Cough
An approach to symptom management to guide decision-making in the management of patients with life-threatening illness
Explanation to patient and family
Non-pharmacological interventions
Review assessment and management
Involuntary cough is initiated by rapidly adapting ‘irritant ‘ receptors (RAR) that transmit trough vagal fibres. The most sensitive sites for cough induction are the larynx, main carina and the branching points of the tracheobroncial tree. Cough has two main functions: to prevent foreign material entering the lower respiratory tract and to clear secretions from the lungs and bronchial tree. Excessive cough can impair QOL by preventing sleep, interrupting communication and causing social embarrassment. It can also cause haemodynamic changes, ruptured vessels, urinary incontinence, hernias, neurological problems, lung barotrauma, and rib fractures.
Assessment and Severity
History:
- Duration: cough for more than 3 weeks is considered chronic
- Course: constant, worsening, intermittent, diurnal variation
- Dry or productive (nature and volume)
- Other:
- Shortness of breath
- Associated with pain
- Wheeze or tightness of chest
- Loss of weight
- Fever and night sweats
Physical Examination:
- General: distress, fever, sweating, loss of weight, cyanosis and clubbing
- Respiratory: Respiratory rate, hyperinflation, dullness, crackles, wheeze, bronchial breathing, pleural rub
Investigations: will depend on the most likely cause determined clinically. It is important to note that due to the high incidence of TB in South Africa, PTB should be excluded in all patients who have a chronic cough or any other symptoms of PTB.
Causes and Therapy
| Non-malignant | Treatment |
| Upper respiratory viral infection | Support; but consider prophylactic antibiotics |
| Bronchopneumonia | Antibiotics |
| Asthma | Bronchodilators and corticosteroids |
| Chronic obstructive pulmonary disease | Bronchodilators, trial of steroids, trial of oxygen & physiotherapy |
| Foreign body | Removal |
| Cigarette smoke | Avoidance |
| Oesophageal reflux | Proton pump inhibitors |
| Left ventricular failure | Cardiac drugs |
| Bronchiectasis | Postural drainage and antibiotics if needed |
| Motor neuron disease | See palliative care guidelines |
| Multiple sclerosis | See palliative care guidelines |
| Angiotensin converting enzyme inhibitors | Covert to other hypertension drugs |
| Inhaled drugs | Avoidance |
| Post nasal drip | Decongestants and antibiotics |
| Cystic fibrosis | - |
| Interstitial fibrosis | -- |
| Malignant | -- |
| Endobronchial disease | Steroids |
| Pleural Effusion | Tap and pleurodesis |
| Mesothelioma | Refer to oncology |
| Lymphangitis | Steroids |
| Multiple pulmonary metastases | Steroids |
| Radiation pneumonitis | Steroids |
| Hilar tumour or lymphadenopathy | Consider palliative radiotherapy |
Explanation to patient and family
- Discuss the most probable cause and planned management
- Persistent cough can precipitate vomiting, exhaustion, pain and insomnia
- Continued coughing at night can keep a household awake & it is therefore important for the family to be counselled
- Avoid smoke and fumes
- If an infection is suspected e.g. TB, family members must be tested and infection control should be put into place
- Atmospheric humidification
Non-pharmacological interventions
- Steam inhalation can help for tenacious sputum.
- A combination of lemon, honey and hot water can have a soothing effect
- Physiotherapy for standard vibration, percussion and postural drainage
- Suctioning in the patient who is unable to cough with loose secretions
First line treatment
Productive cough in patient who can cough effectively:
Tenacious sputum:
- Nebulised saline (0.9 percent) 2.5 ml q 6 h and prn
- Simple linctus: Currently none on state code, but with private patients:
- Acetylcysteine 200mg tds
- Bromhexine 10mg tds
- Carbocisteine 750mg tds
- Bronchospasm must be treated with nebulised salbutamol
- Cough suppressant can be considered in the exhausted patient and to prevent further physical trauma
Purulent sputum:
- Antibiotics specific to cause
- Cough suppressants can be considered in the exhausted patient.
Loose secretions but unable to cough:
- Hyoscine butylbromide
- Inhalations with Ipratroprium bromide 250-50mcg q 6h
- Morphine through a CSCI (It is the most effective antitussive agent and acts on the central cough centre)
Dry cough:
- Saline inhalations 2.5ml q 6h
- Codeine Phosphate 30-60mg 4-6 hourly
- Morphine 5mg q 4h
- Pholcodine 5-10mg 3-4 times daily
Second line treatment
Loose secretions but unable too cough:
- Corticosteroids
- Macrolide antibiotics
- Nebulised furosemide
Dry cough:
- Methadone 2mg 3-4hourly
- Nebulised local anaesthetics
- This must be done with great care.
- The patient must be NPO for an hour after nebulisation
- Bronchodilators must be on standby
- Use lignocaine 5ml 2% solution every 6 hours or bupivacaine 5ml of a 0.25% solution every 8 hours
Review assessment and management
If no response to initial antibiotics, repeat an MC&S and a TB AFB and culture.
At all stages consider the involvement of the interdisciplinary team.
The physiotherapist has a key role to play in managing respiratory problems.
Referral
If cause remains unknown refer to a pulmonologist or referring oncologist.