What is the recommended treatment for severe coughing?

Treatment Recommendations for Severe Coughing

For patients with severe coughing, treatment should be directed at the underlying cause, with central cough suppressants such as codeine and dextromethorphan recommended for short-term symptomatic relief when appropriate. 1

Diagnostic Approach to Severe Cough

Before initiating treatment, it's essential to determine the cause of severe cough:

• Chest radiograph and spirometry are mandatory initial tests for evaluating severe cough 1
• Consider bronchial provocation testing in patients with normal spirometry but suspected asthma 1
• High-resolution computed tomography may be useful when other targeted investigations are normal 1

Treatment Based on Specific Causes

Asthma-Related Cough

• Initial treatment should include standard antiasthmatic regimen of inhaled bronchodilators and inhaled corticosteroids 1
• For refractory cough due to asthma, consider:
  • Adding a leukotriene receptor antagonist before escalating to systemic steroids 1
  • Short course (1-2 weeks) of systemic corticosteroids followed by inhaled corticosteroids for severe cases 1

Chronic Bronchitis

• For acute exacerbations, use short-acting β-agonists or anticholinergic bronchodilators 1
• Short course (10-15 days) of systemic corticosteroids for acute exacerbations 1
• For stable chronic bronchitis, long-acting β-agonist with inhaled corticosteroids is recommended 1
• Avoid long-term maintenance therapy with oral corticosteroids due to high risk of serious side effects 1

GERD-Related Cough

• Intensive acid suppression with proton pump inhibitors and alginates for a minimum of 3 months 1
• Implement antireflux diet (≤45g fat/24h, no coffee, tea, soda, chocolate, mints, citrus, tomatoes, alcohol) 1
• Add prokinetic therapy if response to acid suppression is inadequate 1

Upper Airway Cough Syndrome

• Trial of topical corticosteroids when prominent upper airway symptoms are present 1

Lung Cancer-Related Cough

• Centrally acting cough suppressants such as dihydrocodeine and hydrocodone are recommended 1
• For stages I and II non-small cell lung cancer, surgical removal is treatment of choice 1
• For advanced stages, external beam radiation and/or chemotherapy should be offered 1

Symptomatic Treatment for Severe Cough

When specific treatment of the underlying cause is not immediately effective or when the cause remains unclear:

• Central cough suppressants such as codeine and dextromethorphan are recommended for short-term symptomatic relief 1, 2, 3
  • Caution: Do not use dextromethorphan with MAOIs 2
• Guaifenesin may help loosen phlegm and thin bronchial secretions to make coughs more productive 4
• For idiopathic chronic cough, consider:
  • Low-dose morphine 1
  • Neuromodulators like gabapentin or pregabalin for suspected cough hypersensitivity syndrome 5

Important Considerations and Cautions

• Avoid antibiotics for acute bronchitis in otherwise healthy adults 6
• Expectorants have not shown effectiveness in chronic bronchitis and should not be used 1
• For acute bronchitis, systemic corticosteroids are not justified in healthy adults 6
• Cough suppressants may be contraindicated when cough clearance is important (e.g., pneumonia, bronchiectasis) 1
• Combination cough preparations should generally be avoided 7
• Patients with persistent cough despite optimal treatment should be referred to a specialist cough clinic 1

Red Flags Requiring Urgent Evaluation

• Hemoptysis 1
• Breathlessness 1
• Prolonged fever and feeling unwell 1
• Cough in patients with underlying conditions (COPD, heart disease, diabetes, asthma) 1
• Recent hospitalization 1
• Symptoms persisting for more than three weeks 1