CPDCough Module

Ref: IHL-CPD-HILLS-001

OBJECTIVESBy the end of this module you will:

• Understand what a cough is

• Understand and explain the causes of coughs

• Identify symptoms which may require referral

• Understand the differential diagnoses for coughs

• Know the drug treatment and self-care options available

COUGH & ITS CAUSES

A cough is a sudden reflex which has a protective mechanism of clearing the airways of mucus and irritants. It is simulated by irritation in the pharynx (throat), the trachea (wind pipe) or the respiratory mucosa in the lungs. It is associated with a characteristic sound which is due to a forced expulsive action against a closed glottis.

Examples of irritants include cigarette smoke and dust.

CLASSIFICATION OF COUGHS

Coughs can be placed in two broad categories: productive (sputum present i.e. chesty cough) and non-productive (no sputum present i.e. dry coughs).

Depending on the duration, coughs can be acute, subacute or chronic.

Treatment of coughs depends on the duration and the category of the cough. The following tables give more detail on both the category and duration and frequency of coughs.

THE DURATION & FREQUENCY

OF COUGHS

ACUTE SUBACUTE CHRONIC

DURATION

CAUSE

REFERRAL

Less than 3 weeks

Commonly viral

infectionsSelf-limiting

If no improvement

after 3 weeks

3-8 weeks

Post infection,

Post nasal drip, bacterial

sinusitis or asthma

If no improvement

after 8 weeks

More than 8 weeks

Chronic bronchitis,

chronic lung disease, certain

medication

Recurrent, long-standing

coughs

SPUTUM

SYMPTOMS

CAUSES

NON-PRODUCTIVE PRODUCTIVE

Non-present

Dry, tickling

sensation

Viral infections, allergies,

medicines, bronchospasm,

response to irritants

Present - clear or white in colour

Productive, bringing up

phlegm

Viral or bacterial infections,

postnasal drip, tobacco use or

the reflux of stomach acid

THE TYPES OF COUGHS

DANGER SYMPTOMS

• Dyspnoea• Haemoptysis• Severe chest pain• Swollen face and hives

Patients with sudden onset of cough associated with the following symptoms should be admitted:

• Oedema• Weight loss• Persistent fever• Risk factors for TB or HIV infection• Recent exposure to whooping cough• Wheezing that is not resolved with inhalers

or new wheezing• Cough that has lasted for longer than 3 weeks• Swelling of lymph nodes in the neck

Patients with cough and the following symptoms should be referred to the GP:

DIFFERENTIAL DIAGNOSESMedication:Some medicines may increase the risk of cough. These include angiotensin converting enzyme inhibitors (ACEI). Corticosteroids used in inhalers or nasal sprays may induce cough. Some antibiotics such as aminoglycosides, erythromycin and amphotericin increase the risk of cough as does sitagliptin.

Asthma may present as a non-productive cough especially in young children where the cough is worse at night. Monitor for following symptoms that require referral:• Frequent throat clearing, coughing, wheeze, chest

tightness, and shortness of breath. • Symptoms may be variable, intermittent and worse at

night.• Often associated with family history of atopy.• Refer for tests e.g. peak flow, spirometry, fractional

exhaled nitric oxide (FeNO), airway responsiveness test.

• An unlikely cause of cough may be lung cancer • 20 – 90% of cancer patients will develop a cough• Marked change in sound of cough, blood in sputum• Watch for weight loss, loss of appetite, and recurring

infections such as bronchitis or pneumonia• Refer for tests e.g. CT chest, sputum cytology,

bronchoscopy

Asthma

Lung Cancer

• Characterised by sinus or nasal discharge that drips into the throat.

• Coughs caused by allergies are often seasonal, non-productive and worse at night with the following associated symptoms: sneezing, nasal discharge/blockage, conjunctivitis and itchy mouth.

Upper airways cough syndrome (previously referred to as post nasal drip)

• Symptoms similar to viral upper respiratory tract infection plus dyspnoea and wheeze.

• Duration 7 – 10 days but can persist for three weeks.• Most common occurrence in autumn and winter.• Symptoms resolve without antibiotic treatment.

CONDITIONS TO ELIMINATE:

Acute Bronchitis

MANAGEMENTCoughs are self-limiting and often resolve within 3 weeks. There are many treatment options for cough symptoms however, there is limited evidence to support the use of cough suppressants or mucolytic agents and thus should be used selectively. The principles of evidence-based medicine and the potential for adverse effects should always be considered before recommending any over-the-counter (OTC) cough preparations. According to the MHRA, OTC cough and cold medicines should not be given to children under the age of six years. Children aged 6 -12 years should only receive cough and cold preparations on the advice of a pharmacist or doctor. SPCs may differ in advise given for use in children restricting use in ages 12 and under.

SELF-CARE

• Cough drops may ease a dry cough and soothe an irritated throat. Do not give to children under age 6 due to choking hazard.

• Analgesics. Cough associated with fever may give paracetamol or ibuprofen to ease discomfort.

• Humidify the air. Use a vaporizer or take a steamy shower.

