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Research ArticleTools for Practice

Bronchodilators or inhaled corticosteroids for postinfectious cough

Samantha S. Moe, Emélie Braschi and G. Michael Allan
Canadian Family Physician March 2023; 69 (3) 180; DOI: https://doi.org/10.46747/cfp.6903180
Samantha S. Moe
Clinical Evidence Expert at the College of Family Physicians of Canada (CFPC).
PharmD ACPR
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Emélie Braschi
Hospitalist at the Élisabeth Bruyère Hospital in Ottawa, Ont, and a physician adviser at the CFPC.
MD PhD CCFP
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G. Michael Allan
Director of Programs and Practice Support at the CFPC.
MD CCFP FCFP
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Clinical question

Do bronchodilators or inhaled corticosteroids (ICS) help postinfectious cough (PIC) in adults without asthma?

Bottom line

Data are limited, with results from only 2 ICS RCTs and 1 bronchodilator RCT. In adults, PIC scores may improve about 50% when taking placebo and about 5% to 10% more with ICS over 2 weeks. Ipratropium-salbutamol may resolve cough in more patients than will placebo at day 10 (37% vs 69% have ongoing cough) but most patients (>80%, regardless of treatment) will have cough resolution by day 20.

Evidence

Differences were statistically significant unless indicated.

  • For ICS versus placebo: In 4 systematic reviews of treatments for persistent cough (4 to 9 RCTs, 335 to 750 patients) interpretation of results was limited by inclusion of RCTs with acute (<3 weeks)1,2 and chronic (>8 weeks)2,3 cough, and multiple drug classes.4

    • - The most useful systematic review2 (2 RCTs, 163 patients, 3 to 8 weeks) of mainly subacute cough found ICS had a standard mean difference of 0.42 versus placebo. This means that at 2 weeks placebo improved cough scores by roughly 50% to 56% and ICS improved scores about 2% to 13% more.

    • - The largest RCT5 (133 patients) reported additional outcomes (eg, days off work, nocturnal awakenings, adverse effects), but there was no difference in treatments.

      • — The proportion of non-smokers with more than 50% cough improvement was 81% versus 54% (placebo) (number needed to treat=4). There was no improvement among smokers.

      • — Limitations: Not all patients had PIC; the study was industry funded.

  • Bronchodilators versus placebo: One RCT6 of 92 patients (cough duration 3 to 4 weeks) using a combination of nebulized salbutamol and ipratropium found the proportion with ongoing cough at day 10 was 37% versus 69% placebo (number needed to treat=3). There was no difference at day 20 (both >80% resolved).

    • - Limitations: Studies were small, used nonvalidated cough scores, and recorded multiple outcomes.

Context

  • Postinfectious cough persists 3 to 8 weeks after an acute respiratory illness.7

  • In an RCT8 of beclomethasone versus placebo, it is likely patients did not have not true PIC (subacute). Yet, ICS improved 3 of 6 outcomes on device-measured cough (no difference in patient-reported symptoms).

  • Guidelines suggest considering a trial of inhaled ipratropium or, if refractory, ICS.9

  • The RCTs did not include patients with COVID-19.

Implementation

Upper airway cough syndrome (ie, postnasal drip) can cause PIC. If suspected, intranasal steroids can be tried. Other causes of subacute cough include exacerbation of asthma or chronic obstructive pulmonary disease, gastroesophageal reflux disease, and medications.7 Red flags are hemoptysis, smoking, prominent dyspnea, hoarseness, systemic symptoms, dysphagia, recurrent pneumonia, and abnormal physical examination findings.7 Tuberculosis should be considered in high-risk populations.7 Follow-up via a telephone call or an in-person appointment should occur 4 to 6 weeks after the initial evaluation to ensure cough resolution.7

Notes

Tools for Practice articles in CFP are adapted from peer-reviewed articles at http://www.toolsforpractice.ca and summarize practice-changing medical evidence for primary care. Coordinated by Dr G. Michael Allan and Dr Adrienne J. Lindblad, articles are developed by the Patients, Experience, Evidence, Research (PEER) team and supported by the College of Family Physicians of Canada and its Alberta, Ontario, and Saskatchewan Chapters. Feedback is welcome at toolsforpractice{at}cfpc.ca.

