What is the preferred treatment between L-salbutamol (albuterol) and terbutaline for a patient presenting with acute cough?

Salbutamol vs Terbutaline for Acute Cough

Neither salbutamol (albuterol) nor terbutaline should be used for acute cough unless the patient has documented asthma or COPD with bronchospasm. The American College of Chest Physicians explicitly states that albuterol is not recommended for acute or chronic cough not due to asthma (Grade D recommendation) 1, 2.

When Beta-Agonists Are NOT Indicated

For acute cough from common cold or acute bronchitis without wheezing:

• β2-agonist bronchodilators should not be routinely used to alleviate cough 1
• In unselected patients with acute, nonspecific cough, oral albuterol showed no significant difference from placebo in cough severity, sleepless nights, or return to activity, but caused significantly more shakiness and nervousness 3
• Newer nonsedating antihistamines are ineffective and should not be used 1

Recommended alternatives for acute cough without bronchospasm:

• First-generation antihistamine/decongestant combinations (e.g., brompheniramine with sustained-release pseudoephedrine) 1
• Naproxen for symptomatic relief 1
• Ipratropium bromide for cough suppression in upper respiratory infections or chronic bronchitis 1, 2
• Central cough suppressants (codeine or dextromethorphan) for chronic bronchitis 1

When Beta-Agonists MAY Be Appropriate

Select patients with acute bronchitis AND wheezing:

• Treatment with β2-agonist bronchodilators may be useful in adult patients with wheezing accompanying the cough 1
• However, this represents a subgroup with likely underlying reactive airway disease, not typical acute bronchitis 1

Confirmed asthma or COPD with acute exacerbation:

• Salbutamol 2.5-5 mg via nebulizer or 200-400 μg via hand-held inhaler for acute exacerbations 2, 4
• Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea in stable chronic bronchitis patients 1

Critical Diagnostic Steps Before Prescribing

Confirm reversible airflow obstruction through spirometry:

• Measure FEV1 before and after bronchodilator administration 2, 4
• Do not rely on single peak expiratory flow measurements 4
• Do not use beta-agonists as a diagnostic trial without objective evidence of bronchospasm 5

Rule out other causes first:

• Evaluate for post-nasal drip, gastroesophageal reflux, or other non-asthmatic causes 2, 5
• Distinguish between common cold (which should be ruled out first) and acute bronchitis 1

Salbutamol vs Terbutaline: No Direct Comparison

There is no evidence comparing salbutamol to terbutaline specifically for acute cough. Both are short-acting β2-agonists with similar mechanisms of action 6. The guidelines do not differentiate between these agents for cough management, and both would be equally inappropriate for acute cough without documented bronchospasm 1.

Common Pitfalls to Avoid

• Do not prescribe beta-agonists empirically for acute cough without establishing an asthma or COPD diagnosis, as this delays appropriate treatment of the actual cause 5
• Acute bronchitis is often overdiagnosed, leading to inappropriate antibiotic prescriptions in 65-80% of cases; the same applies to inappropriate beta-agonist use 1
• Using beta-agonists for non-asthmatic cough may delay appropriate diagnosis and treatment of the underlying cause 4
• In elderly patients or those with known/suspected heart disease, supervise the first treatment as beta-agonists may rarely precipitate cardiac problems 2