What is the treatment for respiratory distress and cough?

Treatment of Respiratory Distress and Cough

For acute respiratory distress with cough, immediately assess for life-threatening causes requiring urgent intervention (foreign body aspiration, anaphylaxis, pneumonia, ARDS), provide supplemental oxygen to maintain saturation ≥94%, and address the underlying etiology before considering symptomatic cough suppression. 1, 2

Immediate Assessment and Stabilization

Critical Red Flags Requiring Emergency Management

• Sudden onset respiratory distress without fever or antecedent respiratory symptoms suggests foreign body airway obstruction (FBAO) rather than infection 1
• Increasing breathlessness with cough warrants immediate assessment for asthma or anaphylaxis 3
• Fever, malaise, purulent sputum, tachycardia, tachypnea, or abnormal chest examination indicates possible pneumonia requiring antibiotics, not cough suppressants 3, 4
• Significant hemoptysis requires specialist referral immediately 3

Oxygen Therapy

• Provide supplemental oxygen to maintain oxygen saturation ≥94% in patients with respiratory distress 1
• Use simple oxygen masks (30-50% FiO2) or non-rebreathing masks with 15 L/min flow for higher concentrations 1
• Nasal cannulas are suitable for spontaneously breathing patients with less severe distress 1
• Wean FiO2 when saturation reaches 100% to maintain ≥94% 1

Bronchodilator Therapy for Wheezing/Bronchospasm

• Administer albuterol 2.5 mg (one vial of 0.083% solution) via nebulization three to four times daily for bronchospasm 5
• Deliver over 5-15 minutes via nebulizer 5
• If previously effective dosage fails to provide relief, reassess immediately as this indicates worsening condition 5

Systematic Approach to Cough Management

Step 1: Identify and Treat Underlying Causes

A systematic approach to diagnosis and treatment is the most effective way to manage chronic cough 1

Common Treatable Causes to Address First:

• Smoking cessation is mandatory - smoking is one of the commonest causes of persistent cough and cessation leads to significant symptom remission 1
• Discontinue ACE inhibitors immediately - no patient with troublesome cough should continue these medications 1
• GORD (gastroesophageal reflux disease) - failure to consider this is a common reason for treatment failure; reflux-associated cough may occur without GI symptoms 1
  • Treat with intensive acid suppression using proton pump inhibitors and alginates for minimum 3 months 1
• Rhinosinusitis/upper airway disease - trial topical corticosteroid when prominent upper airway symptoms present 1
• Asthma/eosinophilic airway inflammation - trial 2-week oral steroid course; if no response, eosinophilic inflammation unlikely 1

Step 2: Symptomatic Cough Suppression

Cough suppression may be relatively contraindicated when cough clearance is important (e.g., pneumonia, bronchiectasis) 1

First-Line Non-Pharmacologic Approach:

• Simple home remedies: honey and lemon are the simplest, cheapest, and often effective first-line treatment 3, 4, 6
• Voluntary cough suppression through central modulation may reduce cough frequency 3, 4

First-Line Pharmacologic Options:

Dextromethorphan is the preferred antitussive due to superior safety profile compared to opioids 3, 6

• Effective dose is 60 mg for maximum cough reflex suppression - standard OTC doses (15-30 mg) are subtherapeutic 3, 4, 6
• Provides prolonged relief with dose-response relationship 3, 6
• Meta-analysis demonstrates effectiveness for acute cough 3, 6
• Caution: some preparations contain additional ingredients like paracetamol requiring dose adjustment 3, 4

Menthol by inhalation provides acute, short-lived cough suppression 3, 4, 6

• Prescribe as menthol crystals or proprietary capsules 3, 4
• Effect is immediate but temporary 3

Second-Line Options:

First-generation sedating antihistamines (e.g., chlorpheniramine) suppress cough but cause drowsiness 3, 4, 6

• Use specifically for nocturnal cough in patients who don't need to operate machinery 3, 4
• Sedative effect is valuable when cough disturbs sleep 7

Medications NOT Recommended:

Codeine and pholcodine have no greater efficacy than dextromethorphan but significantly worse adverse effects (drowsiness, nausea, constipation, physical dependence) 3, 4, 6

• Should not be used as first-line therapy 6, 8
• Codeine not shown to effectively treat cough from common cold 9

Step 3: Anticholinergic Therapy for Excessive Secretions

For dyspnea, cough, wheeze, and respiratory distress due to increased respiratory gland secretion, use selective M1/M3 receptor anticholinergic drugs 1

• Reduces secretion, relaxes airway smooth muscle, relieves airway spasm 1
• Improves pulmonary ventilation 1

Step 4: Specialized Interventions

Cough suppression exercises (education, identifying triggers, pursed lip breathing, swallowing, sipping water, breathing exercises) show promising results 1

• 88% improvement in speech pathology group vs 14% in controls 1
• Significant improvements in cough frequency, severity, and quality of life 1

Special Considerations

When Cough Persists Beyond 3 Weeks:

• Reassessment is mandatory rather than continuing antitussive therapy 4
• Evaluate for post-viral cough, pertussis, pneumonia, or chronic conditions 4
• Chronic cough (>8 weeks) requires investigation for asthma, GERD, post-nasal drip, or other treatable causes 4

Pediatric Considerations:

• Avoid codeine-containing medications in children due to potential for serious side effects including respiratory distress 1
• Honey may offer relief but is not better than dextromethorphan 1
• Over-the-counter cough and cold medicines should not be prescribed until proven effective 1

Combination Therapy Approach:

A combination of selected diagnostic testing and empirical trials of treatment is likely most cost-effective 1

• No single diagnostic protocol can be recommended 1
• Referral to specialist cough clinic should be encouraged for refractory cases 1

Common Pitfalls to Avoid

• Do not suppress cough when clearance is important (pneumonia, bronchiectasis) 1
• Do not prescribe subtherapeutic doses of dextromethorphan (15-30 mg); use 60 mg 3, 4, 6
• Do not continue ACE inhibitors in patients with troublesome cough 1
• Do not miss GORD as underlying cause - may occur without GI symptoms 1
• Do not use antitussives as substitute for proper diagnosis when cough becomes chronic 4