What is the appropriate first‑line oral tablet regimen for an adult who develops a new cough after tracheostomy decannulation?

Oral Tablet for Post-Decannulation Cough

For an adult with new cough after tracheostomy decannulation, dextromethorphan 30–60 mg orally is the recommended first-line tablet, with a maximum daily dose of 120 mg divided into 3–4 doses. 1

Understanding Post-Decannulation Cough

Post-decannulation cough is common and typically results from:

• Tracheal irritation from the healing stoma site 2
• Increased secretions as the airway adjusts to normal breathing patterns 2
• Upper airway sensitivity following prolonged tracheostomy 3

The vast majority of decannulation-related issues occur within 12–36 hours after tube removal, making this the critical monitoring window. 2

First-Line Pharmacologic Management

Dextromethorphan (Preferred Agent)

Dextromethorphan is the recommended first-line oral antitussive due to its superior safety profile compared to codeine-based alternatives. 1

Dosing regimen:

• Standard dose: 10–15 mg three to four times daily (every 6–8 hours) 1
• For more severe cough: 30–60 mg per dose provides optimal cough reflex suppression 1
• Maximum daily dose: 120 mg 1
• Bedtime dosing: 15–30 mg at bedtime may help suppress nocturnal cough and promote sleep 1

Critical safety consideration: Many combination products contain acetaminophen or other ingredients—verify the formulation to avoid inadvertent overdose when using higher dextromethorphan doses. 1

Why Dextromethorphan Over Codeine

Codeine-containing products should be avoided because they:

• Provide no greater cough suppression efficacy than dextromethorphan 1
• Carry a significantly higher adverse effect burden, including drowsiness, nausea, constipation, and risk of physical dependence 1
• Are explicitly not recommended by the British Thoracic Society for cough management 1

Alternative and Adjunctive Options

For Nocturnal Cough

First-generation sedating antihistamines (excluding promethazine) may be considered specifically for nighttime cough, as their sedative properties help reduce cough while promoting sleep. 1 However, promethazine itself should be avoided due to serious adverse effects including hypotension, respiratory depression, and extrapyramidal reactions. 1

Non-Pharmacologic Approaches

Simple home remedies like honey and lemon may be as effective as pharmacological treatments for benign post-procedural cough and should be considered as initial therapy. 1

Short-Acting Relief

Menthol inhalation (menthol crystals or proprietary capsules) provides acute but short-lived cough suppression useful for temporary symptom relief. 1

When to Escalate or Investigate Further

Red Flags Requiring Immediate Evaluation

• Blood in secretions may precede catastrophic hemorrhage and requires urgent assessment 2
• Respiratory distress or stridor suggests upper airway obstruction requiring immediate intervention 3
• Inability to manage secretions may indicate aspiration risk or airway compromise 3
• Hypoxemia or hypercapnia developing after decannulation 3

Persistent Cough Beyond 3 Weeks

Cough lasting more than 3 weeks requires full diagnostic workup rather than continued antitussive therapy to evaluate for:

• Granulation tissue at the internal stoma site 2
• Unresolved subglottic narrowing 3
• Tracheomalacia or functional airway obstruction 3
• Gastroesophageal reflux disease (GERD) 2
• Aspiration from swallowing dysfunction 3

Endoscopic evaluation may be necessary if upper airway pathology is suspected, particularly in the absence of vocalization, inability to manage oral secretions, or unsafe swallowing. 2

Practical Prescribing Algorithm

1. Start with non-pharmacologic measures: Honey and lemon mixtures, adequate hydration 1

2. If pharmacologic treatment needed: Dextromethorphan 10–15 mg three to four times daily 1

3. For inadequate response: Increase to 30–60 mg per dose (verify no acetaminophen in formulation) 1

4. For nocturnal cough disrupting sleep: Add first-generation sedating antihistamine at bedtime (not promethazine) 1

5. For temporary relief of severe paroxysms: Menthol inhalation 1

6. If no improvement after short course: Discontinue and investigate for underlying pathology rather than continuing ineffective therapy 1

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (less than 30 mg) that fail to provide adequate cough suppression 1
• Prescribing codeine-containing products which lack efficacy advantage but increase side-effect burden 1
• Overlooking combination product ingredients when prescribing higher dextromethorphan doses, risking acetaminophen toxicity 1
• Continuing antitussive therapy beyond 3 weeks without diagnostic workup for persistent cough 1
• Failing to monitor for decannulation complications during the critical 24–48 hour post-procedure window 3
• Neglecting to assess for aspiration risk in patients with swallowing dysfunction, as this may require different management 3