NOVEMBER 2016 T R A I N I N G M A T T E R S 15www.tmmagazine.co.uk

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THE PROFESSIONAL ASSISTANTLEARN & ADVISE

tra

ining excellence

in association with

CIG

Quality Seal 2016

This module is suitable for all members of the pharmacy team who wish to increase their knowledge of common conditions and treatment options . This module has been endorsed with the NPA’s Training Seal as suitable for use by pharmacy teams as part of their ongoing learning. This module can also form part of your Team Tuesday training.

Coughs are very common, and can be caused by a variety of triggers. A cough is a refl ex response that aims to clear the airway of irritants, and several parts of the body are involved in the cough action.

Cough receptors are located in the walls of the airways and are triggered by irritants such as smoke, microorganisms or conditions such as asthma. The receptors trigger an impulse that runs along the vagus nerve to the cough centre, which is located in the medulla oblongata of the brain. This in turn sends nerve impulses to the respiratory muscles, causing a sudden inhalation of air. This air becomes momentarily trapped in the lungs

due to closure of the glottis and vocal cords in the throat. The intercostal muscles between the ribs, the abdominal muscles and the diaphragm then contract and force air out through the re-opened glottis. The pressure of the air forces the glottis and vocal cords to open. The pressure of the air as it leaves the body, hopefully taking with it the original airway irritant, causes the sensation – and characteristic noise – known as a cough.

After studying this module, assistants will:

OBJECTIVES

Coughs

Understand how and why a cough occurs

Recognise the symptoms that might warrant referral

Know the treatment options available, including self care measures.

Diaphragm

Glottis

Nasal cavity

Vocal cords

Bronchioles

Trachea

Left lung

Tongue

Right bronchus

Right lung

16 T R A I N I N G M A T T E R S NOVEMBER 2016 www.tmmagazine.co.uk

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Understanding the problemCoughs can be classifi ed according to their duration:

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Coughs can also be referred to as chesty or dry. A chesty (productive) cough will often make the sufferer feel as if they are trying to bring something up – usually described as mucus or phlegm. On the other hand, a dry (tickly or non-productive) cough often starts as a tickle at the back of the throat, which causes the person to cough.

Pregnant women are advised to be vaccinated against whooping cough to protect their baby’s health.

DID YOU KNOW??

Acute coughs usually last less than three weeks and have a sudden onset, perhaps caused by an upper respiratory tract infection such as a cold or sinusitis; an infection of an area further down the airways (as is the case in pneumonia and bronchitis); inhalation of dust, smoke or another foreign substance; an allergy such as hayfever, or a fl are-up of a long-term respiratory condition such as asthma or chronic obstructive pulmonary disease (COPD).

Subacute coughs usually last around three to eight weeks. Infections are the most common cause, particularly whooping cough (pertussis) in children.

Chronic cough sufferers are less likely to be able to put a fi nger on what has caused their cough, as it usually has a more gradual onset. Examples include a long-term allergy (e.g. to house dust mites); an undiagnosed respiratory condition such as chronic bronchitis or asthma, or a side effect of smoking or medication, particularly ACE inhibitors (e.g. captopril). Postnasal drip – mucus dripping from the nose into the throat because of a condition such as sinusitis – is another possible cause, as is irritation of the throat by leaking stomach acid as a consequence of gastro-oesophageal refl ux disease (GORD). Persistent coughs can also be a sign of something more serious (e.g. lung cancer, tuberculosis, pulmonary embolism or heart failure), although this is rare.

Every year, fl u cases put extra pressure on the NHS. An outbreak of fl u can have a devastating impact, causing severe complications in young children and in people with long-term conditions. This winter, community pharmacies are once again providing the fl u vaccination service to eligible patients. And pharmacy teams have already surpassed the total number of NHS fl u vaccinations delivered last year in less than eight weeks.

Do you know the groups of people who are eligible for free fl u vaccinations under the NHS? Do you know the process to follow when people come into the pharmacy for their fl u jab? What about those who aren’t eligible for a free jab, but are prepared to pay for the vaccination? If you haven’t already got notes on this displayed in your pharmacy, make a list and share it with your colleagues.

The ineffectiveness of antibiotics for the common cold, fl u and the vast majority of coughs has been at the centre of health campaigns for many winters now. Prescribing antibiotics for these conditions can actually cause patients harm as its puts them at risk of adverse side effects without providing any benefi ts. Some antivirals may be used to reduce the severity and duration of fl u symptoms, but only in certain patient groups and under set circumstances, such as during an epidemic and by those considered at risk of complications.

There are certain symptoms that should ring warning bells. Get your pharmacist involved if a customer reports any of the following:

Unexplained weight loss A cough that is worse fi rst thing in the morning, at night or after exercise Pain in the chest or shoulder A fever that does not respond to medication such as paracetamol Breathing problems such as fast or laboured breathing, breathlessness

or wheezing Coughing up blood or brown/green mucus Vomiting after coughing A cough that has persisted for longer than three weeks Taking other medication or affected by other medical conditions.

Antibiotics and

Flu vaccination eligibility

When to refer

antivirals

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Assuming underlying causes such as asthma and allergy have been eliminated, acute coughs will usually get better on their own. This is because most are due to a viral infection such as a cold, which means antibiotics won’t have any effect.

Treatment options

OTC products

Cough suppressants such as dextromethorphan or pholcodine are thought to work by suppressing the cough refl ex in the brain and are therefore most suited to dry or tickly coughs. OTC examples include Benylin Dry Coughs and Robitussin Dry Cough.

