Cough Management in the Emergency Department

First-Line Approach

The American College of Chest Physicians recommends starting with non-pharmacological measures before prescribing medications, such as simple home remedies like honey and lemon, which are as effective as many pharmacological treatments for benign viral cough 1, 3
Voluntary cough suppression techniques through central modulation may be sufficient to reduce cough frequency 1, 3
Most acute viral cough is self-limiting, lasting 1-3 weeks, and often does not require prescribed medication 1

The American Academy of Emergency Medicine recommends dextromethorphan 60 mg as the preferred agent for acute cough due to its superior safety profile compared to codeine 1, 2
Dextromethorphan is a non-sedating opiate with a superior safety profile compared to codeine, and is recommended for chronic or acute bronchitis for short-term symptomatic relief 1, 2, 4
Ipratropium bromide is the only inhaled anticholinergic agent recommended for cough suppression in URI or chronic bronchitis, with a level of evidence: fair; benefit: substantial; grade of recommendation: A 4, 5, 2
First-generation antihistamines can suppress cough but cause drowsiness, and are particularly useful for nocturnal cough due to sedative effects 1, 3
Menthol inhalation suppresses cough reflex when inhaled, but has an acute and short-lived effect 1, 3

The American College of Emergency Physicians recommends a step-wise approach to cough management, including ruling out serious pathology, determining cough type and duration, and using non-pharmacological measures first 1, 4, 5, 2
Dextromethorphan 60 mg is recommended for bronchitis or severe symptoms, while ipratropium bromide is recommended for URI-related cough 1, 3, 2, 4, 5
First-generation antihistamines are recommended for nocturnal cough, and menthol inhalation is recommended for quick temporary relief 1, 3, 2

Using subtherapeutic doses of dextromethorphan (30 mg or less) - maximum suppression requires 60 mg 1, 3, 2
Prescribing codeine-based antitussives - no efficacy advantage with worse side effects 1, 2
Using central cough suppressants for URI-related cough - limited efficacy for this indication 4, 5, 1
Prescribing cough suppressants for productive cough - where secretion clearance is beneficial 3, 2
Continuing antitussive therapy beyond 3 weeks - requires full diagnostic workup 2
Not recognizing that dextromethorphan should not be used when pneumonia assessment is needed 1