What is the recommended treatment for a patient with Covid-19 (Coronavirus disease 2019) experiencing a cough?

Management of Cough in COVID-19 Patients

For patients with COVID-19 experiencing cough, honey (for patients over 1 year old) should be used as first-line treatment, followed by short-term use of codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution for distressing cough if simple measures are ineffective. 1

First-Line Approach to COVID-19 Cough

Non-Pharmacological Interventions

• Positioning: Avoid lying on the back as this makes coughing ineffective 1
• Hydration: Ensure adequate fluid intake (up to 2 liters per day) 1
• Honey: Use honey as a first-line treatment for patients over 1 year of age 1

Initial Pharmacological Options

1. Guaifenesin: Helps loosen phlegm and thin bronchial secretions to make coughs more productive 2
2. Dextromethorphan: Acts as a cough suppressant for non-productive coughs 3

Second-Line Treatment for Distressing Cough

When simple measures are insufficient and cough is distressing, consider:

• Codeine linctus
• Codeine phosphate tablets
• Morphine sulfate oral solution 1

These medications should be used for short-term relief only, as they can cause respiratory depression and may mask worsening respiratory status.

Special Considerations

Monitoring for Respiratory Deterioration

• Closely monitor patients for signs of respiratory deterioration, especially:
  • Older patients
  • Those with comorbidities
  • Patients with frailty
  • Those with impaired immunity
  • Patients with reduced ability to cough and clear secretions 1

Breathlessness Management Techniques

For patients experiencing breathlessness alongside cough:

• Controlled breathing techniques:
  • Pursed-lip breathing: Inhale through nose for several seconds, exhale slowly through pursed lips for 4-6 seconds
  • Relaxing shoulders to reduce hunched posture
  • Sitting upright to increase peak ventilation
  • Leaning forward with arms bracing a chair 1

Antibiotic Considerations

• Empiric antibiotics are not routinely recommended for all patients with confirmed COVID-19 pneumonia 1
• Consider antibiotics only if:
  • Clinical suspicion of bacterial co-infection
  • Elevated procalcitonin
  • Clinical deterioration after initial improvement 1, 4
• If antibiotics are initiated:
  • Obtain blood and sputum cultures
  • For low-risk inpatients: β-lactam plus either a macrolide or doxycycline, or a respiratory fluoroquinolone as monotherapy
  • For high-risk inpatients: β-lactam plus macrolide or β-lactam plus fluoroquinolone 1
  • Limit duration to 5 days if no evidence of bacterial infection 4

Cautions and Pitfalls

1. Avoid nebulized medications before or after bronchoscopy procedures as they may increase aerosol generation 1

2. Dexamethasone use may increase the risk of secondary pulmonary infections, particularly in ICU patients 5

   • Monitor closely for signs of superinfection when using corticosteroids

3. Potential drug interactions between COVID-19 treatments and other medications should be carefully evaluated, especially in patients with respiratory diseases 6

4. Do not use antipyretics with the sole aim of reducing body temperature; use paracetamol if fever is present with other symptoms 1

5. Avoid high-flow nasal oxygen therapy during bronchoscopy procedures 1

By following this approach to managing cough in COVID-19 patients, clinicians can provide effective symptom relief while monitoring for potential deterioration in respiratory status.