What medications can be given for a cough in the Emergency Department (ED)?

Medications for Cough Management in the Emergency Department

For patients with cough in the Emergency Department, first-line treatment options include inhaled ipratropium bromide, oral central-acting antitussives such as codeine or dextromethorphan, and inhaled corticosteroids depending on the underlying cause. 1

Assessment and Classification

• Determine if the cough is acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks) to guide treatment approach 1
• Identify potential underlying causes such as postinfectious inflammation, upper airway cough syndrome, asthma, or gastroesophageal reflux disease 1
• Assess for paroxysmal cough with post-tussive vomiting or inspiratory whooping sound, which may indicate Bordetella pertussis infection 1

First-Line Medications for Acute Cough

For Postinfectious Cough

• Inhaled ipratropium bromide is recommended as first-line therapy as it may attenuate cough 1
• Central-acting antitussives such as codeine and dextromethorphan should be considered when other measures fail 1
• Inhaled corticosteroids may be used when cough adversely affects quality of life and persists despite ipratropium 1
• Oral prednisone (30-40 mg daily for a short period) may be considered for severe paroxysms of postinfectious cough when other common causes have been ruled out 1

For Cough Associated with Asthma

• Inhaled short-acting beta-agonists (albuterol) by nebulizer or MDI with valved holding chamber 1, 2
• Inhaled corticosteroids for patients with asthma-related cough 1
• For severe exacerbations, consider nebulized albuterol plus ipratropium, hourly or continuous 1

Special Considerations

For Suspected Pertussis

• Macrolide antibiotics (erythromycin, clarithromycin, or roxithromycin) should be administered early in the course of infection 1
• Note that antibiotics are not effective if given after the first 7-10 days of symptoms 1

For Cough Associated with Upper Airway Cough Syndrome

• First-generation antihistamine/decongestant preparations are recommended 1
• Newer generation non-sedating antihistamines are ineffective for reducing cough and should not be used 1

For Cough Associated with Lung Cancer

• Centrally acting cough suppressants such as dihydrocodeine and hydrocodone are recommended 1

Important Caveats

• Antibiotics have no role in treating postinfectious cough unless there is evidence of bacterial infection 1
• In severe asthma exacerbations, avoid sedatives which can suppress respiratory drive 1
• For patients with reduced level of consciousness, cough suppressants should be used with caution due to risk of aspiration 1
• Dextromethorphan is available as an extended-release formulation providing up to 12 hours of cough relief 3

Treatment Algorithm

1. Identify the likely cause of cough

   • If postinfectious: Start with inhaled ipratropium 1
   • If asthma-related: Use inhaled beta-agonists and corticosteroids 1
   • If upper airway cough syndrome: Use first-generation antihistamine/decongestant 1

2. For persistent symptoms

   • Add central-acting antitussives (codeine or dextromethorphan) 1
   • Consider short course of oral corticosteroids for severe symptoms 1

3. For specific conditions

   • For pertussis: Add macrolide antibiotics if within first 7-10 days 1
   • For lung cancer-related cough: Use dihydrocodeine or hydrocodone 1

By following this approach, most cases of cough presenting to the Emergency Department can be effectively managed with appropriate medication selection based on the underlying cause.