What is a good additional inhaler to help with constant cough in a patient with Chronic Obstructive Pulmonary Disease (COPD) on Breztri (budesonide, glycopyrrolate, and formoterol)?

Managing Persistent Cough in COPD Patients on Breztri

Add ipratropium bromide (short-acting anticholinergic) 36 μg (2 inhalations) four times daily as the most evidence-based intervention for persistent cough in COPD patients already on triple therapy. 1, 2, 3

Why Ipratropium Bromide is the Optimal Choice

Ipratropium bromide has the strongest evidence (Grade A recommendation) specifically for reducing cough in stable COPD patients with chronic bronchitis. 1, 2, 3 This is critical because your patient is already on Breztri (budesonide/glycopyrrolate/formoterol), which contains a long-acting anticholinergic (glycopyrrolate), but the addition of a short-acting anticholinergic addresses the immediate cough reflex more effectively. 1

Evidence Supporting Ipratropium for Cough

• Ipratropium bromide demonstrates substantial benefit for cough reduction with significant decreases in cough frequency, cough severity, and volume of sputum expectorated in patients with chronic bronchitis. 1, 3

• The effects of ipratropium on cough are more reliable and consistent compared to short-acting β-agonists, which show inconsistent results for cough improvement. 1

• Standard dosing is ipratropium bromide 36 μg (2 inhalations) four times daily. 1, 2

Treatment Algorithm

Step 1: Add Ipratropium Bromide

• Start with ipratropium bromide 36 μg (2 inhalations) four times daily while continuing Breztri. 1, 2
• Monitor for improvement in cough frequency and severity after starting treatment. 1

Step 2: If Inadequate Response After 2 Weeks

• Consider adding a short-acting β-agonist (albuterol 200-400 μg four times daily) for additional bronchodilation and potential cough relief. 1, 3
• Short-acting β-agonists may help control cough in some patients, though effects are less consistent than ipratropium. 3

Step 3: For Temporary Symptomatic Relief

• If cough remains particularly troublesome and requires temporary suppression, codeine or dextromethorphan can reduce cough counts by 40-60%. 2, 3
• These antitussive agents should only be used for short-term symptomatic relief when cough is especially bothersome. 3

Important Caveats and Pitfalls

What NOT to Do

• Do not add expectorants – currently available expectorants have not been proven effective for cough in chronic bronchitis and should not be used. 2, 3

• Do not add oral corticosteroids for stable COPD due to lack of evidence of benefit and well-known side effects. 3

• Do not use theophylline during acute exacerbations if they occur, though it may be considered for stable chronic cough with careful monitoring for complications. 1, 2

Critical Considerations

• Ensure proper inhaler technique with the current Breztri regimen, as suboptimal technique can significantly reduce drug delivery and efficacy. 4

• Address smoking status if applicable – smoking cessation is the most effective means to improve or eliminate cough in chronic bronchitis, with 90% of patients reporting resolution after cessation. 2

• If the patient has severe airflow obstruction (FEV1 <50%) or frequent exacerbations, the current Breztri regimen is appropriate, but the persistent cough warrants the additional ipratropium. 1, 5

When to Escalate Care

If cough persists despite adding ipratropium bromide and optimizing inhaler technique, consider:

• Evaluating for acute exacerbation requiring systemic corticosteroids (10-15 day course). 2
• Assessing for other causes of chronic cough beyond COPD/chronic bronchitis. 1
• Referral to pulmonary specialist for further evaluation if cough remains refractory to standard therapy. 6