What is the appropriate management for a post‑viral cough?

Management of Post-Viral Cough

First-Line Treatment: Inhaled Ipratropium Bromide

For post-viral cough persisting 3–8 weeks after an acute respiratory infection, prescribe inhaled ipratropium bromide 2–3 puffs (17–34 mcg per puff) four times daily, which has the strongest evidence for symptom reduction, with clinical improvement expected within 1–2 weeks. 1

• Post-viral cough is defined as cough lasting 3–8 weeks following resolution of acute URI symptoms, diagnosed clinically after excluding bacterial sinusitis, pertussis, and pneumonia 1, 2
• The pathophysiology involves extensive epithelial disruption, widespread airway inflammation, mucus hypersecretion, impaired mucociliary clearance, and transient bronchial hyperresponsiveness—not ongoing infection 1, 2
• Ipratropium is the only agent with controlled trial evidence demonstrating efficacy in attenuating post-infectious cough 1

Initial Supportive Care (Before or Alongside Ipratropium)

• Recommend honey and lemon for symptomatic relief through central modulation of the cough reflex 1
• Guaifenesin 200–400 mg every 4 hours (up to 6 times daily) helps loosen phlegm and thin bronchial secretions to make coughs more productive 1, 3
• Advise adequate hydration, warm facial packs, steamy showers, and sleeping with head of bed elevated 1

Second-Line: Inhaled Corticosteroids

If cough persists despite ipratropium and significantly impairs quality of life, add an inhaled corticosteroid such as fluticasone 220 mcg or budesonide 360 mcg twice daily, allowing up to 8 weeks for full therapeutic response. 1

• Inhaled corticosteroids suppress airway inflammation and bronchial hyperresponsiveness that persist after viral injury 1
• This step is appropriate only when quality of life is markedly affected, not for mild residual cough 1

Third-Line: Oral Corticosteroids (Reserved for Severe Cases)

Oral prednisone 30–40 mg daily for 5–10 days should be reserved exclusively for severe cough paroxysms that substantially impair quality of life, and only after systematically excluding upper airway cough syndrome, asthma, and gastroesophageal reflux disease. 1

• Prednisone is not appropriate for routine post-viral cough and should never be first-line therapy 1
• Before prescribing prednisone, you must rule out UACS (treat with first-generation antihistamine-decongestant plus intranasal corticosteroid), asthma (optimize inhaled corticosteroids and bronchodilators), and GERD (trial high-dose PPI therapy) 1

What NOT to Do: Antibiotics Are Contraindicated

Antibiotics are explicitly contraindicated for post-viral cough because the etiology is non-bacterial; they provide no clinical benefit, contribute to antimicrobial resistance, and cause unnecessary adverse effects. 1, 2

• The only exceptions permitting antibiotics are documented bacterial sinusitis or confirmed early pertussis infection 1, 2
• Green or colored sputum does NOT indicate bacterial infection—most short-term coughs produce colored phlegm despite viral etiology 1

Red Flags Requiring Re-Evaluation

• Fever development, hemoptysis, or symptom worsening mandate immediate reassessment for pneumonia or alternative diagnoses 1
• Cough persisting beyond 8 weeks must be reclassified as chronic cough and trigger systematic evaluation for upper airway cough syndrome (UACS), asthma, and GERD 1, 2
• Paroxysmal cough ≥2 weeks with post-tussive vomiting or inspiratory "whoop" requires exclusion of pertussis via testing and consideration of macrolide therapy 1

Diagnostic Work-Up When Cough Exceeds 8 Weeks

• Obtain chest radiograph to exclude structural lung disease, malignancy, or persistent infiltrate 1
• Systematically evaluate for the three most common causes of chronic cough:
  • UACS: Treat with first-generation antihistamine-decongestant combination plus intranasal corticosteroid (fluticasone or mometasone); expect response within days to 1–2 weeks 1
  • Asthma: Consider bronchoprovocation challenge or empiric trial of inhaled corticosteroids plus beta-agonists; allow up to 8 weeks for response 1
  • GERD: Initiate high-dose PPI (omeprazole 40 mg twice daily) with dietary modifications; response may require 2 weeks to several months 1
• If all empiric therapies fail, obtain high-resolution CT chest and consider bronchoscopy to evaluate for bronchiectasis, interstitial lung disease, eosinophilic bronchitis, or occult endobronchial lesions 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics reflexively for colored sputum or prolonged cough without evidence of bacterial superinfection 1, 2
• Do not jump to prednisone for mild post-viral cough; reserve it for severe, quality-of-life-impairing paroxysms after excluding other causes 1
• Do not fail to recognize when cough crosses the 8-week threshold, which mandates reclassification as chronic cough and systematic work-up 1
• Do not stop one therapy when adding the next—chronic cough is frequently multifactorial, and partial improvement with one agent should prompt continuation plus addition of the next intervention 1

Timeline Expectations

• Post-viral cough typically resolves spontaneously within 3–8 weeks from the initial viral infection 1, 2
• Ipratropium response is expected within 1–2 weeks 1
• Inhaled corticosteroid response may require up to 8 weeks 1
• If symptoms have not improved within 3–5 days of initiating treatment, reassess for alternative diagnoses 1