What is the management and treatment for coughing?

Management and Treatment of Cough

For acute viral cough, the simplest and most cost-effective approach is a home remedy such as honey and lemon, as prescribed treatments are largely unnecessary and most over-the-counter preparations show little evidence of specific pharmacological benefit. 1

Acute Cough Management

Initial Assessment

• Determine if the cough reflects a serious illness (pneumonia, pulmonary embolism) versus a benign respiratory tract infection, exacerbation of pre-existing conditions (COPD, asthma), or environmental exposure 1
• Physical examination findings suggesting pneumonia include dullness on percussion, bronchial breathing, and crackles on auscultation 1

Treatment Approach for Acute Viral Cough

Acute viral cough is almost invariably benign and prescribed treatment can be regarded as unnecessary 1

First-Line Recommendations:

• Home remedies such as honey and lemon are the simplest and cheapest option 1
• Simple voluntary suppression of cough may be sufficient to reduce cough frequency through central modulation of the cough reflex 1

Pharmacological Options (if symptomatic relief needed):

Dextromethorphan:

• The generally recommended dosage is probably subtherapeutic 1
• Maximum cough reflex suppression occurs at 60 mg and can be prolonged 1
• However, evidence is conflicting: one meta-analysis showed benefit 1, but a well-conducted study found a single 30 mg dose provided very little if any clinically significant antitussive activity 2
• FDA-approved for temporary relief of cough due to minor throat and bronchial irritation 3

Menthol:

• Suppresses the cough reflex acutely but effect is short-lived 1
• May be prescribed as menthol crystals or proprietary capsules 1

Sedative antihistamines:

• First-generation antihistamines with sedative properties suppress cough but cause drowsiness 1
• May be suitable specifically for nocturnal cough 1

Codeine or pholcodine:

• These opiate antitussives have no greater efficacy than dextromethorphan but have a much greater adverse side effect profile and are NOT recommended 1

Important Caveats:

• A Cochrane review found no good evidence for or against the effectiveness of OTC medicines in acute cough, with many studies showing conflicting results 4, 5
• Over-the-counter combination cold medications (except older antihistamine-decongestant combinations) are not recommended until randomized controlled trials prove effectiveness 1
• Preparations containing zinc are not recommended for acute cough due to the common cold 1

Postinfectious Cough (Subacute: 3-8 weeks)

Diagnostic Criteria:

• Cough present following acute respiratory infection for at least 3 weeks but not more than 8 weeks 1
• If cough persists beyond 8 weeks, consider diagnoses other than postinfectious cough 1

Treatment Algorithm:

Step 1: Identify contributing factors - postviral airway inflammation, bronchial hyper-responsiveness, mucus hypersecretion, upper airway cough syndrome (UACS), asthma, or GERD 1

Step 2: Antibiotics have NO role as the cause is not bacterial infection 1

Step 3: Inhaled ipratropium - consider a trial as it may attenuate the cough (Grade B evidence) 1

Step 4: Inhaled corticosteroids - if cough adversely affects quality of life and persists despite ipratropium 1

Step 5: Oral corticosteroids - for severe paroxysms, prescribe 30 to 40 mg prednisone daily for a short, finite period after ruling out other common causes (UACS, asthma, GERD) 1

Step 6: Central antitussives - codeine and dextromethorphan should be considered when other measures fail 1

Pertussis Considerations:

• Suspect when cough lasts ≥2 weeks with paroxysms, post-tussive vomiting, and/or inspiratory whooping sound 1
• Obtain nasopharyngeal aspirate or swab for culture confirmation 1

Chronic Cough Management (>8 weeks)

Systematic Evaluation Approach:

Key Initial Steps:

• Determine if patient is on an ACE inhibitor - no patient with troublesome cough should continue ACE inhibitors 1
• Assess smoking status - smoking cessation should be encouraged as it is dose-related and accompanied by significant remission 1

Common Causes to Address Sequentially:

1. Eosinophilic Airway Disease (Asthma/NAEB):

• Cough may be the only manifestation 1
• No currently available tests can reliably exclude a corticosteroid-responsive cough 1
• Cough is unlikely to be due to eosinophilic airway inflammation if there is no response to a two-week oral steroid trial 1
• For confirmed non-asthmatic eosinophilic bronchitis (NAEB), first-line treatment is inhaled corticosteroids 1

2. Gastroesophageal Reflux Disease (GERD):

• Failure to consider GERD is a common reason for treatment failure 1
• Reflux-associated cough may occur in the absence of gastrointestinal symptoms 1
• Intensive acid suppression with proton pump inhibitors and alginates should be undertaken for a minimum of 3 months 1
• Add prokinetic agents like metoclopramide and rigorous dietary measures before labeling as medically refractory 1

3. Upper Airway Cough Syndrome (Rhinosinusitis):

• Commonly associated with chronic cough 1
• In the presence of prominent upper airway symptoms, a trial of topical corticosteroid is recommended 1

4. Chronic Bronchitis:

• Long-acting β-agonist coupled with inhaled corticosteroid should be offered to control chronic cough (Grade A evidence) 1
• For FEV1 <50% predicted or frequent exacerbations, inhaled corticosteroid therapy should be offered (Grade A evidence) 1
• Central cough suppressants (codeine, dextromethorphan) are recommended for short-term symptomatic relief (Grade B evidence) 1
• Peripheral cough suppressants (levodropropizine, moguisteine) are recommended for short-term symptomatic relief (Grade A evidence) 1

Advanced Evaluation (if initial treatments fail):

• HRCT scan to evaluate for bronchiectasis or occult interstitial disease 1
• Bronchoscopy to look for occult airway disease (endobronchial tumor, sarcoidosis, eosinophilic or lymphocytic bronchitis) 1
• Consider uncommon causes: nonacid reflux disease, swallowing disorder, congestive heart failure 1

Important Clinical Pitfalls:

• Sequential and additive therapy may be crucial because more than one cause of cough may be present 1
• Adequate treatment duration is essential - many treatments require weeks to months for full effect 1
• Quality of life assessment should be included using validated instruments like the Leicester Cough Questionnaire 1
• Referral to a specialist cough clinic should be considered before labeling cough as unexplained/idiopathic 1

Medications to AVOID:

• Albuterol for cough not due to asthma (Grade D evidence) 1
• Expectorants (guaifenesin) - no evidence of effectiveness in stable chronic bronchitis 1, 6
• Long-term oral corticosteroids in stable chronic bronchitis - no benefit and high risk of serious side effects 1
• Theophylline for acute exacerbation of chronic bronchitis (Grade D evidence) 1