Cough and Cold: Congestion, Cough Flashcards
Cough and Cold - Congestion
stuffy nose
symptoms
Mucopurulent discharge Nasal mucosal edema Post‐nasal drip Choking or gagging feeling Mouth breathing (increased drying) Sinus headache (usually mild) ◦ Can be a sign of sinusitis ◦ Facial pain over sinus cavities, “splitting headache” ◦ Duration of symptoms > 20 days ◦ Purulent discharge
Cough and Cold - Congestion
Decongestants
general
Topical (onset 5‐10 mins) vs oral (onset 30 mins) formulations
Due to the sympathomime c effects, decongestants can cause elevate on in blood pressure →
caution in hypertensive patients
- lack evidence for children <12
Cough and Cold - Congestion
Decongestants
prolonged topical decong = rhinitis medicamentosa
which pdts are more common for it?
◦ Rebound vasodila on → rebound conges on and rhinitis
◦ Occurs after 3‐5 days of use
◦ More common with shorter‐acting agents (phenylephrine) than with longer‐acting (oxymetazoline,
xylometazoline)
◦ Patient may have to be titrated off topical decongestant with nasal saline and nasal steroids
Cough and Cold - Congestion
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Oral Decongestants
name 2
MOA?
evidence of effectiveness?
dosing see table
~~~
Pseudoephedrine, phenylephrine
MOA: Sympathomimetic agents that relieve nasal congestion (a and b‐adrenergic agonists)
a: vasoconstriction in mucosa and respiratory tract (decreases edema and increases drainage of sinus cavities)
b: relaxation of bronchial smooth muscle
- moiderate efficacy for single doses, conflicting for repeated dosing
Cough and Cold - Congestion
Oral Decongestants
AE?
DI
Precautions
AE: Mild CNS stimulation, peripheral vasodilation, tachycardia, palpitations, increase in bp, may adversely affect blood sugar control in diabetics
DI: Effectiveness of b blockers may be reduced, MAOIs and ergot derivatives may increase hypertensive effects, SNRIs may
enhance tachycardic and vasopressive effects, antagonizes effects of a‐blockers
Precautions: heart disease, hypertension, hyperthyroidism, diabetes, angle‐closure glaucoma, prostatic
enlargement, seizure disorder, prostatic hypertrophy
Cough and Cold - Congestion
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Topical Decongestants
name 3
MOA?
evidence of effectiveness?
dosing see table
~~~
Oxymetazoline, phenylephrine, xylometazoline
MOA: Sympathomimetic agents that relieve nasal congestion
moderate efficacy for single doses, conflicting for repeated dosing
Cough and Cold - Congestion
Topical Decongestants
AE?
DI
AE: Local burning stinging, sneezing, dryness of nasal mucosa, rhinitis medicamentosa, brady/tachycardia, hypo/hypertension
DI: MAOIs may increase hypertensive effects
Other drug interactions less likely than with systemic
Cough and Cold - Congestion
other treatment options (4)
Saline spray or drops
Nasal syringing/irrigation
Counter‐irritants (eg. Buckley’s Mixture)
Neti‐Pot
Cough and Cold - Congestion
nasal rinses
evidence, safety?
- Limited evidence but may have some symptomatic relief
- Temporarily remove bothersome nasal secretions
- Improve mucociliary clearance
- Can lead to vasoconstriction (decongestion)
Safety
• Ensure that distilled, sterile, or boiled and cooled tap water is used
• Cases of amebic encephalitis have been associated with nasal irrigation with
contaminated tap water
• Ensure the device is washed properly and regularly
Cough and Cold - Cough
what are these?
◦ Upper airway cough syndrome [UACS] (Postnasal drip) ◦ Acute bacterial sinusitis ◦ Chronic bronchitis ◦ Allergic rhinitis ◦ Rhinitis due to environmental irritants ◦ Drugs: ACEI, beta blockers, ASA or NSAIDS ◦ Cigarette smoke ◦ Heart failure ◦ Cystic fibrosis ◦ Pulmonary embolism ◦ GERD ◦ Foreign body
common causes of cough
Cough and Cold - Cough
what are these?
