Cough

Question 1

What is products are available for dry cough?

Answer 1

Cough Suppressants – use for a dry cough
(Act by depressing the medullary cough centre to provide symptom relief in non-productive cough. Do not use a cough suppressant for a productive cough, as it may result in pooling and retention of mucous in the lungs, increasing the risk of infection)
- Note: Avoid cough suppressants in children 2
- Dosage:
o Adults: 10-20mg every 4 hours, or 30mg every 6-8 hours (max 120mg daily)
o Child: ​>6 years – 5-10mg every 4 hours, or 15 mg every 6-8 hours (max 60mg daily)
2-6 years – 2.5-5mg every 4 hours, or 7.5mg every 6-8 hours (max 30mg daily)
- Contraindicated within 14 days of treatment with a MAOI, and should not be combined with drugs that may contribute to serotonin syndrome

3. Pholcodine
   - Duro-Tuss Dry Cough Liquid Regular® - 1mg/mL
   - Pregnancy: Okay **
   - Breastfeeding: Okay **
   - Children: Okay in >2
   - Dosage:
   o Adult:​ 10-15mg, 3-4 times daily
   o Child: ​5-12 years – 2.5-5mg, 3-4 times daily
   2-5 years – 2-2.5mg, 3 times daily
   - Centrally acting. Shouldn’t cause sedation, but it may in sensitive individuals
4. Dihydrocodeine
   - Rikodeine® - 1.9mg/mL
   - Pregnancy: Okay **
   - Breastfeeding: Okay **
   - Children: Okay in >2
   - Dosage:
   o Adult: ​5-10mL every 4-6 hours
   o Child:​>5 years – 2.5-5mL per dose, up to 6 times per day
   2-5 years – 1.25-2.5mL/dose, up to 6 times per day
   - May be abused by some patients, avoid use if possible

Avoid combination products if possible

Question 2

What products are available for chesty cough?

Answer 2

Mucolytics – use for a productive cough
(Aim of mucolytic treatment is to reduce mucous viscosity and aid its expectoration)

1. Bromhexine
   - Bisolvon Chesty® - 4mg/5mL
   - Pregnancy: Okay, category A
   - Breastfeeding: Okay
   - Children: Okay in >1
   - Dose: **
   o Adult: 8-16mg, up to 3 times per day
   o Child:​>3 years – 8mg, up to 3 times per day
   1-3 years – 4mg, up to 3 times per day
   - Side effects: nausea, vomiting, diarrhoea

Expectorants – use for a productive cough
(Used to promote expectoration of bronchial secretions – there is no real evidence for their use)
1. Guaifenesin
- Robitussin EX® - 100mg/5mL
- Pregnancy: ****
- Breastfeeding: ****
- Children: Okay in >2 ***
- Dose:
o Adult: 10-20mL, every 4 hours **
o Child:​6-12 years – 5-10mL, every 4 hours
2-6 years – 2.5-5mL, every 4 hours

2. Ammonium salts, senega, sodium citrate

Question 3

Non drug measures?

Answer 3

Non-drug measures

• Keep up fluids
• Honey lemon tea may provide soothing relief
• The mouth should be covered during periods of coughing (to reduce transmission of infection)
• Irritative environments should be avoided (such as cold air)
• Humidifiers may help to loosen chest congestion and reduce throat irritation

Question 4

When do you refer?

Answer 4

When to refer

• Cough as a single, unexplained symptom
• Cough lasting >2 weeks (and not improving)
• Coloured phlegm – green/yellow (may be bacterial), red/rusty (indicative of blood)
• Chest pain
• Shortness of breath, wheezing
• Cough caused by medication
• Patients who are elderly, alcoholics, immunosuppressed
• Patients who have recently immigrated to Australia
• Young children with signs of whooping cough
• Recurrent nocturnal cough (especially in children)
• Failed treatment

Question 5

What are the medications used for dry cough ie. antitussives/cough suppressants.

