Treatment Options for Cough
The most effective approach to treating cough requires identifying and addressing the underlying cause through a systematic evaluation, followed by targeted therapy based on the specific diagnosis. 1
Initial Assessment and Classification
- Determine if cough is acute (< 3 weeks), subacute (3-8 weeks), or chronic (> 8 weeks) as this guides diagnostic approach and treatment 1, 2
- Assess for red flags requiring urgent evaluation: hemoptysis, weight loss, fever, recurrent pneumonia 2
- Obtain chest radiograph to rule out serious conditions like pneumonia, lung cancer, or interstitial disease 1
Common Causes and Targeted Treatments
Upper Airway Cough Syndrome (UACS)
- First-line treatment includes first-generation antihistamines with decongestants 1, 3
- For chronic rhinosinusitis, add intranasal corticosteroids 4
Asthma and Cough-Variant Asthma
- Inhaled corticosteroids are the cornerstone of treatment 5
- Consider bronchodilators for symptomatic relief 4
- Diagnosis confirmed by spirometry showing variable airflow obstruction or airway hyperresponsiveness 5
Gastroesophageal Reflux Disease (GERD)
- Dietary modifications and proton pump inhibitors are first-line treatments 1
- Consider adding prokinetic agents like metoclopramide if standard therapy fails 1
- Rigorous adherence to dietary measures is essential before considering surgical options 1
Nonasthmatic Eosinophilic Bronchitis
- Responds well to inhaled corticosteroids 5
- Diagnosis confirmed by sputum eosinophilia without airway hyperresponsiveness 5
Chronic Bronchitis
- Treat underlying COPD with bronchodilators and anti-inflammatories 1
- Mucolytics may help with productive cough 1
Drug-Induced Cough
- ACE inhibitors are common culprits; consider discontinuation if possible 1
- If medication cannot be stopped, symptomatic treatment may be necessary 1
Symptomatic Treatment Options
Non-Productive (Dry) Cough
- For temporary relief of dry cough due to minor throat and bronchial irritation, dextromethorphan is recommended 6
- Codeine and other opioid derivatives are effective but have side effects including drowsiness, nausea, constipation, and potential for dependence 1, 7
- For refractory chronic cough, consider gabapentin or pregabalin 4, 2
Productive Cough
- Avoid cough suppression when clearance of secretions is important (e.g., pneumonia, bronchiectasis) 1
- Consider mucolytics to facilitate expectoration 1
Cough in Lung Cancer
- Treat the underlying cancer with appropriate oncologic therapy 1
- For symptomatic relief, centrally acting cough suppressants such as hydrocodone are recommended 1
- Consider cough suppression exercises where available 1
Special Considerations
- In patients with aspiration risk, swallowing evaluation is essential before oral feeding 1
- For idiopathic chronic cough, options include dextromethorphan, low-dose morphine, baclofen, or nebulized local anesthetics 1
- Speech therapy and cough suppression techniques show promise for refractory cough 1, 2
Important Cautions
- Do not use dextromethorphan with MAOIs or within 2 weeks of stopping MAOIs 6
- Dextromethorphan contains sodium metabisulfite which may cause allergic reactions 6
- Seek medical attention if cough persists beyond 7 days, returns, or occurs with fever, rash, or persistent headache 6
- Cough suppression may be contraindicated when cough is a protective mechanism (e.g., pneumonia, bronchiectasis) 1
Treatment Algorithm
- Identify and treat the underlying cause first
- If specific diagnosis is made, use targeted therapy
- For symptomatic relief while awaiting diagnosis or response to treatment:
- For dry cough: dextromethorphan or codeine-based preparations
- For productive cough: mucolytics rather than suppressants
- For refractory cases: consider gabapentin/pregabalin and speech therapy