Treatment of Cough in Upper Respiratory Infections
For cough due to upper respiratory infections (URIs), ipratropium bromide inhaler is the only recommended medication with substantial evidence of benefit, while commonly used over-the-counter cough suppressants like dextromethorphan and codeine have limited to no efficacy and are not recommended. 1
First-Line Recommended Treatment
Ipratropium bromide inhaler is the only inhaled anticholinergic agent recommended for cough suppression in URI, with a Grade A recommendation based on fair evidence showing substantial benefit. 1 This represents the strongest evidence-based recommendation from the American College of Chest Physicians (ACCP) guidelines specifically for URI-related cough.
What Does NOT Work (Despite Common Use)
The following medications are specifically not recommended for URI cough based on good evidence:
Central cough suppressants (codeine, dextromethorphan) have limited efficacy for symptomatic relief in URI and are not recommended (Grade D recommendation). 1 Multiple studies show these agents fail to demonstrate clinically significant benefit in acute URI cough. 1, 2
Peripheral cough suppressants have limited efficacy in URI and are not recommended (Grade D). 1
Expectorants and mucolytics show no consistent favorable effect and are not recommended (Grade I). 1
Albuterol is not recommended for acute cough not due to asthma (Grade D). 1
Over-the-counter combination cold medications (except older antihistamine-decongestant combinations) are not recommended until proven effective (Grade D). 1
Alternative Symptomatic Options
If symptomatic treatment is desired despite limited evidence:
Simple home remedies like honey and lemon may provide relief through central modulation of the cough reflex and are the simplest, cheapest option. 1, 3
Dextromethorphan at higher doses (60 mg) may provide some benefit, though standard over-the-counter dosing is subtherapeutic. 1, 3 However, this contradicts the ACCP Grade D recommendation against its use in URI. 1
Menthol inhalation provides acute but short-lived cough suppression. 1, 3
Important Clinical Caveats
Most acute viral URI coughs are self-limited, lasting 2-3 weeks, and resolve without treatment. 1
If cough persists beyond 3 weeks, reassessment is mandatory to rule out other causes (post-viral cough, pertussis, pneumonia, asthma, GERD) rather than continuing antitussive therapy. 3, 4
The widespread use of OTC cough medicines is not supported by evidence—a Cochrane review found no good evidence for or against their effectiveness in acute cough. 5, 6
In children specifically, there is no evidence that OTC cough and cold medicines are effective, and they carry potential risks. 6, 7
Practical Algorithm
- Confirm diagnosis of URI (exclude pneumonia, asthma exacerbation, COPD exacerbation)
- First choice: Ipratropium bromide inhaler 1
- If unavailable or patient prefers oral treatment: Simple home remedies (honey and lemon) 1, 3
- Avoid prescribing: codeine, standard-dose dextromethorphan, expectorants, mucolytics, or combination products 1
- Reassess if cough persists >3 weeks for alternative diagnoses 3, 4