Answer 5

• pholcodine
• dextromethorphan
• dihydrocodeine
• codeine

Don’t use if:

• coughs with significant mucus production
• asthma/COPD

Question 6

What are the dose ranges and AEs of cough suppressants?

Answer 6

Class: Opioid analgesics (?)

• Dextromethorphan
> Adult dose: 10–20mg q4h or 30mg tds/qid. Max. 120 mg d
> AEs:
- few side effects at recommended doses
- hallucinations in large doses
- risk of serotonin toxicity when used with other serotonergic drugs: avoid or use combination with caution
- shouldn’t be taken within 14 days of a monoamine oxidase inhibitor

• Dihydrocodeine
> Adult dose: 10–20mg tds/qid
> AEs:
- constipation 
- drowsiness 
- risk of dependence with prolonged use

• Codeine
> Adult dose: 15–30mg tds/qid
> AEs:
- constipation 
- drowsiness 
- risk of dependence with prolonged use

• Pholcodine. 
> Adult dose: 10–15mg tds/qid
> AEs: 
- less likely than codeine/dihydrocodeine to cause constipation and respiratory depression
- less likely to produce dependence

Counseling:

• this medication may make you drowsy; do not drive or operate machinery if you are affected
• avoid taking alcohol as it may increase the feeling of drowsiness

Note: all cat A

Question 7

What medications are used to tx a productive cough?

Answer 7

Expectorants:
> facilitate the removal of secretions by ciliary transport and coughing
* guaifenesin (also has antitussive properties)
AEs (well tolerated): nausea & vomiting
* ammonium salts (C/I in hepatic and renal impairement)
AEs: nausea & vomiting w large doses
* senga

Mucolytics:
> reduce mucus viscosity and facilitate the expulsion of thick secretions
> might disrupt the gastric mucosal barrier therefore use with caution in patients with a hx of peptic ulcer disease (PUD)
* Bromhexine *
Adult dose: 8–16mg tds
AEs:
- N&V&D 
- allergic reactions

Question 8

Demulcents.

Answer 8

Demulcents:
- glycerol
- simple linctus
- lemon 
- honey
> can relieve the irritation that causes coughing by coating the throat
> safe alternative for children

Question 9

What are the non-pharmacological management you would recommend for cough?

Answer 9

Non-pharmacological management:
- non-medicated lozenges 
- demulcents
- adequate hydration
- reducing voice use 
- avoiding throat clearing 
- steam inhalations 
> can promote expectoration
> no evidence that adding substances such as menthol/eucalyptus to inhaled steam offers any further benefit. When used, they should be at a dilution of 5 mL in about 500 mL of hot (not boiling) water
> alternatively, steam can be inhaled during a hot shower

Question 10

When do you refer a patient presenting with cough?

Answer 10

Referral necessary:
• chest pain—possible cardiovascular cause
• persistent fever
• stridor and other respiratory noises—suggestive of
whooping cough or croup
• wheeze—possible asthma
• shortness of breath—possible asthma, pulmonary
embolism, congestive heart failure
• discoloured or purulent sputum
– thick, yellow or green (possible bronchiectasis or bronchitis)
– blood stained (possible lung cancer or tuberculosis)
– rust coloured (possible pneumonia)
– frothy and pink–red (possible heart failure)
• pain on inspiration—possible pleurisy or
pneumothorax

Referral recommended:
• suspected ADR
• recurrent nocturnal cough, especially in children—
possible asthma
• a cough that recurs regularly, especially in chronic
smokers over 45 years of age
• a hx or SMx of chronic underlying disease
associated with cough—e.g. asthma, COPD,
chronic bronchitis
• a cough that becomes worse during self-treatment
• a cough that lasts longer than 3 weeks—
could be indicative of a more serious underlying condition, although symptoms that are suggestive of postnasal drip or rhinitis, which can last for more than three weeks, might not necessitate referral if suitably managed