Is Tessalon Perles (Benzonatate) appropriate for a patient with COPD (Chronic Obstructive Pulmonary Disease) exacerbation and pneumonia who complains of a dry cough?

Benzonatate (Tessalon Perles) Use in COPD Exacerbation with Pneumonia

You should not order Tessalon Perles (benzonatate) for this patient with COPD exacerbation and pneumonia presenting with dry cough. The priority in this clinical scenario is treating the underlying infectious exacerbation with appropriate bronchodilators and antibiotics, not suppressing the cough reflex.

Why Cough Suppression is Inappropriate Here

In patients with COPD exacerbation and pneumonia, cough serves a protective function to clear secretions and pathogens from the airways. Suppressing this mechanism could impair mucus clearance and worsen outcomes 1, 2.

• The European Respiratory Society guidelines specify that when pneumonia is suspected with acute cough, the focus should be on treating the underlying infection, not symptom suppression 1.
• COPD exacerbations are characterized by increased mucus production, cough, and sputum purulence—these are physiologic responses that aid in clearing bacterial pathogens like Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2, 3.

What Should Be Prescribed Instead

The evidence-based approach for this patient includes:

Bronchodilator Therapy (First-Line)

• Short-acting β-agonists and/or anticholinergic bronchodilators should be administered during acute exacerbation 1.
• If the patient doesn't show prompt response, add the other agent after maximizing the first 1.
• These medications improve cough in COPD patients while treating bronchospasm and dyspnea 1.

Antibiotic Therapy

• Antibiotics should be given when all three cardinal symptoms are present: increased dyspnea, increased sputum volume, and increased sputum purulence 1.
• With concurrent pneumonia confirmed, antibiotic treatment is definitively indicated 1.
• First-choice antibiotics include amoxicillin or tetracycline derivatives; macrolides (azithromycin, clarithromycin) are alternatives in penicillin-allergic patients 1.

Systemic Corticosteroids

• While systemic corticosteroids are standard for COPD exacerbations, evidence suggests they may not provide clinical benefit when pneumonia is also present 4.
• A 2018 study found no difference in length of stay, treatment failure, or mortality when steroids were used in patients with both COPD exacerbation and pneumonia 4.

When Cough Suppressants Might Be Considered

Only in stable COPD patients with chronic dry cough that is bothersome and non-productive should antitussives be considered 1.

• The European Respiratory Society states that dextromethorphan or codeine can be prescribed for dry, bothersome cough in stable lower respiratory tract infections 1.
• This recommendation explicitly does not apply to acute exacerbations with pneumonia 1.

Critical Diagnostic Considerations

Ensure pneumonia diagnosis is accurate, as it is frequently underdiagnosed in COPD patients:

• Chest radiography is mandatory to confirm pneumonia and exclude other causes like pneumothorax, pulmonary edema, or lung cancer 2, 3.
• A 2019 study found that only 42.9% of COPD patients with radiographic consolidation received a discharge diagnosis of pneumonia, indicating significant underdiagnosis 5.
• Sputum culture should be obtained when purulent sputum is present or in severe exacerbations requiring hospitalization 2, 3.

Common Pitfall to Avoid

Do not assume all acute respiratory worsening in COPD represents simple exacerbation—cardiovascular conditions (heart failure, acute coronary syndrome, pulmonary embolism, atrial fibrillation) can trigger or mimic COPD exacerbation and require different management 2, 3.