Management of Persistent Cough

Introduction to Treatment Options

The American College of Chest Physicians recommends adding inhaled ipratropium bromide as the next step for persistent cough despite albuterol, Tessalon Perles, and QVAR (beclomethasone), followed by a short course of oral prednisone (30-40 mg daily) if ipratropium fails and other common causes have been excluded 1, 2

Ipratropium bromide is the only inhaled anticholinergic specifically recommended for cough suppression in postinfectious or persistent cough, with fair evidence (Grade B recommendation) for reducing cough frequency in patients with persistent cough not responding to initial bronchodilator and inhaled corticosteroid therapy 1, 2, 3
If ipratropium fails and the cough adversely affects quality of life, prescribe prednisone 30-40 mg daily for a short, finite period (typically 5-7 days), with low evidence level but intermediate net benefit (Grade C recommendation) 1, 2

The American College of Cardiology recommends stopping any ACE inhibitor immediately if present, as it is the most common medication-related cause of persistent dry cough, occurring in 5-50% of patients, and typically resolves within 1-2 weeks of discontinuation 4
If cough has lasted ≥2 weeks with paroxysms, post-tussive vomiting, or inspiratory whooping sound, obtain nasopharyngeal culture or swab for Bordetella pertussis (Grade B recommendation) 1, 2

Codeine (30 mg three times daily) or dextromethorphan (30 mg as needed) should be considered when other measures fail, with fair evidence (Grade B for codeine) for chronic bronchitis but limited efficacy for upper respiratory infection-related cough 1, 2, 3
Levodropropizine or moguisteine are recommended for short-term symptomatic relief in chronic or acute bronchitis (Grade A recommendation) 3

Albuterol alone is not recommended for cough not due to asthma (Grade D recommendation) 3
Over-the-counter combination cold medications (except older antihistamine-decongestant combinations) are not recommended until proven effective in trials 3
Zinc preparations are not recommended for acute cough due to common cold (Grade D) 3
Mucolytic agents have no role in cough suppression for chronic bronchitis (Grade D) 3