• Hydrate. Drink plenty of fluids e.g. water and warm liquids, such as broth tea or honey and lemon. Note that honey cannot be given to children under the age of 1 year

• Avoid tobacco smoke. Smoking or breathing second hand smoke can exacerbate cough symptoms.

Expectorants decrease mucosal viscosity and facilitate expectoration of secretions. Guaifenesin is the most commonly used expectorant as it has no serious adverse effects, but multiple expectorants exist, including squill, bromhexine, ipeacacuanha, and saturated solution of potassium iodide (SSKI).

Topical treatments such as acacia, liquorice, glycerin, honey, and wild cherry cough drops or demulcent syrups may soothe symptoms but their use is not supported by scientific evidence.

A combination of active ingredients may be used to target underlying cause of all coughs by targeting cough reflex hypersensitivity e.g. diphenhydramine, ammonium chloride, levomenthol and highly concentrated natural cocoa flavour.

NOTE: For children simple cough syrups containing glycerol may be given alongside self-care measures. Do not give children any product with any of the above active ingredients antihistamines, expectorants, antitussives as the risk of side effects is greater than any possible therapeutic benefit.

Advise patients to take the cough medicine for the shortest period of time necessary. Most coughs resolve within 2-3 weeks, if the cough persists refer to the doctor.

Expectorants:

Topical treatments:

Other medicines:

Antitussives:

DRUG TREATMENT

Productive Cough: Expectorants

Squill Dextromethorphan

Dry Cough: Antitussives

PholcodineGuaifenesin

Ipeacacuanha

Antitussives may help some patients with chronic cough who have a reflex or psychogenic component to their cough or who develop bronchial mucosal injury. Antitussives such as dextromethorphan and pholcodine depress the medullary cough centre.

3. A child aged 5 develops a chesty cough and mild symptoms of malaise. Which one of the following medicines would you recommend?

a. Pholcodine b. Capsicumc. Guaifenesind. Squille. Self-care

a. A 18 year old patient complains of nasal congestion and a productive cough that has lasted 7 days.

b. A 5-year-old who presents with barking cough that is worse at night but has improved in the last 2 days.

c. A 10-year- old who presents with chest pain when coughing or breathing in along with shortness of breath and productive cough, shortness of breath

d. A 45-year-old who complains of dry cough, nasal congestion, post nasal drip, and sneezing.

e. A 16-year-old patient with headache, itchy eyes, and dry cough.

4. In which one of the following scenarios would it be most appropriate to refer the patient?

a. Allopurinol b. Ramiprilc. Losartand. Levomenthole. Pholcodine

a. Dizziness b. Drowsinessc. Dry mouthd. Excitatione. Sputum retention

TEST YOURSELF

1. Which one of the following medicines may induce dry cough?

2. Which one of the following side effects is NOT associated with pholcodine linctus?

a. Weight loss b. Recurrent pneuomoniac. Drooping or weakness of one eyelidd. Haemoptysise. Hypernatraemia

5. Which one of the following symptoms is NOT indicative of lung cancer?

6. List 2 causes of cough

7. What is the difference between a dry cough and a productive cough?

9. What self-care measures can a patient take when they are suffering from a cough?

8. What are the danger symptoms associated with a cough which warrants referral?

10. Give two examples of antitussives. Which type of coughs they can be used to alleviate?

1. ANSWER B Ramipril is an angiotensin converting enzyme inhibitor – accumulation of bradykinin may cause dry cough, switch to ARB. Do not supply cough syrup in this case.

2. ANSWER C Dry mouth is not typically associated with use of pholcodine linctus. Side effects such as drowsiness, dizziness, excitation, confusion, sputum retention, vomiting, gastrointestinal disturbances and rash are cited in the summary product characteristics.

3. ANSWER E Guaifenesin is used for chesty cough however, it should not be used in children under the age of 6. Self care is the most appropriate option in this case.

4. ANSWER C This child is presenting with symptoms of possible pneumonia and should be referred urgently.

5. ANSWER E Haemoptysis is the most well known alarm symptom associated with cancer. In more advanced stages of lung cancer hypercalcaemia NOT hypernatraemia occurs.

6. Cigarette smoke and dust

7. No sputum production with a dry cough

ANSWERS ANSWERS8. Dyspnoea

Haemoptysis Severe chest pain Swollen face and hives

10. Dry Cough: Antitussives Dextromethorphan Pholcodine

9. Cough drops may ease a dry cough and soothe an irritated throat. Do not give to children under age 6 due to choking hazard.

Analgesics. Cough associated with fever may give paracetamol or ibuprofen to ease discomfort.

Humidify the air. Use a vaporizer or take a steamy shower.

Hydrate. Drink plenty of fluids e.g. water and warm liquids, such as broth tea or honey and lemon. Note that honey cannot be given to children under the age of 1 year.

Avoid tobacco smoke. Smoking or breathing second hand smoke can exacerbate cough symptoms.

