Pharmaceutical Care of Cough

Questions to ask when assessing cough (SOCRATES).

Site (upper or lower chest)

Onset (acute or chronic)

Character (dry, productive, tickly, chesty)

Radiation (pain)

Associated symptoms

Timing (when is it worst)

Exacerbating features (eating, exercise)

Severity (impact on ADLs)

What is cough variant asthma?

An isolated cough in a patient without objective evidence of asthma, bronchial hyperresponsiveness is present. Clinical features include nocturnal cough, or cough after exercise or after allergen exposure.

Treatment for cough variant asthma?

Eliminate allergen, first line treatment is inhaled corticosteroids. Can also give SABA, antihistamines or leukotriene receptor antagonist.

Treatment for cough caused by GORD?

PPI or H2 receptor antagonist, eliminate causative medications, give lifestyle advice and review after 6-8 weeks.

What are the symptoms of upper airway disease?

Cough, nasal stuffiness, sinusitis, post-nasal drip.

Treatment for cough caused by upper airway disease?

Antihistamines (limited efficacy), topical nasal steroids for 2-8 weeks.

Idiopathic cough treatment?

Treatment largely disappointing, mainly limited to non-specific antitussive therapy such as dextromethorphan.

When to refer cough patient to specialist / GP / A&E?

Cough for longer than 3 weeks, signs of infection, HR >130 bpm, chest pain, associated with SOB, RR >30 per minute, O2 saturation <92%, PEFR <33%, recurrent nocturnal cough in children, suspected adverse drug effect.

What is an expectorant?

A medication that promotes the expulsion of bronchial secretions (not NICE recommended).

When would a cough suppressant be recommended?

Where there is no underlying cause, and may be useful eg. Disturbed sleep.

Name 3 antitussives.

Codeine, pholcodeine, dextomethorphan.

Name 3 antihistamines that can be used in the treatment of cough.

Diphenhydramine, brompheniramine, promethazine.

When should antihistamines be avoided in the treatment of cough?

Avoid in patients who take phenothiazines and tricyclic antidepressesants. Also avoid drinking alcohol.

Which conditions should care be taken in when administering sympathomimetics (eg. Pseudoephedrine)?

Hypertension, diabetes, coronary artery disease, hyperthyroidism.

Which medications do sympathomimetics have interactions with?

MOAs, beta blockers, tricyclic antidepressants.

What CRP reading would indicate the use of an antibiotic in a cough associated with a respiratory tract infection?

CRP >100mg/L start treatment

CRP 20-100mg/L delay antibiotic therapy for 3 weeks or until symptoms become significantly worse.