Expectorants such as guaifenesin, ipecacuanha and squill help to loosen and clear mucus from the chest and are more suitable for chesty or productive coughs. OTC examples include Covonia Chesty Cough Mixture Mentholated and Veno’s Expectorant.

Demulcents such as glycerol coat and soothe the throat and stop a cough. OTC examples include glycerin, lemon and honey, and CalCough Children’s Soothing Syrup.

Antihistamines such as diphenhydramine suppress a cough. They may cause drowsiness, which can be useful for a night-time cough. OTC examples include Benylin Dry Coughs Night Syrup and Covonia Hot Dose Cough & Cold Syrup.

Decongestants such as pseudoephedrine or menthol may also be recommended as they clear associated congestion, blocked nose and sinus symptoms. OTC examples include Day Nurse Capsules and Galpseud Linctus.

Some cough medicines may be used for all acute coughs – whether they are dry, tickly or chesty. Examples include traditional herbal medicinal products (e.g. Bronchostop – containing thyme herb extract and marshmallow root extract) or the pharmacy-only product UniCough (containing diphenhydramine, ammonium chloride and levomenthol). This can be used for the relief of all common coughs associated with upper respiratory tract congestion and aids restful sleep.

Soothing ingredients such as glycerin, honey and lemon are useful for people who can’t use a cough suppressant for their dry, non-productive cough. These work by coating the back of the throat to create a soothing effect. They often have a high sugar content and may therefore not be suitable for people with diabetes.

Sucking on lozenges or pastilles may also be helpful to keep the throat lubricated.

The MHRA reviewed the use of OTC cough and cold medicines in 2009 and many of the ingredients are no longer recommended for children under six years old. Simple linctus paediatric or glycerol-based products may be used if necessary. For children aged six to 12 years, OTC cough and cold medicines containing these ingredients are available, but are only allowed to be sold in pharmacies, with clear advice, and treatment is restricted to fi ve days or less. OTC liquid medicines that contain codeine should not be used for coughs in people under 18.

Although there is no robust evidence to support the use of cough products, customers may fi nd them useful, and there are plenty of options available OTC. Products are available as cough linctuses or all-in-one cough and cold tablets. The following ingredients can be found in OTC cough products:

Drink plenty of fl uids as this will keep the throat lubricated and prevent dehydration if the person’s temperature is raised Sucking ice cubes or boiled sweets or sipping hot water

containing honey and lemon can help to relieve a tickly cough. Note that honey should not be given to infants under the age of one year Simple painkillers such as paracetamol or ibuprofen can

help to ease discomfort and reduce a fever Avoid smoking and smoky environments, as well as any

other triggers that may exacerbate asthma or an allergy.

For more information, you can:

SIGNPOSTING

Use your Counter Intelligence Plus training guideVisit NHS Choices: nhs.uk/conditions/cough.

ACE inhibitors, which are used to treat high blood pressure and cardiovascular disease, can cause a cough in some people.

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Self care tips

DID YOU KNOW??

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GOOD PRACTICE KNOWLEDGE IS IMPORTANT WHEN ADVISING CUSTOMERS

Questions Scenario?

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Go to www.tmmagazine.co.uk to submit your answers to these questions. When you pass, you’ll be able to download a certifi cate to showcase your learning.

You can also add this to your online, personalised learning log.

www.tmmagazine.co.uk

TEST YOURSELF ONLINE

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1) Where can you fi nd cough receptors in the body?a) The medulla oblongatab) The vagus nervec) The intercostal muscles d) Walls of the airways

2) Which of the following is TRUE of a chronic cough?a) It is always accompanied with a whooping soundb) It lasts three to eight weeksc) It could be a consequence of stomach acid refl uxd) It is often caused by an upper respiratory tract infection

3) Which of the following symptoms would you refer to the pharmacist if it accompanied a cough?a) Wheezing b) Clear mucusc) Runny nosed) Mild headache

4) Which of the following is NOT used in cough medicines for cough suppression?a) Pholcodineb) Squillc) Dextromethorphand) Diphenhydramine

5) Which of the following statements is TRUE?a) A warm drink with honey and lemon can help to soothe a cough for a three-year-old childb) Codeine linctus can be used to suppress coughs in customers over eight years of agec) A four-year-old child can be given OTC pholcodine for a dry coughd) A six-month-old baby can be given a spoonful of honey for a tickly cough

6) Which of the following is an example of a decongestant?a) Glycerinb) Marshmallow root extractc) Dextromethorphand) Pseudoephedrine

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Ask further questions to fi nd out what type of

cough it is and if he has other symptoms.

Sell him an OTC product for any type of cough.

Refer him to his GP.

What if?Tony says that his cough is chesty and he’s had it for four weeks. He puts it

down to smoking.

Ask if he has considered stopping smoking.

Refer him to the smoking cessation service and sell

him an expectorant.

Refer him to his GP.

What if?Tony says he has lost his appetite

slightly and gets a bit of chest pain.

Refer him to A&E.

Recommend a nutritional supplement

and an OTC cough product.

Refer him to the pharmacist.

What would you recommend?For each part of this scenario, think about the decision you would make and, importantly, why you would choose that option. In addition, for each decision that you make, think about how you would talk to the customer and provide

the necessary advice, and discuss this with your team and pharmacist.

Tony is in his 50s. He tells you that he’s suffering from a very annoying cough and asks if you could recommend a product that might help relieve it. He tells you that he’s not on any other medication and doesn’t have any other health problems.