What medications can be given to a patient with Upper Respiratory Tract Infection (URTI) associated cough?

Medications for URTI-Associated Cough

Inhaled ipratropium bromide is the only first-line medication recommended for URTI-associated cough, with substantial benefit and high-quality evidence (Grade A). 1, 2, 3

First-Line Treatment

Inhaled ipratropium bromide is the sole agent recommended as first-line therapy for URI-related cough based on American College of Chest Physicians (ACCP) guidelines. 1, 2

• Mechanism: Works through anticholinergic activity in the airways, with only 7% systemic absorption, minimizing side effects. 2
• Dosing: Standard inhaled formulation (36 μg or 2 inhalations four times daily). 3
• For nasal symptoms/postnasal drip: Ipratropium nasal spray 0.03% (42 mcg per nostril three times daily) specifically targets rhinorrhea. 3
• Evidence quality: Grade A recommendation with substantial benefit for URI-associated cough. 1, 2

Second-Line Options (Limited Use Only)

Benzonatate

• Can be offered for short-term symptomatic relief only in acute bronchitis, particularly for dry, bothersome cough disrupting sleep. 1
• Dosing: 100-200 mg three times daily. 1
• Evidence quality: Grade C recommendation (fair quality, small/weak benefit). 1
• Important caveat: Mixed evidence—one study showed benefit on days 3,5, and 6, but two other studies found no difference versus placebo. 1

Dextromethorphan and Codeine

• Only for dry, bothersome cough that disrupts sleep—NOT for routine URI cough. 4, 1
• Evidence quality: Grade C1 recommendation (fair quality) for this specific context. 1
• Critical limitation: ACCP does NOT recommend central cough suppressants (codeine, dextromethorphan) for URI-related cough due to limited efficacy (Grade D recommendation). 1, 2
• Multiple studies show these agents are no more effective than placebo for acute cough. 5, 6

What NOT to Use

The following medications should NOT be prescribed for URTI cough:

• Expectorants, mucolytics, antihistamines, and bronchodilators: Grade A1 recommendation against use in acute LRTI in primary care. 4
• Over-the-counter combination cold medications: Not recommended until proven effective in randomized trials. 1, 2
• Antihistamines alone: Three trials showed no benefit over placebo for cough symptoms. 5
• Nasal corticosteroids: Do NOT provide symptomatic relief from the common cold. 3

Clinical Algorithm

1. For dry, bothersome cough (especially disrupting sleep):

   • First choice: Inhaled ipratropium bromide 1, 2
   • Alternative: Benzonatate 100-200 mg three times daily for short-term relief 1

2. For productive cough with sputum:

   • Do NOT suppress cough—it serves a physiological function to clear mucus 1
   • Avoid antitussives in this scenario 1

3. For persistent post-URI cough (3-8 weeks):

   • Continue ipratropium as first-line treatment 2, 3
   • If ineffective, consider inhaled corticosteroids as second-line 3

Critical Caveats

• Rule out serious conditions first: Must exclude pneumonia, asthma, COPD exacerbation, or bacterial sinusitis before treating as simple URTI. 1, 3
• Self-limiting nature: Most URTI episodes resolve in 1-3 weeks without treatment. 1
• Antibiotics have no role: The cause is viral, not bacterial. 3
• Ipratropium limitations: Has no effect on nasal congestion, only rhinorrhea and cough. 3
• Pediatric considerations: There is no evidence that OTC cough and cold medicines are effective in children, and they carry potential risks. 6, 7, 8
• If cough persists beyond 8 weeks: Reconsider diagnosis and evaluate for upper airway cough syndrome, asthma, or gastroesophageal reflux disease rather than continuing symptomatic treatment. 3