What medications are recommended for different types of coughs, such as dry, productive, and allergic coughs, and those associated with underlying conditions like asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Medication Selection for Different Types of Cough

Chronic Bronchitis (Productive or Dry Cough)

For chronic bronchitis, use peripheral cough suppressants (levodropropizine, moguisteine) or central suppressants (codeine, dextromethorphan) for short-term symptomatic relief, and ipratropium bromide as the only recommended inhaled anticholinergic. 1

• Peripheral cough suppressants (levodropropizine, moguisteine) provide substantial benefit with Grade A recommendation for short-term relief 1
• Central cough suppressants (codeine, dextromethorphan) offer intermediate benefit with Grade B recommendation 1
• Ipratropium bromide is the only inhaled anticholinergic recommended for cough suppression in chronic bronchitis with Grade A recommendation 1, 2
• Hypertonic saline and erdosteine increase cough clearance on a short-term basis with Grade A recommendation 1, 3
• Agents that alter mucus characteristics are NOT recommended for cough suppression 1

Upper Respiratory Infection (URI) - Acute Viral Cough

For URI-related cough, avoid both peripheral and central cough suppressants as they have limited efficacy; instead use simple home remedies like honey and lemon, adequate hydration, and menthol lozenges. 1, 4, 3

• Peripheral cough suppressants have limited efficacy and carry Grade D recommendation (not recommended) 1
• Central cough suppressants (codeine, dextromethorphan) have limited efficacy with Grade D recommendation 1
• Honey and lemon mixtures are effective first-line approaches 4, 3
• Menthol lozenges or inhalation provide short-term suppression through cold and menthol receptors 4
• First-generation antihistamines with sedative properties help particularly for nocturnal cough 4, 3
• Over-the-counter combination cold medications (except older antihistamine-decongestant combinations) are not recommended until proven effective 1
• Zinc preparations carry Grade D recommendation 1, 4

Nonproductive Dry Cough (Non-URI Related)

For nonproductive dry cough, dextromethorphan is the first-line treatment due to substantial benefit and favorable safety profile, with maximum suppression at 60 mg doses. 4, 3

• Dextromethorphan is preferred over codeine with fewer side effects and better safety profile 4, 3
• Maximum cough reflex suppression occurs at 60 mg, though standard OTC preparations contain lower doses 4
• First-generation antihistamines with sedative properties are particularly helpful for nocturnal cough 4, 3
• Benzonatate can be considered for opioid-resistant cough when other options fail 4
• Codeine carries risks of respiratory depression, hypoventilation, drowsiness, and physical dependence 4

Idiopathic Chronic Cough

For idiopathic chronic cough (predominantly middle-aged women with heightened cough reflex), treatment is disappointing and limited to dextromethorphan, with weak evidence for baclofen, nebulized local anesthetics, and low-dose morphine. 1

• Dextromethorphan remains the non-specific antitussive of choice 1
• Baclofen and nebulized local anesthetics (lidocaine, mepivicaine) have weak evidence of benefit 1
• Low-dose morphine has recently shown helpfulness 1
• These patients typically present with long-standing chronic dry cough starting around menopause, often following viral infection 1
• Organ-specific autoimmune disease is present in up to 30%, particularly autoimmune hypothyroidism 1

Asthma-Related Cough

For cough not due to asthma, albuterol is NOT recommended with Grade D recommendation; treat the underlying asthma with appropriate controller medications rather than targeting cough specifically. 1

• Albuterol carries Grade D recommendation for acute or chronic cough not due to asthma 1
• The focus should be on treating underlying asthma with inhaled corticosteroids and bronchodilators as per asthma guidelines, not cough suppressants 1

COPD-Related Cough

For COPD-related cough, avoid manually assisted cough as it may be detrimental; teach huffing as an adjunct to sputum clearance, and consider inhaled corticosteroids for severe airflow obstruction. 1, 2

• Manually assisted cough may be detrimental in airflow obstruction and should not be used with Grade D recommendation 1
• Huffing should be taught as an adjunct to other sputum clearance methods with Grade C recommendation 1
• Inhaled corticosteroid therapy should be considered for severe airflow obstruction or frequent exacerbations as it reduces exacerbation rates and cough 2
• Cough suppression may be relatively contraindicated when cough clearance is important 1
• No studies have evaluated effectiveness of particular treatments on cough itself in COPD 1

Cystic Fibrosis (Adults)

For adult CF patients, use amiloride to increase cough clearance; recombinant DNase improves spirometry but does NOT increase cough clearance. 1

• Amiloride increases cough clearance with Grade A recommendation 1
• Recombinant DNase improves spirometry but carries Grade D recommendation for cough clearance 1
• Chest physiotherapy is effective for mucus clearance but effects are modest and long-term benefits unproven with Grade C recommendation 1
• Autogenic drainage should be taught as an adjunct to postural drainage with Grade C recommendation 1

Pneumonia and Bronchiectasis

For pneumonia and bronchiectasis, cough suppression is undesirable as cough clearance is important for these conditions. 1

• Cough clearance is important and suppression would be undesirable 1
• Treatment should focus on the underlying infection and airway clearance rather than cough suppression 1

Critical Pitfalls to Avoid

• Never use albuterol for cough not due to asthma 1
• Avoid antibiotics for nonproductive cough due to viral infections, even when phlegm is present 4
• Do not use expectorants, mucolytics, or bronchodilators for acute nonproductive cough 4
• Avoid codeine for URI-related cough as it has limited efficacy despite being effective in chronic bronchitis 1
• Caution with dextromethorphan combinations as some preparations contain paracetamol or other ingredients 4
• Do not suppress cough in conditions where clearance is important (pneumonia, bronchiectasis) 1

Red Flags Requiring Medical Attention

Patients should seek immediate medical attention for: 4

• Coughing up blood
• Breathlessness
• Prolonged fever and feeling unwell
• Underlying conditions (COPD, heart disease, diabetes, asthma)
• Recent hospitalization
• Symptoms persisting beyond three weeks