What is the best approach to suppress a cough in a hospital setting?

Cough Suppression in the Hospital Setting

The best approach to suppress cough in hospitalized patients depends critically on the underlying cause: for chronic bronchitis use codeine or dextromethorphan; for upper respiratory infections or chronic bronchitis use ipratropium bromide inhaler; and for lung cancer-related cough use hydrocodone or dihydrocodeine. 1

Etiology-Based Treatment Algorithm

For Chronic or Acute Bronchitis

Peripheral cough suppressants (levodropropizine, moguisteine) are the first-line agents with substantial benefit and good evidence. 1 These provide short-term symptomatic relief with fewer side effects than central agents. 1

Central cough suppressants (codeine, dextromethorphan) are recommended as second-line options with fair evidence and intermediate benefit. 1 Dextromethorphan requires dosing at 60 mg for maximum cough reflex suppression—standard over-the-counter doses of 15-30 mg are subtherapeutic. 2, 3

Ipratropium bromide inhaler is the only recommended inhaled anticholinergic agent for cough suppression in this population, with substantial benefit. 1, 3

For Upper Respiratory Infections (URI)

Central cough suppressants (codeine, dextromethorphan) have limited efficacy and are NOT recommended for URI-related cough despite their widespread use. 1, 2

Peripheral cough suppressants also have limited efficacy in URI and should not be used. 1

Ipratropium bromide inhaler remains the exception as the only agent with substantial benefit for URI-related cough. 1

For Cancer-Related Cough

Opioids are the best cough suppressants in patients with lung cancer, specifically hydrocodone (median effective dose 10 mg/day, range 5-30 mg/day) or dihydrocodeine (10 mg three times daily). 1 These have low-level evidence but intermediate benefit given the palliative context. 1

Levodropropizine (75 mg three times daily) is equally effective to dihydrocodeine with significantly less somnolence (8% vs 22%), though it is not available in the United States. 1

Benzonatate may be effective in 80% of patients with malignant pulmonary involvement and can work when opioids fail, though evidence is limited to small case series. 1, 3

Critical Medications to AVOID

Albuterol should NOT be used for cough not due to asthma—it provides no benefit. 1

Mucoactive agents that alter mucus characteristics are NOT recommended for cough suppression in chronic bronchitis. 1

Over-the-counter combination cold medications (except older antihistamine-decongestant combinations) are NOT recommended until proven effective in randomized trials. 1

Zinc preparations are NOT recommended for acute cough due to common cold. 1

Codeine and pholcodine have no greater efficacy than dextromethorphan but carry significantly worse side effect profiles including drowsiness, nausea, constipation, and physical dependence. 2, 3

Special Clinical Situations

Patients Requiring Intubation

Neuromuscular blocking agents are recommended to suppress coughing during general anesthesia with substantial benefit. 1

Patients with Neuromuscular Impairment

Protussive pharmacologic agents are ineffective and should NOT be prescribed. 1 Instead, manually assisted cough should be considered to reduce respiratory complications. 1

Patients with COPD/Airflow Obstruction

Manually assisted cough may be detrimental and should NOT be used in patients with airflow obstruction. 1

Adjunctive Therapies for Mucus Clearance

When cough clearance (not suppression) is the goal:

• Hypertonic saline and erdosteine are recommended short-term in bronchitis patients to increase cough clearance. 1
• Amiloride is recommended for adult cystic fibrosis patients to increase cough clearance. 1

Common Pitfalls to Avoid

Do not suppress cough when clearance is important—cough suppression may be relatively contraindicated in conditions where airway clearance is critical. 1

Do not continue ACE inhibitors in any patient with troublesome cough—this is one of the most common causes of persistent cough. 1

Do not ignore gastroesophageal reflux disease (GORD) as a cause—failure to consider this is a common reason for treatment failure, and reflux-associated cough may occur without GI symptoms. 1

Do not use standard dextromethorphan doses—therapeutic dosing requires 60 mg for maximum effect, and many combination products contain paracetamol requiring dose adjustment. 2, 3

Do not prescribe antitussives indefinitely—if cough persists beyond 3 weeks, reassessment is mandatory to rule out other causes rather than continuing symptomatic therapy. 3