Footnotes

  • Competing interests

    None declared

  • Copyright © 2023 the College of Family Physicians of Canada

References

  1. 1.↵
    1. El-Gohary M,
    2. Hay AD,
    3. Coventry P,
    4. Moore M,
    5. Stuart B,
    6. Little P
    . Corticosteroids for acute and subacute cough following respiratory tract infection: a systematic review. Fam Pract 2013;30(5):492-500. Epub 2013 Jul 8.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Lee SE,
    2. Lee JH,
    3. Kim HJ,
    4. Lee BJ,
    5. Cho SH,
    6. Price D, et al
    . Inhaled corticosteroids and placebo treatment effects in adult patients with cough: a systematic review and meta-analysis. Allergy Asthma Immunol Res 2019;11(6):856-70.
    OpenUrl
  3. 3.↵
    1. Johnstone KJ,
    2. Chang AB,
    3. Fong KM,
    4. Bowman RV,
    5. Yang IA
    . Inhaled corticosteroids for subacute and chronic cough in adults. Cochrane Database Syst Rev 2013;(3):CD009305.
  4. 4.↵
    1. Speich B,
    2. Thomer A,
    3. Aghlmandi S,
    4. Ewald H,
    5. Zeller A,
    6. Hemkens LG
    . Treatments for subacute cough in primary care: systematic review and meta-analyses of randomised clinical trials. Br J Gen Pract 2018;68(675):e694-702. Epub 2018 Sep 10.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. Ponsioen BP,
    2. Hop WCJ,
    3. Vermue NA,
    4. Dekhuijzen PNR,
    5. Bohnen AM
    . Efficacy of fluticasone on cough: a randomised controlled trial. Eur Respir J 2005;25(1):147-52.
    OpenUrlAbstract/FREE Full Text
  6. 6.↵
    1. Zanasi A,
    2. Lecchi M,
    3. Del Forno M,
    4. Fabbri E,
    5. Mastroroberto M,
    6. Mazzolini M, et al
    . A randomized, placebo-controlled, double-blind trial on the management of post-infective cough by inhaled ipratropium and salbutamol administered in combination. Pulm Pharmacol Ther 2014;29(2):224-32. Epub 2014 Aug 8.
    OpenUrl
  7. 7.↵
    1. Irwin RS,
    2. French CL,
    3. Chang AB,
    4. Altman KW; CHEST Expert Cough Panel
    . Classification of cough as a symptom in adults and management algorithms: CHEST guideline and expert panel report. Chest 2018;153(1):196-209. Epub 2017 Nov 10.
    OpenUrlPubMed
  8. 8.↵
    1. Gillissen A,
    2. Richter A,
    3. Oster H
    . Clinical efficacy of short-term treatment with extra-fine HFA beclomethasone dipropionate in patients with post-infectious persistent cough. J Physiol Pharmacol 2007;58 Suppl 5(Pt 1):223-32.
    OpenUrlPubMed
  9. 9.↵
    1. Irwin RS,
    2. Baumann MH,
    3. Bolser DC,
    4. Boulet LP,
    5. Braman SS,
    6. Brightling CE, et al
    . Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 Suppl):1S-23S.
    OpenUrlCrossRefPubMed
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Canadian Family Physician: 69 (3)
Canadian Family Physician
Vol. 69, Issue 3
1 Mar 2023
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Bronchodilators or inhaled corticosteroids for postinfectious cough
Samantha S. Moe, Emélie Braschi, G. Michael Allan
Canadian Family Physician Mar 2023, 69 (3) 180; DOI: 10.46747/cfp.6903180

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Bronchodilators or inhaled corticosteroids for postinfectious cough
Samantha S. Moe, Emélie Braschi, G. Michael Allan
Canadian Family Physician Mar 2023, 69 (3) 180; DOI: 10.46747/cfp.6903180
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