Tessalon Perles (Benzonatate) Should Generally Be Avoided in COPD Exacerbations
Benzonatate is not recommended for cough suppression during COPD exacerbations because cough serves a protective function to clear increased mucus and secretions, and suppressing this mechanism could worsen outcomes. The available COPD exacerbation guidelines do not include benzonatate as part of standard management, and the focus should be on treating the underlying exacerbation rather than suppressing the cough reflex 1.
Why Cough Suppression Is Problematic in COPD Exacerbations
The Protective Role of Cough
- During COPD exacerbations, patients experience increased sputum production and mucus accumulation as part of the inflammatory process 1
- Cough is a critical mechanism for clearing these secretions and maintaining airway patency 1
- Suppressing cough with agents like benzonatate could lead to mucus retention, worsening gas exchange, and potentially increasing the risk of respiratory failure 1
Standard Management Priorities
The goals of COPD exacerbation management focus on improving airflow, reducing inflammation, and facilitating secretion clearance—not suppressing cough 1:
- Short-acting bronchodilators (beta-agonists and/or anticholinergics) are the cornerstone of acute symptom management 1
- Systemic corticosteroids reduce inflammation and improve clinical outcomes 1
- Antibiotics when indicated (presence of increased dyspnea, increased sputum volume, and purulent sputum) 1
- Encouraging sputum clearance through coughing is explicitly recommended 1
Evidence-Based Approach to Cough in COPD Exacerbations
What the Guidelines Recommend
The American Academy of Family Physicians (AAFP) 2021 guidelines emphasize that standard therapy for COPD exacerbations includes bronchodilators, corticosteroids, and antibiotics when appropriate—with no mention of cough suppressants 1. The GOLD 2017 guidelines similarly focus on bronchodilation and anti-inflammatory therapy without recommending antitussive agents 1.
Addressing Cough Appropriately
Rather than suppressing cough, the evidence supports:
- Bronchodilator therapy can indirectly reduce cough by improving airflow obstruction 1
- Ipratropium bromide has been shown to reduce cough frequency and severity in chronic bronchitis patients 1
- Encouraging fluid intake to help thin secretions 1
- Avoiding sedatives and hypnotics that could suppress respiratory drive 1
Critical Safety Considerations
Respiratory Depression Risk
- Benzonatate is a cough suppressant that works by anesthetizing stretch receptors in the respiratory tract
- In patients with COPD exacerbations who already have compromised respiratory function, suppressing the cough reflex could precipitate respiratory failure
- These patients may have borderline gas exchange with PaO2 levels that make them vulnerable to further respiratory compromise 1
When Cough Requires Attention
If cough is particularly severe or distressing during a COPD exacerbation:
- Optimize bronchodilator therapy first with short-acting beta-agonists and anticholinergics 1
- Ensure adequate corticosteroid treatment to reduce airway inflammation 1
- Treat any underlying infection with appropriate antibiotics if indicated 1
- Consider whether the patient is responding to standard therapy or requires escalation of care 1
Common Pitfalls to Avoid
- Do not reflexively prescribe cough suppressants for any cough in COPD patients—distinguish between stable disease and acute exacerbations 1
- Do not mistake productive cough for a symptom requiring suppression—it is a necessary clearance mechanism during exacerbations 1
- Do not use sedating medications including cough suppressants that could worsen respiratory status 1
- Reassess within 48 hours if managing outpatient to ensure the patient is improving with standard therapy 1
The Bottom Line
Focus treatment on the underlying COPD exacerbation with bronchodilators, corticosteroids, and antibiotics when indicated, rather than suppressing the protective cough reflex with benzonatate 1. If cough remains problematic despite optimal exacerbation management, this suggests inadequate treatment of the exacerbation itself or the need for hospital evaluation rather than addition of a cough suppressant 1.