What is the appropriate treatment for an adult patient presenting with hoarseness and cough, considering potential underlying conditions such as allergies, asthma, chronic obstructive pulmonary disease (COPD), or heart disease?

Treatment of Hoarseness and Cough in Adults

For most adults with hoarseness and cough, start with simple home remedies like honey and lemon, and if pharmacological treatment is needed, prescribe dextromethorphan 60 mg for maximum cough suppression, while immediately ruling out red flag conditions that require urgent evaluation. 1, 2

Initial Red Flag Assessment

Before initiating treatment, directly ask about and rule out the following danger signs that mandate immediate further investigation:

• Hemoptysis (coughing up blood) - requires specialist referral for bronchoscopy 1
• Significant breathlessness - assess for asthma, anaphylaxis, or heart failure 1, 3
• Prolonged fever with malaise and purulent sputum - evaluate for serious acute lung infection 1
• Underlying conditions (COPD, heart disease, diabetes, asthma) - these patients require closer monitoring 1
• Voice change beyond simple hoarseness - may indicate vocal cord palsy 1
• Suspected foreign body inhalation - mandatory bronchoscopy 1
• Symptoms persisting beyond 3 weeks - requires reassessment rather than continued symptomatic treatment 2, 3

Critical consideration for hoarseness specifically: If hoarseness is accompanied by severe paroxysmal cough, consider pertussis even in vaccinated adults, as this can present atypically with laryngeal involvement requiring macrolide antibiotic therapy. 4, 2

First-Line Treatment Approach

Non-Pharmacological Management

• Honey and lemon is the recommended first-line home remedy for symptomatic relief 1, 2
• Smoking cessation is mandatory - continued smoking worsens cough 1
• Avoidance of respiratory irritants including environmental pollutants 5
• Simple voluntary cough suppression may be sufficient, as central modulation of the cough reflex is common 1

Pharmacological Options When Needed

Antitussive therapy:

• Dextromethorphan 60 mg provides maximum cough reflex suppression and prolonged relief - standard over-the-counter doses are subtherapeutic 2, 3, 6
• Use sugar-free formulations especially for diabetic patients 2
• Avoid codeine or pholcodine - they have significant adverse effects without greater efficacy than dextromethorphan 2, 3

Adjunctive symptomatic relief:

• Paracetamol for associated fever and discomfort 1
• Menthol lozenges or vapor for additional symptom relief 1
• Ipratropium bromide inhaler has demonstrated efficacy for post-infectious cough in controlled trials 2, 3

Special Considerations for Underlying Conditions

Patients with COPD or Heart Disease

• Heart failure must be ruled out in elderly patients (median age 75) presenting with congested cough, as it can present atypically 3
• Congested cough with normal oxygen saturation does not exclude acute heart failure 3
• These patients require mandatory medical evaluation rather than empiric over-the-counter treatment 1

Patients with Asthma

• Acute cough with increasing breathlessness should be assessed for asthma exacerbation and treated appropriately with bronchodilators and corticosteroids 1

Critical Pitfalls to Avoid

Never prescribe antibiotics for viral cough - they provide absolutely no benefit for post-viral cough and expose patients to unnecessary adverse effects, except when pertussis is suspected. 2, 5, 7

Do not continue antitussive therapy indefinitely - if cough persists beyond 3 weeks, discontinue symptomatic treatment and evaluate for chronic cough causes including post-viral cough syndrome, pertussis, pneumonia, asthma, or GERD. 2, 3

Avoid opiate antitussives - they have significant adverse side effect profiles without proven superiority. 1

Duration and Follow-Up

• Post-viral cough typically resolves within 2-3 weeks 2, 3
• Mandatory reassessment at 3 weeks if symptoms persist - do not simply continue antitussive therapy 2, 3
• Most acute viral coughs are benign and self-limiting, requiring no specific treatment beyond symptomatic relief 1

When Specialist Referral Is Required

Refer to a specialist cough clinic or pulmonologist when:

• Cough persists beyond 3 weeks despite appropriate management 2, 3
• Red flag symptoms are present 1
• Diagnostic uncertainty exists, as this often leads to inappropriate prescribing of antibiotics and inhaled corticosteroids 1