Cough Management

Introduction to Cough Management

The American College of Chest Physicians suggests that nebulized lidocaine should be considered only as a third or fourth-line therapy for intractable cough that has not responded to other pharmacological approaches, particularly in patients with lung cancer 1

Demulcents, such as simple linctus or glycerol-based linctus, should be tried initially for cough management, with a typical dosage of 5 mL three to four times daily, due to their low side effect profile and potential effectiveness for mild to moderate cough 1
Opioid derivatives, including pholcodine, hydrocodone, dihydrocodeine, and morphine, should be considered when demulcents fail, with specific dosage recommendations for each option 1
Codeine is less preferred due to its greater side effect profile, with a recommended dosage of 30-60 mg four times daily 1
Peripherally-acting antitussives, such as levodropropizine, moguisteine, levocloperastine, and sodium cromoglycate, should be considered when opioids fail, with specific dosage recommendations for each option 1
Local anesthetics, including nebulized lidocaine and nebulized bupivacaine, can be used for cough management, with specific dosage recommendations and administration guidelines 1
Benzonatate is recommended for symptomatic relief of cough, particularly in clinical scenarios such as management of cancer-related cough unresponsive to opioids, as a fourth-line therapy in the management of cough, by the American College of Chest Physicians 1, 2

Local anesthetics can increase the risk of aspiration, which should be assessed prior to use, particularly in frail patients 1
The first dose of local anesthetics should be administered in an inpatient setting to monitor for reflex bronchospasm 1
Post-administration precautions include avoiding food and drink for at least 1 hour after administration 1
Benzonatate is contraindicated in children under 10 years of age due to the risk of accidental ingestion and death, and in patients with hypersensitivity to benzonatate or related compounds, based on clinical expertise, as recommended by the American College of Chest Physicians and the American Academy of Pediatrics 1, 2
Patient education about proper dosing is critical to avoid serious adverse effects with overdose, and if a short course of benzonatate does not improve symptoms, treatment should be discontinued and another approach tried, as recommended by the American College of Chest Physicians 1

For patients already receiving opiates for other symptoms, increasing the morphine dose by approximately 20% may help suppress cough, although this is based on clinical experience rather than evidence 1
For patients with lung cancer in the palliative stage experiencing nonspecific cough, a bedtime dose of codeine/pholcodine or morphine may help suppress cough and improve sleep 1
Elderly patients with cardiovascular or renal comorbidities may be safer using menthol-based products, according to the American Geriatrics Society 3
The typical treatment sequence for cough is: first-line demulcents, second-line opiate derivatives, third-line peripherally acting antitussives, and fourth-line local anesthetics including benzonatate, as recommended by the American College of Chest Physicians 1
Benzonatate has shown efficacy in controlling cough in patients with lung cancer when opioids were ineffective, with moderate-quality evidence, and is one of the few antitussives specifically studied in cancer and advanced cancer cough, showing effectiveness and safety at recommended doses, as stated by the American College of Chest Physicians and the National Comprehensive Cancer Network 2, 4
Clinicians should carefully weigh the benefits of benzonatate against potential risks, particularly in patients with a history of cardiac conditions or those at risk for accidental overdose, based on clinical expertise, as recommended by the American College of Chest Physicians 1