What is the recommended dosing for ipratropium (Inhalation, Anticholinergic) for treating a cough?

Ipratropium Dosing for Cough

For postinfectious cough in adults, use inhaled ipratropium bromide 2 puffs (36 mcg total) four times daily as the first-line pharmacologic treatment, as this is the only therapy with fair evidence supporting its use for cough suppression. 1

Clinical Context for Use

Ipratropium should be considered specifically for:

• Postinfectious cough lasting 3-8 weeks following an upper respiratory infection, where the cough is self-limited but troublesome 1
• Chronic bronchitis-related cough, where ipratropium is the only inhaled anticholinergic with Grade A evidence (fair evidence, substantial benefit) for cough suppression 2
• Cough that has not responded to observation alone and is adversely affecting quality of life 1

Standard Dosing Regimens

Metered-Dose Inhaler (MDI) - Preferred for Cough

• Adults: 2 puffs (36 mcg total) four times daily on a regular schedule 3, 4
• Each puff delivers 18 mcg of ipratropium bromide 1, 5
• Maximum 12 inhalations per day 6

Nebulized Solution

• Adults: 500 mcg (0.5 mg) three to four times daily, with doses 6-8 hours apart 4
• This is the FDA-approved dosing for maintenance therapy 4

Treatment Algorithm

Step 1: Confirm the diagnosis is postinfectious cough (3-8 weeks duration following respiratory infection) and rule out bacterial sinusitis, pertussis, upper airway cough syndrome, asthma, or GERD 1

Step 2: Initiate ipratropium bromide MDI 2 puffs four times daily 1, 3

Step 3: If inadequate response after trial of ipratropium, escalate to inhaled corticosteroids when cough adversely affects quality of life 1

Step 4: For severe paroxysmal cough unresponsive to ipratropium, consider prednisone 30-40 mg daily for a short course after excluding other common causes 1

Step 5: Reserve centrally-acting antitussives (codeine, dextromethorphan) for when other measures fail 1

Evidence Quality and Strength

The recommendation for ipratropium in postinfectious cough carries Grade B evidence (fair evidence, intermediate benefit) from the American College of Chest Physicians guidelines 1. This is notably the only pharmacologic intervention with fair-quality evidence for this indication—all other treatments (inhaled corticosteroids, oral corticosteroids, antitussives) carry only expert opinion-level evidence 1.

One controlled trial demonstrated that ipratropium 320 mcg daily (equivalent to 2 puffs four times daily) significantly reduced daytime and nighttime cough (p<0.05) in non-smoking adults with protracted post-viral cough, with 12 of 14 patients showing clinical improvement and 5 achieving complete resolution 7.

Critical Caveats

• Antibiotics have no role in treating postinfectious cough, as the cause is not bacterial infection (Grade I evidence—expert opinion, no benefit) 1
• Ipratropium has a delayed onset of action (within 15 minutes) compared to beta-agonists, making it unsuitable as monotherapy for acute bronchospasm 6
• Not for asthma exacerbations: While ipratropium can be added to beta-agonists in severe asthma, it should not be used as first-line therapy for cough in asthmatic patients 1, 5
• If cough persists beyond 8 weeks, reconsider the diagnosis—this is no longer postinfectious cough 1
• Ensure proper inhaler technique to maximize drug delivery to the lungs 3, 2

Adverse Effects

Side effects are generally mild and include:

• Dry mouth and respiratory secretions 1, 2
• Cough, nausea, nervousness, gastrointestinal distress (all mild) 6
• Increased wheezing in some individuals (rare) 1