What are good cough medications to prescribe in the emergency room for acute coughs?

Cough Medications in the Emergency Department

For acute cough in the ED, the evidence does not strongly support most cough medications, but when pharmacological treatment is needed, dextromethorphan 60 mg is the preferred agent due to its superior safety profile compared to codeine, while ipratropium bromide is the only recommended inhaled option for URI-related cough. 1, 2

First-Line Approach

Start with non-pharmacological measures before prescribing medications:

• Simple home remedies like honey and lemon are as effective as many pharmacological treatments for benign viral cough and should be recommended first 1, 3
• Voluntary cough suppression techniques through central modulation may be sufficient to reduce cough frequency 1, 3
• Most acute viral cough is self-limiting, lasting 1-3 weeks, and often does not require prescribed medication 1

When Pharmacological Treatment is Indicated

Dextromethorphan (Preferred Antitussive)

Dosing is critical - standard OTC doses are subtherapeutic:

• Maximum cough suppression occurs at 60 mg, which is higher than typical OTC preparations 1, 3, 2
• Standard 30 mg doses provide only modest reduction (19-36%) in cough counts 3
• Dextromethorphan is a non-sedating opiate with a superior safety profile compared to codeine 1, 2, 4
• Use with caution as some combined preparations contain additional ingredients like paracetamol 1

Appropriate indications:

• Chronic or acute bronchitis for short-term symptomatic relief 5, 2
• Severe paroxysms of postinfectious cough when other measures fail 3, 2

Important limitation: Central cough suppressants like dextromethorphan have limited efficacy for URI-related cough and are not recommended for this indication 5, 1

Ipratropium Bromide (Inhaled Anticholinergic)

• The only inhaled anticholinergic agent recommended for cough suppression in URI or chronic bronchitis 5, 2
• Should be tried before central antitussives in postinfectious cough 3, 2
• Level of evidence: fair; benefit: substantial; grade of recommendation: A 5

First-Generation Antihistamines

• Sedative antihistamines can suppress cough but cause drowsiness 1, 3
• Particularly useful for nocturnal cough due to sedative effects 1, 3
• Antihistamine-decongestant combinations showed effectiveness in adults (not in children) 6

Menthol Inhalation

• Suppresses cough reflex when inhaled 1, 3
• Effect is acute and short-lived 1
• Can be prescribed as menthol crystals or proprietary capsules 1
• Useful for quick but temporary relief 3

Medications NOT Recommended

Codeine and Other Opioids

• Codeine has no greater efficacy than dextromethorphan but has a much worse adverse effect profile 1, 2, 7
• Causes drowsiness, nausea, constipation, and risk of physical dependence 2
• Pholcodine similarly has no efficacy advantage over dextromethorphan 1, 2

Other Agents to Avoid in Acute Cough

• Albuterol is not recommended for acute or chronic cough not due to asthma 5, 2
• Zinc preparations are not recommended for acute cough due to common cold 5
• Over-the-counter combination cold medications (except older antihistamine-decongestant) are not recommended 5
• Peripheral cough suppressants (levodropropizine, moguisteine) have limited efficacy for URI-related cough 5

Clinical Algorithm for ED Cough Management

Step 1: Rule out serious pathology

• Assess for pneumonia: tachycardia, tachypnea, fever, abnormal chest examination 1
• Evaluate for increasing breathlessness (asthma, anaphylaxis) 1
• Check for fever, malaise, purulent sputum (serious lung infection) 1
• Assess for significant hemoptysis or foreign body aspiration 1

Step 2: Determine cough type and duration

• URI-related cough: Consider ipratropium bromide 5, 2
• Acute/chronic bronchitis: Dextromethorphan 60 mg or peripheral suppressants 5, 2
• Postinfectious cough: Try ipratropium first, then dextromethorphan if needed 3, 2

Step 3: Non-pharmacological first

• Recommend honey and lemon 1, 3
• Teach voluntary cough suppression 1, 3

Step 4: Pharmacological options if needed

• Dextromethorphan 60 mg for bronchitis or severe symptoms 1, 3, 2
• Ipratropium bromide for URI-related cough 5, 2
• First-generation antihistamine for nocturnal cough 1, 3
• Menthol inhalation for quick temporary relief 1, 3

Step 5: Special circumstances

• Severe paroxysms of postinfectious cough: Consider prednisone 30-40 mg daily for short course 3, 2
• Suspected pertussis: Macrolide antibiotics with 5-day isolation 3

Critical Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (30 mg or less) - maximum suppression requires 60 mg 1, 3, 2
• Prescribing codeine-based antitussives - no efficacy advantage with worse side effects 1, 2
• Using central cough suppressants for URI-related cough - limited efficacy for this indication 5, 1
• Prescribing cough suppressants for productive cough - where secretion clearance is beneficial 3, 2
• Continuing antitussive therapy beyond 3 weeks - requires full diagnostic workup 2
• Not recognizing that dextromethorphan should not be used when pneumonia assessment is needed 1