What are appropriate take‑home medications for an outpatient presenting with a dry cough, coarse crackles, and wheezing?

Management of Dry Cough with Coarse Crackles and Wheezing

For an outpatient with dry cough, coarse crackles, and wheezing, prescribe a short-acting beta-agonist bronchodilator (salbutamol/albuterol 200-400 µg via metered-dose inhaler every 4-6 hours) combined with an inhaled corticosteroid (fluticasone 100-250 µg twice daily), as this presentation suggests cough-variant asthma or eosinophilic airway disease requiring both bronchodilation and anti-inflammatory therapy. 1, 2

Clinical Assessment and Diagnostic Considerations

The combination of dry cough with wheezing and coarse crackles indicates bronchospasm with possible eosinophilic airway inflammation. 1

Key differential diagnoses to consider:

• Cough-variant asthma (CVA) is one of the most common causes of chronic isolated cough presenting with bronchodilator-responsive airway hyperresponsiveness and eosinophilic inflammation. 3, 4
• Atopic cough presents with bronchodilator-resistant dry cough but involves eosinophilic tracheobronchitis and responds to inhaled corticosteroids. 3
• Bronchiectasis can present with coarse crackles, though typically associated with productive cough; "dry" bronchiectasis exists and should be considered with history of past respiratory insult. 1
• COPD should be considered in smokers with persistent cough and wheezing, as they may be at risk of developing airflow obstruction. 1

Primary Take-Home Medication Regimen

First-Line Bronchodilator Therapy

Prescribe a short-acting beta-agonist as the immediate bronchodilator:

• Salbutamol (albuterol) 200-400 µg via metered-dose inhaler every 4-6 hours as needed for symptom relief. 1
• Alternative: Terbutaline 500-1000 µg via metered-dose inhaler every 4-6 hours. 1
• Beta-agonists provide rapid bronchodilation and may suppress cough by "resetting" airway receptors. 5

Anti-Inflammatory Therapy

Add an inhaled corticosteroid as the cornerstone of treatment:

• Fluticasone propionate 100-250 µg twice daily via metered-dose inhaler or dry powder inhaler. 6, 3, 4
• Inhaled corticosteroids are the first-line treatment for cough-variant asthma and eosinophilic airway disease, improving cough and reducing risk of progression to classical asthma. 3, 4
• Critical instruction: Patients should use the bronchodilator BEFORE the inhaled corticosteroid to prevent cough and bronchoconstriction that can occur from the corticosteroid aerosol itself. 7

Adjunctive Therapy for Persistent Symptoms

If symptoms persist despite bronchodilator and inhaled corticosteroid:

• Add ipratropium bromide 250-500 µg via nebulizer or metered-dose inhaler 4-6 hourly, as the combination of beta-agonist with anticholinergic provides additive bronchodilator benefit. 1, 8
• Consider adding a leukotriene receptor antagonist (montelukast 10 mg once daily in the evening) for patients with atopic features or inadequate response to inhaled therapy. 9, 3

Cough Suppressant Therapy

For symptomatic relief of dry cough interfering with daily activities or sleep:

• Dextromethorphan 60 mg (maximum cough suppression dose) as needed, up to four times daily. 2, 10
• Alternative for nocturnal cough: First-generation antihistamine (chlorpheniramine 4 mg or diphenhydramine 25-50 mg at bedtime) for sedative effect. 2, 10
• Avoid codeine-based preparations as they have no greater efficacy than dextromethorphan but carry a significantly higher adverse effect profile. 2

Critical Pitfalls to Avoid

• Do not suppress cough if it serves a protective clearance function in conditions like pneumonia or productive bronchiectasis. 2
• Do not prescribe inhaled corticosteroids alone without bronchodilator pretreatment, as 20% of asthmatic patients experience severe cough and wheezing from the corticosteroid aerosol itself. 7
• Do not use subtherapeutic doses of dextromethorphan (less than 60 mg), as a dose-response relationship exists with maximum efficacy at 60 mg. 2
• Do not delay escalation if symptoms worsen—persistent bronchospasm despite 2-hourly bronchodilator use indicates treatment failure requiring immediate medical re-evaluation. 8

Red Flags Requiring Urgent Medical Evaluation

Instruct the patient to seek immediate care if:

• Unable to complete sentences or respiratory rate >25/min (indicates severe bronchospasm). 1, 8
• Developing high fever, significant hemoptysis, or cyanosis. 1, 2
• No improvement within 30 minutes to 1 hour of appropriate bronchodilator therapy. 8
• Requiring bronchodilator more frequently than every 2 hours. 8

Follow-Up and Monitoring

• Baseline chest radiograph is mandatory to exclude structural lung disease, malignancy, or other abnormalities that would account for symptoms. 1
• Spirometry should be performed to assess for airflow obstruction and bronchodilator response. 1
• If symptoms persist beyond 10-12 days without improvement, re-evaluate for alternative diagnoses including bacterial infection, pertussis, or gastroesophageal reflux disease. 1, 11
• For elderly patients, use caution with beta-agonists (may precipitate angina) and ipratropium (may worsen glaucoma—consider mouthpiece use). 1