What is the management of acute cough?

Management of Acute Cough

For acute cough management, central cough suppressants such as codeine should be limited to short-term symptomatic relief (3-7 days) for persistent dry cough not responding to first-line treatments, with treatment reserved for patients with chronic bronchitis, nocturnal cough disrupting sleep, or minor throat and bronchial irritation. 1

First-Line Approaches

1. Simple home remedies:

   • Honey and lemon are recommended as initial treatment for acute viral cough 1
   • These should be tried before moving to pharmacological options

2. Expectorants:

   • Guaifenesin helps loosen phlegm and thin bronchial secretions to make coughs more productive 2
   • Can be effective in reducing cough symptoms in some patients 3

Second-Line Pharmacological Options

For Dry, Irritating Cough:

1. Dextromethorphan:

   • Dosage: 10-15 mg three to four times daily 1
   • Non-sedating opiate derivative that can effectively suppress acute cough 1
   • Maximum cough reflex suppression occurs at higher doses around 60 mg 1
   • Evidence for efficacy is mixed, with some studies showing benefit and others showing no difference from placebo 3, 4

2. Codeine:

   • Dosage: 30-60 mg every 4 hours (maximum 120mg daily) 1
   • Temporarily relieves cough due to minor throat and bronchial irritation 5
   • Can suppress cough counts by 40-60% in patients with chronic bronchitis 1
   • Should be limited to 3-7 days of use due to dependency risk 1
   • Not recommended for children due to safety concerns 1

3. Other options:

   • Benzonatate: 100-200 mg four times daily 1
   • Levodropropizine: 75 mg three times daily 1

For Productive Cough:

• Mucolytics can be effective in reducing cough frequency and symptom scores 3
• Ipratropium bromide inhaler is recommended for cough due to URI or bronchitis 1

Special Populations and Considerations

• Elderly patients: Should use lower doses of codeine due to increased sensitivity to side effects 1
• Pregnant women: Codeine should be avoided, especially in the third trimester 1
• Children: Antitussives and antihistamine-decongestant combinations have not shown significant efficacy compared to placebo 3

Monitoring and Duration

• Assess response after 2-4 days of therapy 1
• Discontinue if no improvement is seen 1
• Monitor for adequate expectoration despite cough suppression 1
• Treatment with codeine should not exceed 7-10 days due to dependency risk 1

Red Flags Requiring Immediate Attention

• Hemoptysis
• Foreign body inhalation
• Increasing breathlessness
• Fever
• Purulent sputum
• Biphasic cough pattern 1

Important Caveats

• Antibiotics are not indicated for acute viral cough or acute bronchitis 1, 6
• Most acute cough (lasting up to 3 weeks) is caused by viral infections and is self-limiting in otherwise healthy individuals 7
• Patients with poor CYP2D6 metabolizer status, renal impairment, or those taking serotonergic drugs require close monitoring if prescribed dextromethorphan 1
• The most common cause of acute cough is viral upper respiratory tract infection ("common cold") 6