◦ Upper airway cough syndrome [UACS] (Postnasal drip) ◦ Acute bacterial sinusitis ◦ Chronic bronchitis ◦ Allergic rhinitis ◦ Rhinitis due to environmental irritants ◦ Drugs: ACEI, beta blockers, ASA or NSAIDS ◦ Cigarette smoke ◦ Heart failure ◦ Cystic fibrosis ◦ Pulmonary embolism ◦ GERD ◦ Foreign body
common causes of cough
Cough and Cold - Cough
how is it induced?
when is it classified as acute, subacute, chronic
Symptom of many respiratory diseases
◦ Viral infections most common
Phlegm does not indicate a bacterial infection
voluntarily induced or involuntarily activated through a reflex arc to the cough center in the medulla oblongata via the afferent limb of the vagus nerve
Classified based on duration ◦ Acute: < 3 weeks ◦ Subacute: 3‐8 weeks ◦ Usually post‐infection ◦ Chronic: > 8 weeks
Cough and Cold - Cough
Upper airway cough syndrome (Post‐Nasal Drip)
symptoms of postnasal drip
READ
- hoarse voice
- occasional cough, persistent cough
- sore throat
- losing voice, scratching, tickling of back of throat
- burning of throat
- need to clear it
Cough and Cold - Cough
Red flags
- prolonged, high fever
- signs of choking on foreign body, food or vomit
- rapid breathing, SOB, wheezing
- chest pain
- blue lips, tongue/face, feeling of suffocation, bloody or frothy pink sputum
- acute confusion or recent change in mental status
- cough present > 3 wks
- comorbid illness, etc, etc, etc
Cough and Cold - Cough
pharm management - Anti-tussives
name 2
MOA
effective?
Dextromethorphan (opioid derivative), Codeine (only available as a combination schedule 2)
MOA: Unknown, acts centrally (likely at the brainstem) to suppress cough (inhibit motor control of cough)
Evidence of effectiveness: limited, does not recommend centrally acting suppressants for cough secondary to URTI
Cough and Cold - Cough
Dextromethorphan (opioid derivative)
AE
DI
- Well tolerated
- Occasional dizziness, drowsiness, and nausea
- Has been abused for euphoric effects
DI: Risk of serotonin syndrome in conjunction with drugs that affect serotonin, CYP 2D6 inhibitors may inhibit metabolism resulting in increased adverse effects
Cough and Cold - Cough
Codeine
AE
DI
Drowsiness, sedation, nausea, vomiting, constipation,
addiction potential
Additive effect with CNS depressants, risk of serotonin
syndrome with MAOIs, CYP 2D6 inhibitors may inhibit
metabolism to active metabolite
Cough and Cold - Cough
pharm management - expectorants
name 1
MOA
effective?
Guaifenesin
MOA: Promotes clearance of airway secretions
Patient must be well hydrated
limited evidence
Cough and Cold - Cough
Guaifenesin
AE
DI
Well tolerated
Dizziness, drowsiness, headache, nausea, and vomiting have been reported at high doses
DI: none
Cough and Cold - Cough
pharm management - 2nd line agent
name 1
MOA
- Diphenhydramine
- MOA: Anticholinergic effect may reduce post‐nasal drip, however, the effect is modest and there is a risk of side effects
Cough and Cold - Cough
NHPs - honey
MOA
evidence
AE
• Mechanism of action: Demulcent, may act to decrease cough antioxidant and
antibacterial
• May be effective in children but studies are
inconclusive
• Use pasteurized honey to immunocompetent
children > 1 y - risk of botulism
Cough and Cold - Cough
NHPs - Zinc lozenges
MOA
evidence
AE
MOA: May prevent rhinovirus from multiplying or lodging in mucous membranes of mouth/nose
Conflicting results in the literature
AE: Unpleasant taste, mouth irritation, nausea, diarrhea, anosmia
Cough and Cold - Cough
NHPs - Menthol/Camphor/Eucalyptus
MOA
evidence
AE
MOA: May increase perception of nasal breathing, cooling sensation
Objective measurements of nasal flow do not indicate improvement
Local irritation
Never place directly under nostrils – increased production and decreased clearance of mucus
Cough and Cold - Cough
NHPs - Echinacea
MOA
evidence
AE
precautions: atopic indiv, immunosupp, ragweed, not evaluated in pregnancy
Potentially stimulates immune system
E purpurea most frequently studied but E. angustifolia most frequently used - Evidence inconclusive
AE: Allergy, nausea, dizziness, tingling of tongue,
excessive salivation
