What are the guidelines for managing cough?

Guidelines for Managing Cough

The management of cough should follow a systematic approach based on cough duration, with treatment directed at the underlying cause whenever possible. 1

Classification of Cough by Duration

• Acute cough: lasting < 3 weeks 1
• Subacute cough: lasting between 3-8 weeks 1
• Chronic cough: lasting > 8 weeks 1

Management of Acute Cough

Common Cold/Viral Upper Respiratory Infection

• First-generation antihistamine/decongestant combinations are strongly recommended as they decrease cough severity and hasten resolution 1
• Nonsteroidal anti-inflammatory drugs like naproxen can favorably affect cough symptoms 1
• Dextromethorphan-containing remedies may be the most effective over-the-counter options 1
• Home remedies such as honey and lemon can provide symptomatic relief 1
• Menthol lozenges or vapors may help alleviate symptoms 1

Important Cautions

• Antibiotics are not indicated for acute cough from common cold, acute bronchitis, or viral infections 1
• Over-the-counter combination cold medications are not recommended except those containing older antihistamine/decongestant ingredients 1
• Cough suppressants containing dextromethorphan should not be used if taking monoamine oxidase inhibitors (MAOIs) 2
• Cough medications should not be used in young children due to potential morbidity and mortality 1

Management of Subacute Cough

• Often represents a post-infectious cough following a respiratory infection 3

• Evaluate for potential contributing factors including:

  • Postviral airway inflammation 3
  • Bronchial hyperresponsiveness 3
  • Mucus hypersecretion 3
  • Upper airway cough syndrome (UACS) 3
  • Gastroesophageal reflux disease (GERD) 3

• Consider Bordetella pertussis infection if cough has lasted ≥2 weeks with paroxysms of coughing, post-tussive vomiting, or inspiratory whooping sound 3

Management of Chronic Cough

Diagnostic Approach

• Obtain chest radiograph to rule out significant pathology 4
• Check if patient is taking an ACE inhibitor, which can cause chronic cough - discontinue if possible 4
• Strongly advise smoking cessation, which can resolve cough symptoms within 4 weeks 4

Sequential Treatment Algorithm

1. First Step: Treat for asthma with inhaled corticosteroids combined with long-acting β-agonists 4
2. Second Step: If incomplete response, add treatment for Upper Airway Cough Syndrome with first-generation antihistamine/decongestant 4
3. Third Step: If still inadequate response, address GERD with proton pump inhibitors 4

Special Considerations

• Consider bronchoprovocation challenge to confirm asthma diagnosis if spirometry is normal 4
• Consider induced sputum testing for eosinophils or empiric trial of corticosteroids for suspected non-asthmatic eosinophilic bronchitis 4

Pharmacologic Options for Cough Suppression

Antitussives

• Dextromethorphan: Effective for symptomatic relief of dry or non-productive cough 5

  • Contraindicated in patients taking MAOIs 2
  • Should not be used if cough lasts more than 7 days or is accompanied by fever, rash, or persistent headache 2

• Codeine: Often used alone or in combination for non-specific cough, though evidence for effectiveness is mixed 5, 6

  • May be effective at high doses but associated with side effects 6

• Slow-release morphine: May be useful in controlling intractable cough with tolerance to constipation and drowsiness 6

Expectorants

• Guaifenesin: May help with cough that occurs with too much phlegm (mucus) 7
  • Should not be used if cough lasts more than 7 days, comes back, or is accompanied by fever, rash, or persistent headache 7

Other Agents

• Ipratropium bromide: Recommended as first-line treatment for cough suppression in certain patients 3
• Mucolytics: May improve mucus clearance in patients with bronchitis 3, 8
• Hypertonic saline solution: Recommended on short-term basis to increase cough clearance in patients with bronchitis 3

Red Flags Requiring Medical Attention

• Cough with hemoptysis 1
• Cough with 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
• Bilateral hazy infiltrates on chest x-ray (suggesting pneumonia) 9

Setting Up a Specialist Cough Clinic

Core Requirements

• Named consultant responsible for the service 1
• Staff with appropriate training 1
• Protocols to supervise treatment trials and assess cough severity 1
• Pulmonary function testing with spirometry 1
• Access to chest radiography and bronchial provocation challenge testing 1
• Facility to refer for oesophageal testing when appropriate 1
• ENT assessment capability 1
• Access to bronchoscopy and chest CT scanning 1
• Regular review of service outcomes 1

Common Pitfalls in Cough Management

• Failure to recognize that multiple causes of cough often coexist, requiring sequential and additive therapy 1
• Inappropriate use of antibiotics for viral causes of cough 1
• Over-reliance on over-the-counter cough medications despite limited evidence for effectiveness 10
• Failure to address environmental triggers and exacerbating factors like tobacco smoke 1
• Inadequate follow-up to assess treatment response 3