg QD × 3 days OR 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5 2

For a patient with a refractory cough secondary to an infective exacerbation of Obstructive Airway Disease (OAD) who is already on a mucolytic and an antihistamine, azithromycin can be considered as an additional treatment option, given its indication for acute bacterial exacerbations of chronic obstructive pulmonary disease.

Prednisone, a corticosteroid, may also be considered for its anti-inflammatory properties in reducing airway inflammation associated with OAD exacerbations 3.

Key considerations:

• The patient's condition and medical history should be carefully evaluated before initiating any new treatment.
• The potential benefits and risks of adding azithromycin or prednisone should be weighed, considering the patient's current medications and potential interactions.
• Monitoring for any adverse effects or interactions is crucial when adding new medications.

From the Research

Additional Treatment Options for Refractory Cough

For a patient with a refractory cough secondary to an infective exacerbation of Obstructive Airway Disease (OAD) who is already on a mucolytic and an antihistamine, several additional treatment options can be considered:

• Bronchodilators: Inhaled beta agonists can be used to help relieve bronchospasm and improve airflow 4.
• Theophylline: A long-acting theophylline preparation can be initiated to help control symptoms 4.
• Corticosteroids: Aerosol atropine or initiation of corticosteroids can be considered if tachyphylaxis appears to be developing 4.
• Antitussives: Codeine or dextromethorphan can be used to help relieve cough symptoms, although evidence for their effectiveness is limited 5, 6.
• Expectorants: Guaifenesin can be used to help thin and loosen mucus, making it easier to cough up 5.
• Antihistamine-decongestant combinations: These can be used to help relieve cough and congestion symptoms, although evidence for their effectiveness is limited 5.
• Mucolytic agents: N-acetylcysteine, carbocysteine, erdosteine, and ambroxol can be used to help reduce the viscosity of mucus and improve expectoration 7, 8.

Considerations for Treatment

When selecting additional treatments, it is essential to consider the patient's individual needs and medical history. The effectiveness of different treatments can vary depending on the underlying cause of the cough and the patient's response to previous treatments. Additionally, potential side effects and interactions with other medications should be carefully considered.

Evidence for Treatment Effectiveness

The evidence for the effectiveness of different treatments for refractory cough in OAD is limited, and more research is needed to fully understand the benefits and risks of different treatment options 5, 7, 6. However, available evidence suggests that mucolytic agents, bronchodilators, and antitussives may be effective in relieving cough symptoms and improving quality of life for patients with OAD 4, 7, 8.