Cough: Drug Therapy

Therapeutic target

  • Improvement of symptoms i.e. symptomatic therapy until definitive therapy when diagnosis is confirmed.

Therapy recommendations [see below guideline of the German Society of Pneumology and Respiratory Medicine]

  • Symptomatic therapy, if necessary: expectorants (e.g., N-acetylcysteine (ACC), bromhexine, Ambroxolt), ensuring adequate drinking (>1.5 l/d); antitussives (e.g., pentoxyverine) at night, if necessary; do not combine antitussives (“cough suppressants”) and expectorants (“cough suppressants”) !Acute cough (duration ≤ 8 weeks).
    • Acute cough usually does not require expectorants.
    • Antibiotic therapy for acute cough is generally not required (strong level of recommendation).
    • Bronchitis.
    • For distressing acute dry irritating cough, dextrometorphan (synthetic morphine; cough suppressant) should be prescribed for a period of about 7 days.
    • For acute cough, the patient should be asked 4 weeks after consultation whether the cough has resolved.
  • Subacute cough (duration 3-8 weeks).
    • Subacute postinfectious cough (after infection) due to transient bronchial hyperresponsiveness (airway hypersensitivity in which the bronchi constrict abruptly) should be treated with inhaled corticosteroids or with inhaled beta2-adrenergic agents for about 2 weeks duration each (see below Bronchial asthma/medication therapy).
    • Viral or postviral rhinosinusitis (simultaneous inflammation of the nasal mucosa (“rhinitis”) and the mucosa of the paranasal sinuses (“sinusitis“)) can be treated with a nasal corticosteroid as part of a curative trial (see below Sinusitis/Pharmacotherapy).
    • For subacute cough, the patient should be asked 4 -8 weeks after the initial consultation whether the cough has resolved.
  • Chronic cough – upper respiratory tract disease.
    • In children with dry irritable cough, a time-limited trial of therapy with inhaled corticosteroids may be attempted.
    • In chronic rhinosinusitis, therapy should be topical (local; topical) with nasal (“belonging to the nose“) glucocorticosteroids, in individual cases with systemic glucocorticosteroids (see below sinusitis/medical therapy).
    • In chronic pharyngitis (pharyngitis) or laryngitis (laryngitis) should be treated with inhaled glucocorticosteroids, in individual cases with hyperfunctional component by means of logopedic therapy (see below the diseases of the same name).
  • Special pharmacotherapy in (see below the respective disease of the same name):
    • Acute cough in acute bronchitis, flu-like infection, influenza (flu), pertussis (whooping cough), pneumonia (pneumonia), etc..
    • Cough as asthma equivalent
    • Bronchiectasis – rreversible (irreversible) pathological (pathological) dilatations (dilations) of the bronchi.
    • Gastroesophageal reflux (reflux disease) – frequent reflux (Latin refluere = to flow back) of acid gastric juice and other gastric contents into the esophagus (esophagus).
  • See also under “Further therapy”.

Note

  • Caveat. The spontaneous course of cough in acute bronchitis is on average four weeks until complete resolution. A cough lasting longer than 8 weeks (= chronic cough) requires a comprehensive workup (in the sense of a staged diagnosis):
    1. X-ray chest/thorax and pulmonary function testing; if chest x-ray and pulmonary function are normal: 2nd step; nonspecific bronchial provocation.
    2. Methacholine test (methacholine provocation test, English methacholine challenge test) – nonspecific, inhaled provocation test to measure bronchial obstruction (constriction (obstruction) of the bronchi) and hyperreactivity (excessively strong (“exaggerated”) reaction to a stimulus), e.g., in bronchial asthma
    3. Bronchoscopy (lung endoscopy) or computed tomography (CT); at the end of the diagnosis, a bronchoscopy is always indicated if the cough remains unclear!
  • Sputum color (color of sputum) has no predictive value (“predictive value”) for the diagnosis of bacterial bronchitis, it also does not allow differentiation between pneumonia (pneumonia) and bronchitis (inflammation of the bronchi).

Further notes

  • A small retrospective study of patients with presumed neurogenic cough (mean for 13 years) demonstrated that relief was possible with an injection of botulinum toxin (2.5 units of Botox in 0.1 ml) into the thyroarytaenoid muscle.
  • A subacute cold cough could not be effectively treated more quickly by any of the cough medications studied, according to a meta-analysis. They examined montelukast 10 mg daily vs. placebo; ipratropium bromide 0.375 mg/0.5 ml plus salbutamol 1,875 mg/0.5 ml vs. placebo; gelatin 5 cc three times daily vs. Continuation of previous antitussive medication; fluticasone propionate 500 µg twice daily inhaled vs. placebo; budesonide four times 100 µg twice daily vs. placebo; NOP1 receptor agonist 100 mg twice daily vs. codeine 30 mg twice daily vs. placebo.

Phytotherapeutics

  • Thyme ivy and a thyme primrose root preparations – shortening and relief of cough symptoms.
  • Sundew, cineol, myrtol, pelargonium

There is no sufficient study basis for inhalation of essential oils. Note: Essential oils should not be used in young children because of the risk of laryngospasm (vocal spasm).