Treatment of Cough in Patients with Asthma or COPD: Role of Levosalbutamol
For patients with cough and underlying asthma or COPD, levosalbutamol (R-salbutamol) can be used as a bronchodilator, but it should not be used as monotherapy for cough—instead, combine it with ipratropium bromide for COPD exacerbations, or with inhaled corticosteroids for asthma-related cough. 1, 2
Disease-Specific Treatment Algorithms
For Asthma-Related Cough
Initiate combination therapy immediately with inhaled corticosteroids PLUS inhaled bronchodilators (such as levosalbutamol) for any chronic cough due to asthma, whether cough is the sole symptom or accompanies wheezing and dyspnea 2
Never use beta-agonists as monotherapy for asthma cough, as LABA monotherapy increases the risk of serious asthma-related events 2
If initial response is incomplete, escalate sequentially: first increase the inhaled corticosteroid dose, then add a leukotriene receptor antagonist, and only consider oral corticosteroids (40-60 mg daily for 1-2 weeks) after these steps fail 2
Avoid newer non-sedating antihistamines entirely—they are completely ineffective for asthma cough and should not be prescribed 2
For COPD/Chronic Bronchitis-Related Cough
Use ipratropium bromide as first-line therapy to improve cough in stable chronic bronchitis, as it has demonstrated superior efficacy over beta-agonists alone 1, 3
For acute exacerbations, administer short-acting beta-agonists (including levosalbutamol) OR anticholinergic bronchodilators; if no prompt response occurs, add the other agent after maximizing the first 1
Combination therapy is superior: nebulized salbutamol with ipratropium bromide produces a 77% improvement in peak flow versus 31% with salbutamol alone in acute airflow obstruction 4
Dosing for acute exacerbations: ipratropium 0.5 mg via nebulizer every 20 minutes for 3 doses, then every 4-6 hours until clinical improvement 3
Theophylline may be considered for stable chronic bronchitis to control cough, but requires careful monitoring for complications and should NOT be used during acute exacerbations 1
Levosalbutamol-Specific Considerations
Clinical utility is established in real-world settings: levosalbutamol-containing bronchodilatory cough formulations improved mean cough scores from 3 to 0.8 in patients with LRTI, AECB, bronchial asthma, and allergic rhinitis 5
Dosing equivalence: levosalbutamol 0.625 mg provides equivalent efficacy to racemic salbutamol 2.5 mg, with potentially superior risk/benefit ratio 6
Side effects are minimal: tremor (1%), palpitations (0.9%), and vomiting (0.7%) were mild and transient, with no treatment withdrawals required 5
Theoretical advantages not consistently proven: despite strong preclinical evidence that (S)-salbutamol opposes beneficial effects and may worsen airway hyperreactivity, levosalbutamol has not shown consistent clinical superiority over racemic salbutamol in COPD or asthma trials 7, 8
Critical Pitfalls to Avoid
Do not use albuterol/levosalbutamol alone for acute or chronic cough not due to asthma—it is not recommended and has no proven benefit 1
Do not use beta-agonists as monotherapy in asthma cough management, as this increases serious adverse events 2
In COPD patients with CO2 retention, drive nebulizers with air, not oxygen, to prevent worsening hypercapnia 3
Do not prescribe expectorants during acute exacerbations of chronic bronchitis—there is no evidence of effectiveness 1
Adjunctive Cough Suppressants
For chronic bronchitis, peripheral cough suppressants (levodropropizine, moguisteine) or central suppressants (codeine, dextromethorphan) are recommended for short-term symptomatic relief 1
For postinfectious cough, inhaled ipratropium may attenuate cough; if quality of life is severely affected, consider inhaled corticosteroids or a short course of prednisone 30-40 mg daily 1
Central suppressants have limited efficacy for URI-related cough and are not recommended for this indication 1