What medication is recommended for a patient with a sore throat, cough with occasional expectoration, and a change in voice, considering potential underlying conditions such as asthma or chronic obstructive pulmonary disease (COPD)?

Management of Sore Throat, Cough with Expectoration, and Voice Change

For a patient presenting with sore throat, productive cough, and voice change, first rule out serious conditions requiring immediate intervention, then provide symptomatic treatment with NSAIDs (ibuprofen or naproxen) for throat pain and consider ipratropium bromide if chronic bronchitis or COPD is suspected, while avoiding antibiotics unless bacterial infection is highly likely.

Initial Assessment: Red Flags Requiring Urgent Evaluation

Before initiating symptomatic treatment, you must exclude serious conditions:

• Voice change may indicate vocal cord palsy and warrants specialist referral for bronchoscopy consideration 1
• Haemoptysis, prominent systemic illness, or suspicion of lung cancer require chest radiograph and further investigation 1
• Significant breathlessness should prompt assessment for asthma, anaphylaxis, or serious acute lung infection 1
• Fever, malaise, and purulent sputum suggest possible pneumonia requiring physical examination for dullness, bronchial breathing, and crackles 1

Symptomatic Treatment for Sore Throat

NSAIDs are the first-line treatment for sore throat pain:

• Ibuprofen shows the best benefit-risk profile among systemic analgesics for sore throat 2
• Naproxen is also recommended by guidelines for symptomatic relief 3
• Flurbiprofen 8.75 mg lozenge provides effective relief for swollen and inflamed throat, with 79.8% greater pain relief than placebo over 24 hours 4

Local anesthetics with confirmed efficacy include:

• Lidocaine 8 mg, benzocaine 8 mg, or ambroxol 20 mg can be recommended as first-line treatment 2
• Ambroxol has the best documented benefit-risk profile among local anesthetics 2

Avoid ineffective treatments:

• Local antibiotics or antiseptics should not be recommended due to lack of efficiency data and predominantly viral etiology 2

Management of Cough

If Acute Viral Cough (Most Likely Scenario)

Acute viral cough is almost invariably benign and prescribed treatment is unnecessary 1:

• The simplest advice is a home remedy such as honey and lemon 1
• Dextromethorphan-containing preparations may provide modest symptomatic relief, particularly for dry cough disturbing sleep 1, 5, 6
• Opiate antitussives have significant adverse effects and are not recommended for acute viral cough 1
• Over-the-counter combination cold medications are not recommended until proven effective in randomized trials 1

If Chronic Bronchitis or COPD is Suspected

Ipratropium bromide is the first-line therapy (Grade A recommendation):

• Ipratropium bromide 36 μg (2 inhalations) four times daily reduces cough frequency, severity, and sputum volume 7, 8, 5
• This is the only inhaled anticholinergic recommended for cough suppression in chronic bronchitis 1

Additional options if ipratropium is inadequate:

• Short-acting β-agonists may control bronchospasm and reduce chronic cough in some patients 7, 8
• Codeine and dextromethorphan reduce cough counts by 40-60% in chronic bronchitis for short-term symptomatic relief 1, 7, 8
• Theophylline may control chronic cough but requires careful monitoring for complications 7, 8, 5

Treatments to avoid:

• Currently available expectorants have not been proven effective and should not be used 7, 8, 5
• Central cough suppressants have limited efficacy for cough due to upper respiratory infection 1

Antibiotic Considerations

Antibiotics should NOT be prescribed for acute bronchitis:

• Antibiotics reduce cough duration by only 0.5 days while causing adverse effects and promoting resistance 5
• For acute sore throat, use clinical scores (Centor, McIsaac, FeverPAIN) to assess bacterial pharyngitis risk 3
• Antibiotics are only indicated if score ≥3 points AND patient has risk factors 3
• Even with high scores, antibiotics only modestly shorten symptom duration 3

Common Pitfalls to Avoid

• Do not prescribe antibiotics reflexively for sore throat and productive cough—most cases are viral 5, 2, 3
• Do not use bronchodilators routinely unless wheezing is present or COPD/asthma is confirmed 5
• Voice change is a red flag—do not dismiss this symptom without proper evaluation for vocal cord pathology 1
• Smoking cessation is the most effective intervention if patient smokes—90% report cough resolution after quitting 7