What are the treatment options for a severe cough?

Treatment Options for Severe Cough

For severe cough, treatment should be tailored to the underlying cause, with options including dextromethorphan for symptom relief, inhaled ipratropium for postinfectious cough, inhaled corticosteroids for persistent cases, and short courses of oral prednisone for severe paroxysms when other treatments fail. 1

Acute Viral Cough

• Simple home remedies like honey and lemon are recommended as first-line treatment for acute viral cough 1
• Dextromethorphan is an effective non-sedating opiate antitussive with dose-dependent efficacy; maximum cough suppression occurs at 60 mg 1, 2
• Menthol by inhalation provides acute, short-lived cough suppression 1
• First-generation antihistamines with sedative properties are particularly useful for nocturnal cough 1
• Avoid codeine or pholcodine as they have no greater efficacy than dextromethorphan but have a much worse side effect profile 1
• Guaifenesin helps loosen phlegm and thin bronchial secretions to make coughs more productive 3

Postinfectious Cough (3-8 weeks duration)

• Inhaled ipratropium should be considered as it may attenuate postinfectious cough 1
• For persistent cases affecting quality of life, consider inhaled corticosteroids when ipratropium is ineffective 1
• For severe paroxysms of postinfectious cough, consider 30-40 mg prednisone daily for a short period when other common causes have been ruled out 1
• Central-acting antitussives (dextromethorphan) should be considered when other measures fail 1, 4

Chronic Cough Due to GERD

• Treatment includes dietary and lifestyle modifications, acid suppression therapy, and prokinetic therapy 1
• Response should be assessed within 1-3 months 1
• Intensive medical treatment may include antireflux diet (≤45g fat/24h, no coffee, tea, soda, chocolate, mints, citrus products, tomatoes, alcohol), proton pump inhibitors, and prokinetic therapy 1
• Antireflux surgery may be considered when maximal medical therapy fails 1

Important Considerations and Red Flags

• Seek medical attention if cough is accompanied by:
  • Hemoptysis (coughing up blood) 1
  • Breathlessness 1
  • Prolonged fever and feeling unwell 1
  • Underlying medical conditions (COPD, heart disease, diabetes, asthma) 1
  • Recent hospitalization 1
  • Symptoms persisting for more than three weeks 1
• When cough lasts ≥2 weeks with paroxysms, post-tussive vomiting, and/or inspiratory whooping sound, consider Bordetella pertussis infection 1

Special Considerations for Dextromethorphan

• Do not use with MAO inhibitors 5
• Contains sodium metabisulfite which may cause allergic reactions 5
• Use with caution in chronic cough associated with smoking, asthma, or emphysema 5
• Discontinue if cough lasts more than 7 days, returns, or occurs with fever, rash, or persistent headache 5

Treatment Limitations

• Current antitussives have limited efficacy at recommended doses 4, 6
• Higher doses that may be more effective often come with increased side effects 4
• Novel therapies targeting specific receptors (TRPV1 antagonists, potassium channel openers) are in development but not yet available 1, 7