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In addition to disease-specific therapy, patients with acute cough may occasionally benefit from antitussives, which block the cough reflex at various locations. Mild cough suppressants, such as the antihistamine diphenhydramine, should be tried first. However, the most effective cough suppressants are the opiates: dextromethorphan, codeine, and oxycodone.7!9 While cough suppressants are usually restricted to patients with a dry cough and avoided in patients with significant sputum production, there is only tradition to support this practice. Demulcents, part of most proprietary cough preparations, soothe the pharynx and somewhat suppress the cough reflex. Inhaled local anesthetics are effective cough suppressants but also suppress protective lung reflexes and may induce bronchospasm; they should be used only with great caution and under careful supervision. 20

Because chronic cough is most often due to a few common disorders, an algorithmic approach to treatment using sequential steps appears to be effective: 21

1. Reduce exposure to lung irritants (e.g., smoking) and discontinue ACE inhibitors and b blockers.

2. Treat for postnasal discharge with an oral antihistamine-decongestant and/or an inhaled nasal steroid. If the cough improves, continue treatment and evaluate for sinus disease with imaging studies.

3. Evaluate and treat for asthma.

4. Obtain chest and sinus radiographs if not already done.

5. Evaluate and treat for GE reflux.

6. Refer the patient for bronchoscopy.

Using a sequential approach, tailoring treatment to the clinical symptoms and the patient's responses, over 95 percent of patients achieve resolution of their cough.«2!

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