What is the treatment plan for acute cough?

Treatment Plan for Acute Cough

For most cases of acute viral cough, simple home remedies like honey and lemon are the most appropriate first-line treatment, as prescribed medications are generally unnecessary for this self-limiting condition. 1

Initial Assessment

When evaluating acute cough, it's essential to determine if it's caused by:

• Common viral infection (most common)
• Potentially serious condition requiring specific treatment

Red Flags Requiring Further Investigation:

• Significant hemoptysis
• Possible foreign body inhalation
• Increasing breathlessness
• Fever, malaise, purulent sputum
• Vocal cord changes
• Cough that worsens after initial improvement (biphasic course) 1

Treatment Algorithm for Acute Cough

1. For Uncomplicated Viral Cough:

• First-line: Simple home remedies such as honey and lemon 1
• Second-line options:
  • First-generation antihistamine/decongestant combinations (strongly recommended unless contraindicated) 1
  • Dextromethorphan (10-15 mg three to four times daily) 2, 3
  • Menthol inhalation for short-term cough suppression 1, 2
  • Sedative antihistamines for nocturnal cough (caution: causes drowsiness) 1, 2
  • Guaifenesin to loosen phlegm in productive cough (expectorant) 4

2. For Specific Conditions:

• Pneumonia, bacterial sinusitis, pertussis: Appropriate antibiotics 1
• Asthma or anaphylaxis: Appropriate bronchodilators/anti-inflammatory medications
• Severe chronic bronchitis exacerbation: Consider antibiotics in current/former smokers with severe airflow obstruction 1

Evidence-Based Medication Recommendations

Effective Options:

• Dextromethorphan: Non-sedating antitussive that suppresses cough reflex. Maximum cough suppression occurs at 60 mg, though typical doses are lower. Use with caution in patients taking MAOIs 1, 3

• Menthol: Provides acute, short-lived cough suppression when inhaled 1

• First-generation antihistamine/decongestant combinations: Effective for cough due to common cold 1, 5

• Guaifenesin: Helps loosen phlegm and thin bronchial secretions to make coughs more productive 4

Not Recommended:

• Codeine or pholcodine: No greater efficacy than dextromethorphan but have a much greater adverse side effect profile 1, 6

• Newer-generation, non-sedating antihistamines: Ineffective for acute cough 1

• Antibiotics: Not indicated for acute viral cough, common cold, or acute bronchitis 1, 7

Important Caveats

• Duration of treatment: Assess response after 2-4 days; discontinue if no improvement 2

• Antibiotic overuse: Acute bronchitis is often overdiagnosed, leading to unnecessary antibiotic prescriptions in 65-80% of patients 1

• Drug interactions: Use caution with dextromethorphan in patients taking MAOIs or other serotonergic medications due to risk of serotonin syndrome 2, 3

• Special populations:

  • Pregnant patients should avoid codeine if possible
  • Elderly patients should start at lower doses
  • Children should not be treated with codeine due to safety concerns 2

• Evidence limitations: Many studies on OTC cough medications show conflicting results or limited efficacy 8, 9, 10

• Normal course: Acute viral cough is typically worst during the first few days and gradually improves over 1-2 weeks. If cough worsens after initial improvement, consider alternative diagnoses 1