What is the appropriate first‑line and subsequent management for an elderly patient with a dry cough due to a viral upper‑respiratory infection?

Management of Viral Dry Cough in the Elderly

Start with simple supportive measures—honey for symptomatic relief—then escalate to inhaled ipratropium bromide if cough persists beyond 1–2 weeks and impairs quality of life. 1, 2

First-Line Approach: Supportive Care (Days 1–14)

• Recommend honey (for patients over 1 year) as the initial intervention, which provides symptomatic relief through central modulation of the cough reflex 1, 3
• Advise patients to avoid lying flat on their back, as this position makes coughing ineffective and worsens symptoms 1
• Encourage adequate hydration (no more than 2 liters per day) to prevent dehydration, particularly if fever is present 1
• Use paracetamol for fever and associated symptoms rather than NSAIDs, continuing only while symptoms persist 1

Critical Assessment: Rule Out Serious Pathology

Elderly patients with comorbidities, frailty, or impaired immunity are at higher risk of developing severe pneumonia leading to respiratory failure and death. 1

• Obtain a chest radiograph immediately if any of the following are present: new focal chest signs, dyspnea, tachypnea, pulse >100 bpm, fever >4 days, or respiratory rate >30 1, 2
• Suspect pneumonia when focal auscultatory abnormalities (crackles, diminished breath sounds, dullness) are detected, as this raises the probability from 5–10% to approximately 39% 1
• In patients ≥65 years, assess for risk factors predicting complicated course: COPD, diabetes, heart failure, previous hospitalization, oral glucocorticoids, confusion, or blood pressure <90/60 1

Second-Line Treatment: Inhaled Ipratropium (Weeks 1–3)

If cough persists beyond 1–2 weeks and significantly affects quality of life, prescribe inhaled ipratropium bromide 2–3 puffs (17–34 mcg per puff) four times daily. 1, 2, 3, 4

• Ipratropium has the strongest evidence for attenuating post-infectious cough, with clinical response typically seen within 1–2 weeks 2, 3
• This anticholinergic agent works by reducing mucus hypersecretion and decreasing airway irritability that persists after viral infection 1, 2

Third-Line Treatment: Upper Airway Management

If upper airway symptoms are present (throat clearing, post-nasal drip sensation, nasal congestion):

• Prescribe a first-generation antihistamine/decongestant combination (e.g., brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine) 1, 2, 3
• Begin with once-daily bedtime dosing for 2–3 days, then advance to twice-daily to minimize sedation 2
• Add intranasal corticosteroid spray (fluticasone or mometasone) to decrease airway inflammation 2, 3
• Improvement typically occurs within days to 1–2 weeks with this regimen 2, 3

Important: Newer "non-sedating" antihistamines (loratadine, terfenadine) are ineffective for post-viral cough—the anticholinergic properties of first-generation agents are essential for efficacy. 1

Fourth-Line Treatment: Inhaled Corticosteroids (Weeks 3–8)

• Consider inhaled corticosteroids (fluticasone 220 mcg or budesonide 360 mcg twice daily) if cough persists despite ipratropium and adversely affects quality of life 2, 3, 4
• Allow up to 8 weeks for full therapeutic response, as these agents work by suppressing airway inflammation and bronchial hyperresponsiveness 2, 3

Fifth-Line Treatment: Short-Term Oral Corticosteroids

Reserve oral prednisone (30–40 mg daily for 5–10 days) only for severe paroxysmal cough that significantly impairs quality of life, and only after ruling out upper airway cough syndrome, asthma, and GERD. 1, 2, 3

Antitussive Agents for Distressing Cough

• For distressing dry cough, consider short-term use of codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution to suppress coughing 1
• Alternatively, dextromethorphan 30 mg every 6 hours can provide cough reflex suppression 2, 5
• These agents should be used only when cough is non-productive and causing significant distress, not when productive cough is helping clear secretions 4

What NOT to Do: Critical Pitfalls

• Do NOT prescribe antibiotics—they provide no benefit for viral or post-infectious cough, contribute to antimicrobial resistance, and cause unnecessary adverse effects 1, 2, 3, 4
• Do NOT use nasal decongestant sprays for more than 3–5 days due to risk of rebound congestion (rhinitis medicamentosa) 2
• Do NOT use antipyretics solely to reduce body temperature—use them only when fever causes discomfort alongside other symptoms 1

When to Reassess and Escalate

• If cough persists beyond 8 weeks, reclassify as chronic cough and systematically evaluate for upper airway cough syndrome, asthma, and GERD 1, 2, 3, 4
• Consider pertussis if paroxysmal cough develops with post-tussive vomiting or inspiratory "whoop," especially if cough lasts ≥2 weeks 2, 3
• Refer to pulmonology when cough persists beyond 8 weeks despite systematic empiric treatment 4

Special Considerations for Elderly Patients

• Monitor closely for deterioration—elderly patients can develop severe pneumonia rapidly, potentially leading to respiratory failure 1
• Assess for left ventricular failure in patients >65 with orthopnea, displaced apex beat, or history of myocardial infarction, hypertension, or atrial fibrillation 1
• Consider pulmonary embolism in patients with history of DVT, recent immobilization (past 4 weeks), or malignancy 1
• Evaluate for aspiration pneumonia in patients with swallowing difficulties who show signs of acute lower respiratory tract infection 1