Is Levosalbutamol (albuterol) effective for treating cough in patients with or without underlying respiratory conditions such as asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Levosalbutamol for Cough

Levosalbutamol (albuterol) should NOT be used for cough unless the patient has confirmed asthma or COPD with documented bronchospasm—it carries a Grade D recommendation for acute or chronic cough not due to asthma and may delay appropriate diagnosis and treatment of the underlying cause. 1, 2

When Levosalbutamol IS Appropriate

Levosalbutamol is indicated only when cough is caused by reversible airflow obstruction:

• Asthma-related cough: Use nebulized levosalbutamol 2.5-5 mg for acute exacerbations, or 200-400 μg via hand-held inhaler for maintenance in cough-predominant asthma where bronchospasm is the underlying mechanism 2
• COPD exacerbations: Nebulized levosalbutamol 2.5-5 mg is appropriate for acute COPD exacerbations with cough 2
• Documented bronchodilator responsiveness: Before prescribing, confirm reversible airflow obstruction through spirometry measuring FEV1 before and after bronchodilator administration—do not rely on single peak expiratory flow measurements 2

When Levosalbutamol Should NOT Be Used

The following cough types should NOT be treated with levosalbutamol:

• Acute viral upper respiratory infections: Simple home remedies like honey and lemon, adequate hydration, and menthol lozenges are more appropriate first-line approaches 1
• Chronic nonspecific cough: A systematic review concluded there is no evidence to support using β2-agonists in children with acute cough and no evidence of airflow obstruction 3
• Chronic bronchitis without asthma/COPD: Use peripheral cough suppressants (levodropropizine, moguisteine) or central suppressants (codeine, dextromethorphan) instead, with ipratropium bromide as the only inhaled anticholinergic recommended 1

Recommended Alternatives Based on Cough Type

For nonproductive dry cough:

• Dextromethorphan 60 mg is first-line treatment with substantial benefit and favorable safety profile 1
• First-generation antihistamines with sedative properties are particularly helpful for nocturnal cough 1

For idiopathic chronic cough:

• Dextromethorphan is the non-specific antitussive of choice 1
• Baclofen and nebulized local anesthetics (lidocaine, mepivicaine) have weak evidence of benefit 1

For chronic bronchitis:

• Ipratropium bromide is the only inhaled anticholinergic recommended for cough suppression (Grade A recommendation) 1
• Central suppressants (codeine, dextromethorphan) provide short-term symptomatic relief 1

Critical Diagnostic Steps Before Prescribing

Perform spirometry in all patients with chronic cough to identify reversible airflow obstruction:

• Measure FEV1 before and after inhalation of salbutamol to determine bronchodilator responsiveness 2
• If chronic cough persists, evaluate for post-nasal drip, gastroesophageal reflux, or other non-asthmatic causes first 4
• Do not use levosalbutamol empirically as a diagnostic trial without objective evidence of bronchospasm 4

Common Pitfalls to Avoid

Never use levosalbutamol for non-asthmatic cough, as this delays appropriate diagnosis and treatment of the underlying cause 2, 4

• Avoid antibiotics for nonproductive cough due to viral infections, even when phlegm is present 1
• Do not increase doses of inhaled corticosteroids for cough unresponsive to initial treatment—reassess the diagnosis instead 3
• Avoid manually assisted cough in patients with airflow obstruction, as it may be detrimental; teach huffing as an adjunct to sputum clearance instead 1

Safety Considerations

Levosalbutamol is generally well-tolerated when used appropriately:

• Side effects include tremor (1%), palpitation (0.9%), and vomiting (0.7%), which are mild and transient in most cases 5
• Elderly patients or those with known/suspected heart disease should have their first treatment supervised, as beta-agonists may rarely precipitate cardiac problems 4
• Beta-mediated adverse effects are dose-dependent and can be minimized by using the lowest effective dose 6