Name of Product: Hills Balsam Chesty Cough Liquid. Active Ingredient(s): Guaifenesin BP 100 mg/5 ml. Product licence number: PL 00415/0202. Name and address of the product licence holder: Infohealth Laboratories Limited, 28 Chipstead Valley Road, Coulsdon, Surrey. CR5 2RA. United Kingdom. Supply classification: GSL. Indications: For symptomatic relief of productive (chesty) cough. Precautions: Should not be used for persistent or chronic cough, such as occurs with asthma, or where excessive secretions accompany cough, unless directed by a doctor. If symptoms persist or worsen, seek medical advice. Do not exceed the stated dose. Caution should be exercised when using the product in the presence of severe renal or severe hepatic impairment. Alcohol containing products, should be avoided whilst patients taking this medicine. Use with extreme caution when other central nervous system depressants are used. Harmful for those suffering from alcoholism. This product is not recommended for those who are pregnant, planning to become pregnant or breast-feeding women, children and high-risk groups such as patients with liver disease, or epilepsy. Consult your doctor or pharmacist before taking this medicine. There are reported cases where excessive consumption of guaifenesin may have contributed to renal stone formation. Keep all medicines out of the reach and sight of children. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine. Contra-Indications: Known hypersensitivity to guaifenesin or to any of the excipients. Pregnancy & lactation: Pregnant and lactating women may wish to avoid this product as it contains 5.9 vol % ethanol (alcohol). Guaifenesin has been used for many years without any definite evidence of adverse effect. However, women who are pregnant or breast-feeding are advised to consult their doctor or pharmacist before taking this product. Effects on ability to drive and use machines: This product contains 5.9 vol % ethanol (alcohol). The product could cause drowsiness. Patients should be aware of these facts, and should not drive, operate machinery, or perform hazardous tasks if they feel drowsy, or dizzy. Dosage: Adults and Children over 12 years:One or Two 5ml spoonfuls to be taken every 2 to 4 hours. Not more than 12 x 5 ml spoonfuls should be given in any 24 hours. Do not exceed the stated dose. There are no special requirements for the elderly. Cost: Amber

glass bottles of 200ml RRP £6.49. Date: May 2017

Name of Product: Hill’s Balsam Dry Cough Liquid. Active Ingredient(s): Pholcodine 10 mg/5 ml. Product licence number: PL 00415/0201. Name and address of the product licence holder: Infohealth Laboratories Limited, 28 Chipstead Valley Road, Coulsdon, Surrey. CR5 2RA. United Kingdom. Supply classification: P CD Sch 5. Indications: For the symptomatic relief of a dry, tickly or painful unproductive cough due to upper respiratory infection or influenza. Precautions: Use with caution in patients with respiratory disease, including a history of asthma. Pholcodine may cause sputum retention and this may be harmful in patients with chronic bronchitis and bronchiectasis. Use with caution in patients with renal or hepatic disease. Caution is also needed in patients with a history of drug abuse. Pholcodine should not be taken with any other cough or cold medicine (see section 4.5 SmPC). Use of pholcodine with alcohol or other CNS depressants may increase the effects on the CNS and cause toxicity in relatively smaller doses. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine. Contra-Indications: Hypersensitivity to the active substance(s) or to any of the excipients listed in section 6.1. of SmPC. History of allergy toward morphine, suxamethonium or other structurally related therapeutic agents. Liver failure. Patients in or at risk of developing respiratory failure or during an attack of asthma. Patients with chronic bronchitis, COPD, bronchiolitis or bronchiectasis due to sputum retention. Patients taking monoamine oxidase inhibitors (MAOIs) or within 14 days of stopping such treatment (see section 4.5 SmPC). Children under 12 years of age. Pregnancy & lactation: Pregnancy: There is no data available. Hill’s Balsam Dry Cough Liquid should not be used in pregnancy unless considered necessary by the physician and the expected benefit is thought to outweigh any possible risk to the foetus. It should be avoided during the first trimester. Breastfeeding: Pholcodine has been detected in human breastmilk. Although the amount is unlikely to affect the suckling infant the use of Hill’s Balsam Dry Cough Liquid during lactation is not recommended. Effects on ability to drive and use machines: As with other opioid, pholcodine may affect the ability to drive or use machines. The use of pholcodine may cause sedation, dizziness and nausea. If affected, driving or operation of machinery would not be advised. This medicine can impair cognitive function and can affect a patient’s ability to drive safely. This class of medicine is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988. Dosage: Adults and children over 12 years: One 5ml spoonful to be taken three times a day and at bedtime (in a little warm water). Cost: Amber glass bottles of 200ml RRP £6.49. Date: October 2015. Reporting of suspected adverse reactions: Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals

are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.

Ref: IHL-CPD-HILLS-001

CPDThe content was Independently produced by: Nadia Bukhari BPharm, FRPharmS, FHEA, PGDip Senior teaching Fellow in Pharmacy Practice, UCL School of Pharmacy Oksana Pyzik MPharm, MRPharmS Teaching Fellow in Pharmacy Practice, UCL School of Pharmacy © Infohealth Laboratories