What to give for cough exacerbation?

Management of COPD Exacerbation-Related Cough

For cough exacerbation in COPD, short-acting bronchodilators (albuterol and/or ipratropium) should be used as first-line treatment, followed by systemic corticosteroids (40mg prednisone for 5 days) if symptoms persist, and antibiotics if purulent sputum is present. 1, 2

First-Line Treatment: Bronchodilators

Short-Acting Bronchodilators

• Short-acting β2-agonists (SABAs) like albuterol:

  • Recommended as initial bronchodilator for acute exacerbations 1
  • Helps control bronchospasm, relieve dyspnea, and may reduce cough 1
  • Dosing: Albuterol via nebulizer (2.5mg) or MDI (180μg/2 puffs) every 4-6 hours 3, 4
  • No significant difference between 2.5mg and 5mg nebulized doses in outcomes 4

• Short-acting anticholinergics like ipratropium bromide:

  • Recommended to improve cough in stable chronic bronchitis 1
  • Can be used alone or in combination with SABAs 1
  • Combination therapy (ipratropium + albuterol) is more effective than either agent alone 5

Administration Method

• Both metered-dose inhalers (with spacers) and nebulizers are equally effective 1
• Nebulizers may be easier for patients experiencing severe symptoms 6

Second-Line Treatment: Anti-inflammatory Therapy

Systemic Corticosteroids

• Recommended for acute exacerbations 1, 2
• Improve lung function, oxygenation, and shorten recovery time 1
• Dosing: 40mg prednisone daily for 5 days 1
• Oral administration is as effective as intravenous 1
• May be less effective in patients with lower blood eosinophil levels 1

Third-Line Treatment: Antibiotics

• Use antibiotics when there is:
  • Increased sputum purulence plus increased dyspnea and/or sputum volume 1
  • Requirement for mechanical ventilation 1
• Duration: 5-7 days 1
• Choice should be based on local bacterial resistance patterns 1
• Common options include aminopenicillins with clavulanic acid, macrolides, or tetracyclines 1

Adjunctive Therapies

Cough Suppressants

• Dextromethorphan may provide short-term symptomatic relief 2, 7
• Should be used cautiously as cough suppression may impair clearance of secretions

Expectorants

• Guaifenesin helps loosen phlegm and thin bronchial secretions 8
• However, evidence for clinical effectiveness is limited 1, 2

Important Considerations

Monitoring

• Assess response to initial bronchodilator therapy
• If inadequate response to one bronchodilator, add the other agent (SABA or anticholinergic) 1
• Monitor oxygen saturation and consider supplemental oxygen to maintain saturation 88-92% 1

Treatments to Avoid

• Methylxanthines (theophylline) are not recommended for acute exacerbations due to side effects 1
• Long-term prophylactic antibiotics are not recommended for stable patients 1
• Postural drainage and chest percussion have not shown proven benefits 1

Prevention of Future Exacerbations

• For stable patients with frequent exacerbations, consider maintenance therapy with:
  • Long-acting β-agonist combined with inhaled corticosteroid 1, 2
  • Inhaled corticosteroids for patients with FEV₁ <50% predicted 1

Treatment Algorithm

1. Start with short-acting bronchodilators (albuterol and/or ipratropium)
2. If symptoms persist, add systemic corticosteroids (prednisone 40mg daily for 5 days)
3. Add antibiotics if purulent sputum is present
4. Consider adjunctive therapies for symptomatic relief
5. Evaluate need for hospitalization or respiratory support for severe symptoms

By following this evidence-based approach, you can effectively manage cough exacerbations in COPD patients while reducing morbidity and mortality and improving quality of life.