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Cough

Introduction

Cough is a forced expulsive manoeuvre usually against a closed glottis, which is associated with a characteristic sound. It usually has a protective function in maintaining patency and cleanliness of the airways.

The impact of cough on patients and relatives is often underestimated. Patients may need symptomatic treatment when cough is persistent, distressing or affecting sleep and/or quality of life. An assessment of the pattern and character of the patient's cough is essential to optimise treatment.  Acute cough is defined as duration of <3 weeks, subacute as 3 to 8 weeks, chronic as >8 weeks.  For information on the nature of cough, see the Management section.

Assessment

  • Ask the patient to rate cough frequency, severity and level of associated distress or anxiety.
  • Explore:
    • understanding of the reasons for cough
    • fears (including fear of choking)
    • impact on:
      • functional abilities (including continence)
      • quality of life
      • families and carers.
  • Clarify:
    • pattern, character and duration of cough
    • precipitating/alleviating factors for cough
    • associated symptoms
    • occupational history.
  • Look for any potentially reversible causes of cough, such as:
    • infection
    • pleural or pericardial effusion
    • pulmonary embolism
    • gastro-oesophageal reflux
    • bronchospasm.
  • Determine if treatment of the underlying disease is appropriate. Seek advice if in doubt.
  • Assess character of sputum and consider sputum culture if necessary. See table 3.
  • Consider chest X-ray.

Management

  • If stridor is present, seek specialist advice. Give high-dose steroids in divided doses: dexamethasone 16mg orally or subcutaneously, or prednisolone 60mg orally. Consider gastric protection.
  • Consider treating any potentially reversible causes.
  • Optimise current therapy (non-drug management and medication); in particular, ensure adequate analgesia as pain may inhibit effective coughing.
  • Acknowledge fear and anxieties, and provide supportive care. Offer written information and verbal explanation.
  • Consider referral to physiotherapy services if difficulty in expectorating retained secretions.
  • Agree a self management plan which could include:
    • cough diary
    • smoking cessation advice.
    • improved ventilation such as opening a window, putting on a fan
    • coping strategies, such as:
      • positioning and posture
      • relaxation
      • controlled breathing technique and effective coughing techniques, eg huffing.
  • Seek specialist advice for the small number of patients who may require suction or a cough assist machine.

 

Specific advice on managing a dry (non-productive) cough

A persistent refractory cough may prompt the initial diagnosis of a primary lung malignancy or pulmonary metastases and specific chemotherapy/radiotherapy may be appropriate, depending on histology and fitness.

Post-radiotherapy lung damage, pneumonitis and lymphangitis (which can be associated with breathlessness and cyanosis) may respond to steroid therapy. Seek oncology advice.

 Table 1 Management of a dry (non-productive) cough

Table 1 Management of a dry (non-productive) cough

Nature of cough

Possible cause

Potential treatment

Onset related to the commencement of medication

Angiotensin-converting-enzyme (ACE) inhibitors

Discontinue or switch to alternative medication

Rapid onset of cough, associated with dyspnoea

Pleural effusion

Consider pleural drainage and pleurodesis

Pericardial effusion Consider pericardiocentesis and pericardiosclerosis
Pulmonary embolism (usually dry cough but may have haemoptysis) Consider merits of anticoagulation with low molecular weight heparin (LMWH)

Barking cough (short duration)

Pharyngitis/tracheobronchitis/
early pneumonia

Consider antibiotics,
humidify room air

Harsh croup (coarse)

Laryngitis

Humidify room air,
advise resting of voice

Bovine cough

Recurrent laryngeal nerve palsy (from intrathoracic compression or disease)

Consider referral to ear, nose and throat (ENT) for possible vocal cord injection

Hard brassy cough (with or without wheeze or stridor)

Tracheal compression from thoracic lesions or nodes,
superior vena cava obstruction (SVCO)

Consider radiotherapy, steroids,
stenting (see SVCO section in the Breathlessness guideline)

Wheezy cough

Airflow obstruction (asthma, chronic obstructive pulmonary disease (COPD))

Optimise inhaled therapy, consider steroids

Cough Table 1. Version 1 May 2014

 

Medication

In addition to the advice described in Table 1, consider treatment to suppress a dry cough:

  • simple linctus
  • morphine (monitor for side effects including opioid toxicity)
    • opioid naive – 2mg orally, 4 to 6 hourly if required (6 to 8 hourly if frail or elderly)
    • already on morphine – continue and use the existing immediate-release breakthrough analgesic dose (oral if able or subcutaneous equivalent) for the relief of cough. A maximum of 6 doses can be taken in 24 hours for all indications (pain, breathlessness and cough). Titrate both regular and breakthrough doses as required.
  • Specialist referral if symptoms persist for consideration of other treatments.

 

Specific advice on managing a moist (productive of mucus, sputum or saliva) cough

Table 2 Management of a moist cough

Table 2 Management of a moist cough

Nature of cough

Possible cause

Potential treatment

Productive

COPD (no infection)

Optimise inhaled therapy, consider steroids

Infection, pneumonia or both Consider antibiotics (assess ceiling of treatment – intravenous (IV) or oral)
COPD exacerbation Consider antibiotics (assess ceiling of treatment – IV or oral) and steroids
Tracheo-oesophageal fistula Consider specialist advice for possible stenting
Aspiration of saliva Antimuscarinics/ anticholinergics, antibiotics
Gastro-oesophageal reflux Proton pump inhibitors (PPIs) and prokinetic, eg metoclopramide, domperidone
Cardiac failure Optimise medical management

After food

Fatigue or weakness causing poor swallow

Assessment by speech and language therapist and dietician

Weak ineffective

Motor neurone disease (MND)/amyotrophic lateral sclerosis (ALS) causing excessive saliva production

Consider antisecretory, eg hyoscine to achieve acceptable moisture levels. 
Titrate carefully.
Consider suction or cough assist machine.

Precipitated by supra pharyngeal secretions

Postnasal drip

Sinusitis/allergies

Nasal steroids

Nasal decongestant spray, antihistamine, nasal steroids

Cough Table 2. Version 1 May 2014

 

Medication

In addition to the advice described in Table 2, consider treatment to aid expectoration:

  • mucolytics - to reduce sputum viscosity, eg carbocisteine.  Stop if no benefit after a 4 week trial.
  • nebulised sodium chloride 0.9% 2.5 to 5ml as required - to help loosen secretions.

When a patient with a moist cough reaches end of life, drying of secretions may be necessary.

Practice Points

  • Non-drug management techniques that help patients and families cope are essential. Using a self management plan can help with symptom relief.
  • As the illness progresses, medication to relieve cough may become more necessary.
  • Starting opioids at a low dose and titrating carefully is safe and does not cause respiratory depression in patients with cancer, airways obstruction or heart failure.

Patient and carer advice points

  • There are many causes of cough. Some coughs require very specific treatments.
  • Encourage discussion to permit alleviation of associated fears or symptoms, eg incontinence.

 Table 3 Character of Sputum

Table 3 Character of sputum
Quality of sputum Cause

Purulent

Infection

Non-infective, jelly-like, clear

Excess saliva or mucus

Bronchorrhoea
(Mucus >100ml/day)

Broncheo-alveolar cancer, asthma, tuberculosis (TB)

Frothy

Left ventricular failure, alveolar cell cancer

Blood-stained

Infection including TB, pulmonary embolus, tumour

Cough Table 3. Version 1 May 2014

Resources

References