Treatment of Cough
The most effective approach to treating cough is to identify and address the underlying cause through a systematic evaluation of common etiologies, followed by targeted therapy based on the specific diagnosis. 1
Classification and Initial Assessment
Cough should be categorized by duration to guide management:
- Acute cough: <3 weeks (usually viral respiratory infections)
- Subacute cough: 3-8 weeks (often post-infectious)
- Chronic cough: >8 weeks (requires thorough investigation) 1
Initial assessment should determine if the cough represents a serious condition requiring immediate attention (pneumonia, pulmonary embolism) versus more common causes like respiratory infections, asthma, or environmental irritants 1
Common Causes and Targeted Treatments
Upper Airway Cough Syndrome (UACS)
- Treat with antihistamines and decongestants for rhinitis-related UACS 1
- Consider nasal corticosteroids for inflammatory conditions 1
Asthma and Cough-Variant Asthma
- Inhaled corticosteroids are the mainstay of treatment 2
- For cough-variant asthma (cough as the predominant symptom), bronchodilators may be added if needed 2
Non-asthmatic Eosinophilic Bronchitis
- Characterized by eosinophilic airway inflammation without airflow obstruction or hyperresponsiveness 2
- Responds well to inhaled corticosteroids 2
Gastroesophageal Reflux Disease (GERD)
- Dietary modifications and proton pump inhibitors are first-line treatments 1
- Consider adding prokinetic agents like metoclopramide if initial therapy fails 1
- Some cases may be due to non-acid reflux and might require surgical intervention 1
Post-infectious Cough
- Antibiotics have no role unless bacterial sinusitis or pertussis is present 1
- Consider inhaled ipratropium to attenuate cough 1
- For persistent cases, inhaled corticosteroids may be beneficial 1
- For severe paroxysms, short-term prednisone (30-40 mg daily) may be considered 1
Symptomatic Treatment for Nonproductive Cough
For dry, nonproductive cough:
- Dextromethorphan is effective for suppressing cough due to minor throat and bronchial irritation 3, 4
- First-generation antihistamines like chlorpheniramine may be helpful, particularly when cough disturbs sleep 4
- Codeine or other opioid derivatives may be used for more severe cases, though side effects limit their use 5, 4
For productive cough:
Treatment of Refractory or Idiopathic Cough
- For chronic cough that persists despite treatment of identified causes:
- Low-dose morphine (slow-release preparation) may be effective for severe cases 1
- Consider trials of amitriptyline, paroxetine, gabapentin, or carbamazepine based on case reports 5
- GABA-B agonists like baclofen have shown some benefit 1
- Nebulized local anesthetics (lidocaine, mepivacaine) may provide relief in selected cases 1
Special Populations
Lung Cancer Patients
- Address underlying causes (tumor effects, infections, GERD, COPD exacerbations) 1
- Differentiate between productive and nonproductive cough to guide treatment 1
- Opioids like hydrocodone may be effective for cancer-related cough 1
- Consider levodropropizine as an alternative to opioids 1
Interstitial Lung Disease (ILD)
- Treatment should target the underlying ILD when possible 1
- For IPF-related cough, antifibrotic therapy with pirfenidone or nintedanib may help reduce cough severity 1
- Thalidomide has shown efficacy but has significant side effects 1
Common Pitfalls to Avoid
- Failing to identify and treat the underlying cause before resorting to symptomatic treatment 7
- Using combination cough preparations indiscriminately without targeting specific symptoms 7
- Suppressing productive cough in conditions where clearance of secretions is beneficial 1
- Overlooking common causes like post-nasal drip, which may have normal physical examination findings 8
- Inadequate duration of treatment, especially for conditions like GERD or asthma 1
Remember that cough may have multiple simultaneous causes, and sequential or additive therapy may be necessary for complete resolution 1.