Best Intervention to Stop Cough Due to RSV in Adults
For otherwise healthy adults with RSV-associated cough, start with honey and lemon as first-line symptomatic treatment, followed by dextromethorphan 30-60 mg if additional cough suppression is needed.
First-Line Treatment: Honey and Lemon
- Honey and lemon mixtures provide symptomatic relief through central modulation of the cough reflex and represent the simplest, most cost-effective initial approach for acute viral cough in adults 1, 2.
- This recommendation is supported by the American Thoracic Society as equally effective as pharmacological treatments but without adverse effects 1, 2.
- Patients report subjective benefit from honey-based remedies, and this approach avoids the side effect profile of opiate antitussives 1.
Second-Line Pharmacological Option
- If honey alone provides insufficient relief, add dextromethorphan at a dose of 30-60 mg (higher than typical over-the-counter dosing) for maximum cough reflex suppression 1, 2.
- Dextromethorphan has a favorable safety profile and proven efficacy in suppressing acute viral cough 2.
- This dose range is more effective than standard OTC formulations for meaningful symptom control 1.
Additional Supportive Measures
- Menthol inhalation can provide acute, short-lived cough suppression by acting directly on the cough reflex 1, 2.
- Adequate hydration and voluntary cough suppression techniques may reduce cough frequency 2.
- Sedating antihistamines may be considered specifically for nocturnal cough when sleep disruption is the primary concern, though drowsiness is expected 1.
What NOT to Do
- Do not prescribe antibiotics for RSV-associated cough, as RSV is a viral illness and antibiotics provide no benefit while contributing to antimicrobial resistance 3, 2.
- Avoid codeine and pholcodine, as these opiate antitussives have no greater efficacy than dextromethorphan but carry significantly more adverse effects 1, 2.
- Do not use ribavirin in otherwise healthy adults, as this antiviral is limited to high-risk populations (immunocompromised, severe disease) and remains controversial even in those settings 4, 5.
When to Reassess
- If cough persists beyond 3 weeks, stop symptomatic treatment and evaluate for alternative diagnoses including postinfectious cough, asthma, upper airway cough syndrome, or gastroesophageal reflux 2.
- Seek immediate medical attention if hemoptysis, progressive breathlessness, high fever with purulent sputum, or systemic illness develops, as these suggest complications requiring chest radiography 2.
- RSV in adults typically presents with cough (85%), shortness of breath (79%), sputum production (63%), and low-grade fever (48%), with most cases being self-limited 6.
Special Populations Requiring Different Management
- Elderly adults, immunocompromised patients, and those with underlying cardiopulmonary disease are at higher risk for severe RSV disease, including pneumonia (10-20% in nursing homes) and death (2-5%) 5, 7.
- These high-risk patients may require hospitalization, supplemental oxygen, or mechanical ventilation, with treatment remaining primarily supportive 6, 5, 7.
- In immunocompromised patients with severe RSV pneumonia, early ribavirin plus intravenous immunoglobulin has been associated with improved survival, though this is not indicated for otherwise healthy adults 5.
Key Clinical Pearls
- RSV infection in adults is often clinically indistinguishable from influenza or other viral respiratory infections, presenting with nasal congestion, cough, wheezing, and low-grade fever 5, 7.
- Diagnosis requires molecular testing (PCR) when clinically indicated, as viral culture and antigen detection are insensitive in adults due to low viral titers 5.
- Annual attack rates in community-dwelling older adults range from 2-10%, making RSV a significant but under-recognized pathogen in adult populations 7.