Chapter 12 - Cough

Question 1

Cough

Answer 1

• Respiratory defensive reflex
• Most common symptom for patients seeking medical care
• Most common reason for visits for emergency department

Question 2

Cough Pathophysiology

Answer 2

• Chemical or mechanical stimulation of vagal mediated pathways
• Number of nerves activated and their strength of activation is indicative of the intensity of the cough
• Medulla processes sensory input to activate motor efferent nerves to cause an involuntary cough
• Voluntary cough: cerebral cortex

Question 3

Cough Steps

Answer 3

1. Deep inspiration
2. Glottis closure
3. Forceful chest wall, abdominal wall, and diaphragmic muscle contraction against glottis
4. Glottis opens and air expelled with foreign debris

Question 4

Cough Categories

Answer 4

1. Acute: <3 weeks
2. Subacute: 3-8 weeks
3. Chronic: > 8 weeks
4. Medication induced
5. Smoking induced

Question 5

Productive Cough

Answer 5

• Wet, “chesty,” expels secretions, can cause impaired ventilation/infection resistance
• Clear discharge: bronchitis
• Purulent discharge: bacterial infections
• Malodor: Anaerobic bacterial infections

Question 6

Nonproductive Cough

Answer 6

• Dry, “hacking”
• Viral, atypical bacterial infections, GERD, cardiac disease, and some medications cause this
• NO useful physiological purpose

Question 7

Cough Complications

Answer 7

• Exhaustion
• Insomnia
• Musculoskeletal pain
• Hoarseness
• Urinary incontinence
• Excessive perspiration
• Sore Throat
• Absence form work or school

Question 8

Cough Treatment Goals

Answer 8

• Decrease in number and severity of cough episodes
• Prevent complications
• Symptomatic relief , need to treat underlying disorder first

Question 9

Self-Care Exclusions - “3”

Answer 9

1. Worsens after 3-5 days
2. Cough that doesn’t improve after 2-3 weeks
3. Temperature over 100 degrees Fahrenheit that lasts longer than 3 days

Question 10

Self-Care Exclusions - “4”

Answer 10

1. Children < 4 y.o.
2. Difficulty, SOB, labored, chronic conditions
3. Temperature > 100.4 F
4. Barking, whooping, aspiration, blood

Question 11

Condition Exclusions

Answer 11

1. TB - night sweats, weight loss
2. COPD
3. CHF
4. HIV

Debatable, the underlying conditions need to be treated but can give some relief in the mean time in most cases

Question 12

Antitussives

Answer 12

• Cough suppressants, control/eliminate coughts
• Better for nonproductive coughs
• Do not use for productive coughs unless the benefits outweigh the risks
• Retaining secretions when used with productive coughs increases the risk of airway obstructions and secondary bacterial infections

Question 13

Protussives

Answer 13

• Change secretion consistency and increases the volume of expectorated sputum
• Allows relief from expelling thick, tenacious secretions

Question 14

Non-Pharmacological Therapy

Answer 14

1. Nonmedicated lozenges - decrease irritation
2. Humidification - increases moisture to soothe irritated pathway
3. Nasal drainage interventions
4. Hydration - less vicious, easier to expel secretions
5. Vaporizers - medicated vapor

Wet Cough: 4, 2/5, 1
Dry Cough: 1, 2/5, 4

Question 15

Children < 2 y.o. Treatment

Answer 15

• Use rubber bulb syringe to clear nose
• Prop upright at night
• Use humidifiers and vaporizers
• Keep hydrated

Question 16

Oral Antitussives

Answer 16

1. Codeine
2. Dextromethorphan
3. Diphenhydramine
4. Chlophedianol HCl

Question 17

Codeine

Answer 17

• CV, narcotic, available without a prescription in 30 states
• Antitussive at low doses, must contain <200 mg per 100 mL
• Abuse potential, purple drank, sizzurp
• MOA: Acts on medulla to increase cough threshold
• Onset: 15-30 minutes
• Duration: 4-6 hours
• Causes CNS depression, GI upset, sedation, and dizziness

