What is the best way to manage a severe cough?

Management of Severe Cough

Start with simple home remedies like honey and lemon as first-line treatment, then use dextromethorphan 60 mg for optimal cough suppression if pharmacological therapy is needed, avoiding codeine-based products entirely due to their poor safety profile without added efficacy. 1, 2

Initial Assessment: Rule Out Danger Signs

Before treating symptomatically, directly ask about and exclude these red flags requiring immediate specialist referral or specific treatment:

• Significant hemoptysis - requires bronchoscopy 1
• Foreign body inhalation - requires bronchoscopy 1
• Acute breathlessness with cough - assess for asthma or anaphylaxis 1
• Fever, malaise, purulent sputum - assess for pneumonia with chest examination; if tachycardia, tachypnea, fever, or abnormal chest findings present, rule out pneumonia before using antitussives 1, 2
• Voice change - may indicate vocal cord palsy 1

First-Line Non-Pharmacological Approach

Simple home remedies are as effective as many over-the-counter preparations and should be tried first:

• Honey and lemon mixtures provide symptomatic relief through central modulation of the cough reflex 1, 2, 3
• Voluntary cough suppression techniques can reduce cough frequency in many patients 1, 2
• These approaches avoid medication side effects and are the simplest, cheapest options 1, 2

Pharmacological Management Algorithm

When Non-Pharmacological Measures Fail

Dextromethorphan is the preferred antitussive agent:

• Optimal dosing: 60 mg provides maximum cough reflex suppression - standard over-the-counter doses (10-15 mg) are often subtherapeutic 1, 2, 3
• Dose-response relationship exists with prolonged effect at 60 mg 1, 2
• Critical safety warning: Check combination products carefully to avoid excessive acetaminophen or other ingredients when using higher doses 1, 3, 4
• Non-sedating opiate with superior safety profile compared to codeine 1, 2, 5
• FDA contraindication: Do not use if taking MAOIs or within 2 weeks of stopping MAOI therapy 4
• Contains sodium metabisulfite - may cause allergic reactions in susceptible individuals 4

Alternative and Adjunctive Options

For specific clinical scenarios:

• Menthol inhalation - provides acute but short-lived cough suppression; can be prescribed as menthol crystals or proprietary capsules 1, 2, 3
• First-generation sedative antihistamines - particularly useful for nocturnal cough disrupting sleep, though they cause drowsiness 1, 2, 3, 5
• Inhaled ipratropium - try before central antitussives for postinfectious cough 3, 5

For Severe Refractory Cases

If initial measures fail:

• Short-course prednisone 30-40 mg daily for severe paroxysms of postinfectious cough 3
• Consider this only after inhaled ipratropium and dextromethorphan have failed 3

What NOT to Use

Codeine and pholcodine are explicitly not recommended:

• No greater efficacy than dextromethorphan 1, 2, 3, 5
• Significantly worse adverse effect profile including drowsiness, nausea, constipation, and physical dependence 1, 2, 6
• The British Thoracic Society specifically advises against their use 1, 2

Critical Pitfalls to Avoid

• Using subtherapeutic dextromethorphan doses - most OTC preparations contain insufficient amounts for optimal effect 2, 3
• Prescribing codeine products - common error given their availability but no benefit over dextromethorphan with worse side effects 1, 2
• Not checking for pneumonia - patients with tachycardia, tachypnea, fever, or abnormal chest examination require pneumonia exclusion before antitussive use 2
• Using dextromethorphan for productive cough - contraindicated when secretion clearance is beneficial 3, 4
• Continuing treatment beyond 7 days without reassessment - if cough persists, returns, or occurs with fever, rash, or persistent headache, stop and reassess for serious underlying conditions 4

Duration and Follow-Up

• Dextromethorphan is for short-term symptomatic relief only 3
• Cough lasting more than 3 weeks requires full diagnostic workup rather than continued antitussive therapy 3
• Stop use and seek medical evaluation if cough persists beyond 7 days or returns 4

Special Populations

• Pregnancy and breastfeeding: Consult healthcare professional before use 4
• Chronic lung disease (asthma, emphysema, COPD): Ask physician before use 4
• Smokers: Encourage smoking cessation as it leads to significant cough remission 2