What is the treatment for post-viral cough?

Post-Viral Cough Treatment

Inhaled ipratropium bromide (2-3 puffs four times daily) should be your first-line treatment for post-viral cough, as it has the strongest evidence for efficacy with minimal side effects. 1

Treatment Algorithm

First-Line Therapy

• Start with inhaled ipratropium bromide as it has demonstrated efficacy in controlled trials for attenuating post-infectious cough 1, 2
• This should be the initial pharmacologic intervention when cough is distressing or affecting quality of life 1
• Antibiotics have no role unless bacterial infection is confirmed—they provide no benefit for viral cough and contribute to resistance and adverse effects including C. difficile infection 1, 2, 3

Second-Line Therapy

• Add inhaled corticosteroids if cough persists despite ipratropium or when cough adversely affects quality of life 1
• The mechanism involves suppression of airway inflammation and bronchial hyperresponsiveness that persists after viral infection 1
• Consider adding a first-generation antihistamine/decongestant combination (brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine) starting once-daily at bedtime for 2-3 days, then advance to twice-daily to minimize sedation 2
• Add intranasal corticosteroid spray (fluticasone or mometasone) to decrease airway inflammation 2

For Severe Paroxysmal Cough

• Oral prednisone (30-40 mg daily) for a short, finite period may be prescribed for severe paroxysms of post-infectious cough 1
• This should only be used after ruling out other common causes such as upper airway cough syndrome, asthma, or gastroesophageal reflux disease 1

When Other Measures Fail

• Central-acting antitussive agents such as dextromethorphan or codeine should be considered when other treatments fail 1
• Dextromethorphan at 60 mg provides maximum cough reflex suppression and is preferred over codeine due to fewer side effects 4
• Codeine and pholcodine have no greater efficacy than dextromethorphan but carry a much greater adverse side effect profile including drowsiness, nausea, constipation, and physical dependence 4, 5
• Menthol by inhalation provides acute but short-lived cough suppression 4
• First-generation sedating antihistamines may be suitable specifically for nocturnal cough 4

Simple Supportive Measures

• "Home remedies" such as honey and lemon can be recommended as the simplest and cheapest initial advice 4
• Simple voluntary suppression of cough may be sufficient to reduce cough frequency through central modulation of the cough reflex 4
• Honey has some evidence in pediatric studies for relieving post-viral acute cough 6

Critical Time Thresholds and Red Flags

Duration Definitions

• Post-infectious cough is defined as cough persisting for 3-8 weeks following acute respiratory infection 1, 3
• If cough persists beyond 8 weeks, it must be reclassified as chronic cough and systematically evaluated for other causes including upper airway cough syndrome, asthma, eosinophilic bronchitis, and GERD 1, 3

Pertussis Must Be Ruled Out

• When cough lasts ≥2 weeks with paroxysms, post-tussive vomiting, or inspiratory whooping sound, consider pertussis infection 1, 2, 3
• Obtain nasopharyngeal culture immediately as this is the gold standard for diagnosis 1, 2, 3
• Macrolide antibiotics (azithromycin or clarithromycin) are indicated for confirmed pertussis, and patients should be isolated for 5 days from the start of treatment 1, 2
• Early macrolide treatment diminishes paroxysms and prevents transmission, even in vaccinated patients with breakthrough infections 2

Other Warning Signs

• Tachypnea (≥24 breaths/min), tachycardia (≥100 bpm), fever (≥38°C), or focal lung findings suggest pneumonia and require immediate evaluation 3
• Asymmetrical lung sounds, focal consolidation, or pleural effusion warrant chest radiography to exclude serious pathology 3

Systematic Evaluation if Treatment Fails After 2 Weeks

• After 2 weeks of adequate therapy without improvement, evaluate sequentially for asthma/non-asthmatic eosinophilic bronchitis and GERD 2
• For patients with severe cough and vomiting fitting the clinical profile for GERD, prescribe antireflux treatment even without typical GI symptoms, as GERD can present with cough alone 2
• High-dose PPI therapy (omeprazole 40 mg twice daily), dietary modifications, and lifestyle changes should be initiated 2
• GERD-related cough may require 2 weeks to several months (sometimes 8-12 weeks) for response, so adequate treatment duration is essential before declaring failure 2

Common Pitfalls to Avoid

• Never prescribe antibiotics for post-infectious viral cough unless bacterial infection is confirmed 1, 2, 3
• Do not use nasal decongestant sprays for more than 3-5 days due to rebound congestion risk 2
• Failing to recognize when post-infectious cough has persisted beyond 8 weeks, which requires reclassification as chronic cough 1, 3
• Overlooking underlying conditions that may contribute to persistent cough (asthma, upper airway cough syndrome, GERD) 1
• Do not assume GERD is ruled out simply because of prior antireflux surgery, as reflux can persist 2

Follow-Up and Monitoring

• Patients should be followed up within 4-6 weeks after initial evaluation 1
• If cough persists beyond 8 weeks, further evaluation for chronic cough causes is warranted 1
• Treatment response should be assessed using validated cough severity tools 1