Question 18

Codeine + Special Populations

Answer 18

• Do not use in children/adolescents younger than 18 y.o.
• Concerns in using with those who are pregnant or breast feeding
• Reduced dose with advanced ages

Question 19

Dextromethorphan

Answer 19

• Non-opioid with no analgesic, sedative, depressant, or addictive properties
• Equipotent to codeine with the same MOA and indication as codeine
• Onset: 30 mins-3 hours (depending on dosage form)
• Duration: 3-6 hours
• Wise margin of safety
• ADR: Drowsiness, N/V, upset stomach, sleep disturbances
• Follow up if no improvement in 2-3 weeks
• Can cause CNS depression, exacerbated with alcohol or antihistamines
• Don’t use within 14 days or using MAOIs

Question 20

Dextromethorphan + Special Populations

Answer 20

• Safety and efficacy not established in pediatric
• Probably safe in pregnant/breast feeding
• Reduce dose and monitor carefully in elderly
• Abuse potential - “Robo-tripping”

Question 21

Diphenhydramine

Answer 21

• Nonselective, first generation antihistamine
• Significant sedative and anticholinergic properties
• Same MAO and indication as codeine
• Onset: 15 minutes
• Duration: 4-6 hours
• SE: drowsiness, disturbed coordination, respiratory depression, blurred vision, urinary retention, dry mouth, respiratory secretions
• Interacts with narcotics, benzos, and alcohol
• Don’t use with narrow angle glaucoma and BPH

Question 22

Diphenhydramine + Special Populations

Answer 22

• Paradoxical reaction in children
• Commonly used during pregnancy
• Paradoxical reaction in elderly and increases their risks of falls, reduce dose and carefully monitor

Question 23

Cholphedianol

Answer 23

• Alkylamine antihistmaine with local anesthetic and mild anticholinergic effects
• Same MOA and indication as codeine
• Slower onset and longer duration than codeine
• Don’t use if used MAOIs within 14 days
• SE: Excitation, hyperirritability, nightmares, hallucinations, allergic reaction, urticaria

Question 24

Guaifenesin

Answer 24

• Only FDA-approved expectorant
• Indication: symptomatic relief of acute, ineffective productive cough
• MOA: Increases effective hydration of respiratory tract and reduces viscosity or musuc to facilitate its removal
• Give with large quantities of fluid
• SE: Dizziness, drowsiness, headache, nausea, GI upset

Question 25

Topical Antitussives

Answer 25

• Camphor and Menthol - only FDA approved
• MOA: creates local anesthetic sensation and sense of improved air flow
• Toxic if injected, can be lethal in children
• Little evidence of efficacy
• Vapors may be ciliotoxic and proinflammatory, especially in children, apply to their cloths and avoid the skin

Question 26

NSAID + Nonproductive Cough

Answer 26

• Use if due to cold

- Viral infections increase upper airway afferent nerve sensitivity and Naproxen may reduce viral-associated cough

Question 27

Decongestants + Nonproductive Cough

Answer 27

• Use in combination with first-generation antihistamine to decrease post-nasal drip
• Can also optionally used naproxen to decrease inflammation in these cases

Question 28

Upper Airway Syndrome Treatment

Answer 28

• First generation antihistamine

- Decongestant

Question 29

Dry, Chronic Coughs/Post-infectious Subacute Coughs Treatment

Answer 29

• Short-term codeine or dextromethorphan

- Dextromethorphan is preferred

Question 30

Acute Productive Cough Treatment

Answer 30

-Guaifenesin

Question 31

Herbal/Natural Options for Kids

Answer 31

• Zarbee’s

- Honey

Question 32

Honey

Answer 32

• Safe in kids older than 1 y.o.
• Short term treatment
• Can significantly reduce nighttime cough frequency and severity and improve sleep in children older than 2 y.o.
• As effective or MORE effective than dextromethorphan and diphenhydramine

Question 33

When to seek medical treatment…

Answer 33

• If symptoms don’t improve or worsen after 7 days

- Other exclusions for self-treatment are apparent at time of inquiry or develop after course of self-treatment

Question 34

When to continue therapy…

Answer 34

• If symptoms improve but persist

- Some conditions take 2-4 weeks to clear up