Atrovent for Subacute Cough
Ipratropium bromide (Atrovent) should be used as first-line therapy for subacute post-infectious cough, as it has demonstrated efficacy in controlled trials for attenuating this condition with fewer systemic side effects. 1, 2
Understanding Subacute Cough
Subacute cough is defined as cough lasting 3-8 weeks 3. The critical first step is determining whether the cough followed a respiratory infection 3:
- If post-infectious: Treat with ipratropium bromide as outlined below
- If non-infectious: Manage as chronic cough with evaluation for upper airway cough syndrome (UACS), asthma, and GERD 3
Treatment Algorithm for Post-Infectious Subacute Cough
First-Line: Ipratropium Bromide
Prescribe inhaled ipratropium bromide 2-3 puffs (36-54 mcg) four times daily 1, 2. This anticholinergic agent works by:
- Interrupting vagally mediated bronchoconstriction 4
- Reducing mucus hypersecretion and airway irritation 1
- Demonstrating specific efficacy in post-viral cough in controlled trials 5
In a double-blind crossover trial of 14 non-smoking patients with persistent post-viral cough, ipratropium 320 mcg/day produced significantly less daytime and nighttime cough (P < 0.05), with 12 of 14 patients showing overall clinical improvement and 5 achieving complete resolution 5.
Second-Line Options (if no improvement in 1-2 weeks)
Add inhaled corticosteroids (e.g., budesonide or fluticasone) when cough persists and adversely affects quality of life 1, 2. These suppress airway inflammation and bronchial hyperresponsiveness 2.
Consider oral prednisone 30-40 mg daily for 5-7 days only for severe paroxysmal cough after ruling out asthma and GERD 1, 2.
Add central-acting antitussives (codeine 15-30 mg or dextromethorphan 30 mg every 6 hours) when other measures fail 1, 2.
Important Caveats
What NOT to Do
- Do not prescribe antibiotics for post-infectious cough—the cause is typically not bacterial and antibiotics are ineffective 1, 2, 6
- Do not use ipratropium for acute asthma exacerbations as monotherapy due to delayed onset of action (15 minutes vs. immediate with beta-agonists) 4
- Do not exceed 12 inhalations per day of ipratropium 4
FDA-Approved Indication Limitation
Note that ipratropium is FDA-approved only for maintenance treatment of bronchospasm in COPD (chronic bronchitis and emphysema), not specifically for cough 7. However, guideline evidence strongly supports its use in post-infectious subacute cough 1, 2.
When to Reassess
If cough persists beyond 8 weeks despite adequate ipratropium therapy, reclassify as chronic cough and systematically evaluate for 1, 2:
- UACS (treat with first-generation antihistamine/decongestant combination)
- Asthma/eosinophilic bronchitis (treat with inhaled corticosteroids)
- GERD (treat with high-dose PPI therapy for 8-12 weeks)
If all empiric therapies fail, obtain high-resolution CT chest and consider bronchoscopy to evaluate for bronchiectasis, interstitial disease, or endobronchial lesions 1.
Combination Therapy Consideration
Ipratropium can be combined with beta-agonists for enhanced bronchodilation if there is evidence of bronchial hyperresponsiveness 4, 8, 9. Studies show greater response with combination therapy than single-drug regimens in obstructive airway disease 8, 9.