What are the pharmacological interventions and lifestyle modifications for managing different types of cough in a general practice setting in India?

Management of Different Types of Cough in General Practice in India

For effective management of cough in Indian general practice settings, physicians should follow a systematic approach based on cough duration and characteristics, with appropriate pharmacological interventions tailored to cough type.

Classification of Cough

Cough can be classified based on duration:

• Acute cough: <3 weeks
• Subacute cough: 3-8 weeks
• Chronic cough: >8 weeks

Diagnostic Approach

Red Flag Symptoms Requiring Immediate Attention

• Hemoptysis
• Breathlessness
• Prolonged fever
• Significant weight loss
• Chest pain
• Hoarseness of voice

Key Diagnostic Elements

1. Chest X-ray (for chronic cough)
2. Pulmonary function testing (if asthma suspected)
3. Evaluation for common causes:
   • Upper airway cough syndrome (UACS)
   • Asthma
   • Gastroesophageal reflux disease (GERD)
   • Non-asthmatic eosinophilic bronchitis
   • ACE inhibitor use

Pharmacological Management

Acute Cough (< 3 weeks)

Dry, Irritative Cough

• First-line: Dextromethorphan 30 mg every 6-8 hours (not exceeding 120 mg/day) 1, 2
• Alternative: First-generation antihistamine plus decongestant (especially for cough associated with common cold) 3
• For nighttime cough: Honey and lemon mixtures 1

Productive Cough

• First-line: Guaifenesin 200-400 mg every 4 hours (not exceeding 2400 mg daily) 1, 4
• Supportive measures: Adequate hydration 5

Subacute Cough (3-8 weeks)

Post-infectious Cough

• First-line: First-generation antihistamine plus decongestant 3
• If bronchial hyperresponsiveness present: Consider short-term inhaled corticosteroids 3

Non-infectious Subacute Cough

• Evaluate and manage as chronic cough 3

Chronic Cough (> 8 weeks)

Upper Airway Cough Syndrome (UACS)

• First-line: Antihistamine-decongestant combination 3, 6
• Duration: Initial trial for 2-3 weeks 3

Asthma-related Cough

• First-line: Inhaled corticosteroids (ICS) with bronchodilators 3, 1
• Alternative: Consider leukotriene receptor antagonists 3

GERD-related Cough

• First-line: Proton pump inhibitors (PPI) 3
• Add-on therapy: Prokinetics and dietary modifications if PPI alone ineffective 3
• Duration: May require 8 weeks to several months for improvement 3

Non-asthmatic Eosinophilic Bronchitis

• First-line: Inhaled corticosteroids 3, 1

ACE Inhibitor-induced Cough

• Management: Discontinue ACE inhibitor 3
• Response time: Usually resolves within 1-4 weeks (median 26 days) 3

Special Considerations for Indian Context

Environmental Factors

• Address exposure to air pollution, particularly particulates 5, 7
• Consider seasonal variations affecting cough patterns 5

Medication Preferences

• For dry cough: Non-opioid antitussives preferred for initial management 5
• For productive cough: Emphasis on mucoactive agents with good hydration 5, 7
• Fixed-dose combinations: Commonly used in India for UACS-associated cough 5

Antibiotic Use

• Avoid routine use for viral coughs 1
• Reserve for specific bacterial infections with clear indications 5

Non-pharmacological Interventions

• Smoking cessation: Essential for smokers with chronic cough 3
• Hydration: Maintain adequate fluid intake 5
• Environmental modifications: Reduce exposure to irritants and allergens 3
• Postural drainage: For patients with bronchiectasis or excessive secretions 3

When to Refer to Specialists

• Cough persisting despite appropriate empiric therapy for 4-8 weeks
• Abnormal chest X-ray findings
• Presence of red flag symptoms
• Suspected occupational causes 3

Algorithm for Cough Management in Indian Primary Care

1. Assess duration and characteristics of cough
2. Rule out red flags requiring urgent attention
3. For acute cough:
   • Dry cough → Dextromethorphan
   • Productive cough → Guaifenesin with adequate hydration
4. For subacute cough:
   • Post-infectious → Antihistamine-decongestant
   • Non-infectious → Evaluate as chronic cough
5. For chronic cough: Sequential empiric trials
   • Start with antihistamine-decongestant for UACS (most common cause)
   • If ineffective, add PPI for GERD
   • If still ineffective, add ICS for asthma/eosinophilic bronchitis
   • Consider multiple causes and maintain partially effective treatments

By following this systematic approach to cough management in Indian general practice, physicians can effectively address different types of cough while considering local environmental factors and medication preferences.