Appropriate Treatment for Cough
The most effective approach to treating cough is to identify and treat the underlying cause while providing symptomatic relief with dextromethorphan for suppression or guaifenesin for productive cough, based on cough characteristics. 1, 2, 3
Initial Assessment
Determine Cough Duration and Characteristics
- Acute cough (<3 weeks): Usually viral upper respiratory infection
- Chronic cough (>8 weeks): Requires thorough evaluation for underlying causes
- Productive vs. dry cough: Guides treatment selection
Red Flags Requiring Immediate Evaluation
- Hemoptysis
- Significant dyspnea (especially at rest or night)
- Fever with systemic symptoms
- Weight loss
- Abnormal respiratory findings (dullness, bronchial breathing, crackles)
- Hoarseness
- Peripheral edema with weight gain 1
Treatment Algorithm
1. Acute Cough (Likely Viral URI)
First-line treatment:
For nighttime cough: First-generation antihistamines with sedative properties may help (use with caution in elderly) 1
2. Specific Causes of Cough
Upper Airway Cough Syndrome
- First-generation antihistamine/decongestant combination for 2-4 weeks 1
Asthma/Bronchial Hyperresponsiveness
- Inhaled corticosteroids and bronchodilators for 4 weeks 1
GERD-Related Cough
- Proton pump inhibitor with lifestyle modifications for 4-8 weeks 1
Post-infectious Cough
- Short course of inhaled corticosteroids if cough affects quality of life
- Inhaled ipratropium bromide as first-line therapy 1
Whooping Cough (Pertussis)
- Macrolide antibiotic within first few weeks
- Isolation for 5 days from start of treatment 4
Cough Due to Lung Cancer
- For patients with cough and confirmed lung cancer, centrally acting cough suppressants such as dihydrocodeine and hydrocodone are recommended 4
3. Chronic Idiopathic Cough
- Non-specific antitussive therapy such as dextromethorphan 4
- Consider baclofen or nebulized local anesthetics (lidocaine, mepivicaine) for refractory cases 4
- Low-dose morphine has shown benefit in severe cases 4
- Neuromodulators like gabapentin and speech pathology therapy for cough suppression techniques 1
Important Considerations
Medication Review
- Check for ACE inhibitors, which can cause persistent cough
- If patient is on an ACE inhibitor, consider discontinuation and replacement with alternative agent 1
When to Avoid Cough Suppression
- Pneumonia and bronchiectasis where cough clearance is important 4
- Suspected foreign body aspiration
Follow-up
- Arrange follow-up within 4-6 weeks
- Re-evaluate if cough persists beyond 3 weeks 1
- Consider referral if cough persists despite appropriate treatment
Cautions
- Avoid antibiotics for viral causes of cough
- Use first-generation antihistamines with caution in elderly patients due to anticholinergic effects and fall risk 1
- Avoid combination cough preparations without clear indication for each component 5
- Narcotic antitussives should be limited due to potential side effects at therapeutic doses 6
By following this structured approach to cough management, most cases can be effectively treated while minimizing unnecessary medication use and ensuring appropriate evaluation of potentially serious underlying conditions.