Symptomatic management of cough in acute bronchitis in adults

Agent or intervention	Dose/frequency	Comments
Pharmacologic therapies*
Dextromethorphan^¶ (OTC)	Immediate release (liquids, lozenges, and capsules): 10 to 20 mg orally every 4 hours or 20 to 30 mg every 6 to 8 hours as needed Extended release (suspension): 60 mg orally twice daily as needed (maximum daily dose: 120 mg)	Cough suppressant: Temporary control of cough by interruption of central cough impulse and decreasing the sensitivity of respiratory cough receptors. Serotonin syndrome may occur when used with pro-serotonergic drugs (eg, SSRIs/SNRIs, linezolid), especially at higher doses Avoid use in patients at-risk for respiratory compromise (eg, acute asthma)
Guaifenesin^¶ (OTC)	Immediate release (liquids and tablets): 200 to 400 mg orally every 4 hours as needed Extended release (tablets): 600 mg to 1.2 g orally every 12 hours as needed (maximum daily dose: 2.4 g)	Expectorant: Helps loosen mucus/bronchial secretions. May reduce viscosity of secretions but does not suppress cough. Adequate hydration is required for maximal efficacy.
Albuterol	Metered-dose inhaler or dry powder inhaler (90 mcg/actuation): 2 inhalations every 4 to 6 hours as needed	Beta₂ agonist: Treatment of bronchospasm in patients with reversible obstructive airway disease. Only appropriate in patients who have wheezing or underlying pulmonary disease For acute asthma exacerbation initial dosing is more frequent; refer to clinical topic
Benzonatate	100 to 200 mg orally 3 times per day as needed (maximum daily dose: 600 mg)	Cough suppressant: Suppresses cough by topical anesthetic action on respiratory stretch receptors. Swallow capsule whole; do not chew or break
Non-pharmacologic interventions
Throat lozenges (oral)	As needed (per labelling instructions)	Lozenges (typically nonmedicated or with menthol) may relieve sore throat and reduce cough frequency and severity
Honey (oral)	As needed	Often taken in hot water or tea May reduce cough frequency and severity
Smoking cessation (and avoidance of second-hand smoke)	––	Smoke is an airway irritant

For adults with bothersome cough from acute bronchitis, we offer nonpharmacologic treatments (eg, honey, hot tea, nonmedicated throat lozenges). While high-quality evidence supporting their efficacy is lacking, patients may derive relief from these measures, and for most, the risk of harm is small.

OTC: over-the-counter (prescription not required); SSRI: selective serotonin reuptake inhibitor; SNRI: serotonin-norepinephrine reuptake inhibitor.

* We avoid the use of opioid cough suppressants (including codeine) in adults with acute bronchitis due their side effect profile and potential for dependency and addiction.

¶ Available guaifenesin-dextromethorphan combinations include: Liquids (guaifenesin 100 mg and dextromethorphan 5 mg per 5 mL) and pills (guaifenesin 200 mg and dextromethorphan 10 mg per capsule); alcohol-free preparations are preferred.

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Symptomatic management of cough in acute bronchitis in adults