What are the recommendations for cough management?

Recommendations for Cough Management

For acute cough management, home remedies like honey and lemon are first-line, followed by dextromethorphan for symptomatic relief, while chronic cough requires systematic evaluation and targeted treatment based on the underlying cause. 1

Acute Cough Management (Duration < 3 weeks)

First-Line Approaches

• Non-pharmacological options:
  • Honey and lemon mixtures provide effective symptomatic relief, especially for nighttime cough 2, 1
  • Adequate hydration to thin secretions
  • Avoid smoking and secondhand smoke exposure 2

Pharmacological Options

• For dry, non-productive cough:

  • Dextromethorphan 30mg every 6-8 hours (not exceeding 120mg/24 hours) 1
  • Extended-release formulations available for 12-hour relief 3
  • Menthol lozenges or vapor inhalation for temporary relief 2, 1

• For productive cough:

  • Guaifenesin 200-400mg every 4 hours (maximum 2400mg daily) to loosen phlegm and thin bronchial secretions 1, 4

• For nocturnal cough:

  • First-generation antihistamines (e.g., chlorpheniramine) may be beneficial due to sedative properties 1, 5

Medications to Avoid

• Codeine or pholcodine (no greater efficacy than dextromethorphan but higher side effect profile) 2, 1
• Antibiotics for viral cough (ineffective and contributes to antibiotic resistance) 2
• OTC combination cold medications (limited evidence of efficacy) 1, 6

Chronic Cough Management (Duration > 8 weeks)

Diagnostic Approach

1. Evaluate for common causes:

   • Upper airway cough syndrome (post-nasal drip)
   • Asthma
   • Gastroesophageal reflux disease (GORD)
   • Non-asthmatic eosinophilic bronchitis
   • ACE inhibitor use 2, 7

2. Initial investigations:

   • Chest X-ray
   • Pulmonary function testing
   • Consider bronchial provocation testing if asthma suspected 2, 7

Targeted Treatment Based on Cause

• For upper airway symptoms:

  • Trial of topical corticosteroids 2

• For suspected asthma or eosinophilic airway inflammation:

  • Two-week oral steroid trial (if no response, eosinophilic inflammation unlikely) 2

• For GORD-related cough:

  • Intensive acid suppression with proton pump inhibitors and alginates for minimum 3 months 2
  • Note: GORD-related cough may occur without typical gastrointestinal symptoms 2

• For ACE inhibitor-induced cough:

  • Discontinue ACE inhibitor (no patient with troublesome cough should continue on ACE inhibitors) 2

• For refractory chronic cough:

  • Consider referral to specialist cough clinic 2
  • Gabapentin or pregabalin may be considered for cough hypersensitivity syndrome 7

When to Seek Medical Attention

• Coughing up blood
• Breathlessness
• Prolonged fever and feeling unwell
• Pre-existing medical conditions (COPD, heart disease, diabetes, asthma)
• Recent hospitalization
• Symptoms persisting beyond three weeks 2, 1

Special Considerations

• Elderly patients: Seek medical evaluation if cough persists beyond 1-2 weeks 1
• Patients with productive cough: Green or yellow sputum suggests bacterial infection; medical consultation advised 8
• Patients with pre-existing conditions: Consult healthcare provider before using OTC cough medications 8

Effectiveness of OTC Medications

The evidence for OTC cough medications is mixed:

• Dextromethorphan shows some efficacy over placebo in adults 6
• Guaifenesin may be helpful for productive cough, though evidence is limited 9, 6
• Antihistamines alone are generally not effective for cough relief 6

Remember that most acute coughs are self-limiting and will resolve without specific treatment. For chronic cough, identifying and treating the underlying cause is essential for effective management.