Cough Self Care

Impact of Cough

● Symptom of diverse infectious and noninfectious disorders

● Important defensive respiratory tract reflex

● Most common symptom for patients seeking medical care

● Often one of most irritating and longest lasting symptom

● More than $4 billion spent annually on OTC cough products

Pathophysiology of Cough

● Initiated by stimulation of chemically and

mechanically sensitive, vagally mediated

sensory pathways in the laryngeal,

esophageal, and tracheobronchial airway

epithelium

● Complex medullary brainstem network

“cough control center” processes

sensory input and stimulates the motor

efferents

path of cough

● First – deep inspiration followed by closure of the glottis and

forceful contraction of the chest wall, abdominal wall, and

diaphragmatic muscles

● Second – glottis opens, air is expelled and propels mucus,

cellular debris, and foreign material out of the respiratory

system

● Cough may occur in epochs “coughing fits”

● Causes:

○ Airway inflammation

○ Excess mucus production

○ Post nasal drip

Acute

< 3 weeks duration

Viral URTI, pneumonia, acute left ventricular failure,

asthma, foreign body aspiration

Subacute

3-8 weeks duration

Post-infectious cough, bacterial sinusitis, asthma

Chronic

> 8 weeks duration

Upper Airway Cough Syndrome (UACS), asthma,

GERD, COPD (chronic bronchitis), ACEIs,

bronchogenic carcinoma, sarcoidosis, left ventricular

failure, aspiration secondary to pharyngeal dysfunctio

Signs/Symptoms - Productive

● “wet” or “chesty” cough

● Expels secretions from lower respiratory tract

● May be effective or ineffective

● Secretions are typically clear with bronchitis & purulent

with bacterial infections

○ Anaerobic bacterial infections have a distinct malodor

Signs/Symptoms - Non

-Productive

● “Dry” or “hacking” cough

● Associated with

○ Viral infections

○ Bacterial infections

○ GERD

○ Cardiac disease

○ Medications (ACE-Is)

● No useful physiological purpose

Cough Complications

● Exhaustion

● Insomnia

● Musculoskeletal pain

● Hoarseness

● Sore throat

● Excessive perspiration

● Urinary Incontinence

Exclusions for Self-Treatment

● Presence of a fever

● Chest pain

● Shortness of breath, cyanosis

● Hemoptysis

● Chills, night sweats

● Hx of cough associated chronic

diseases (Asthma, COPD, CHF)

● Suspected drug-associated cough

● Cough that worsens when cold/flu

resolves

● Unintentional weight loss

● Rash

● Persistent headache

● Children < 4 years

● Cough producing thick yellow,

tan, or green mucus

● Lasts > 7 days or recurrent

● Associated with dust, particles,

or objects if irritant is not

removed from lungs

Patient Outcomes

● 7 days of nonprescription cough treatment sufficient

○ May continue therapy with improvement w/o resolution

● Duration of therapy

○ Cough from viral URTIs ~ 2 weeks

○ Post-viral coughs > 3 weeks

○ Coughs from other respiratory infection resolve in 3-4

weeks

treatment goals

● Reduce bothersome symptoms

● Prevent transmission to others

● Reduce the number and severity

of episodes

● Prevent complications

Non-Pharmacologic Therapy

● Non-medicated lozenges

● Humidification (cool-mist humidifiers)

● Promotion of nasal drainage

○ Rubber bulb in children < 2 years and reduction of

post-nasal drip

● Hydration

○ Helps form less viscous secretions

○ Caution in disease states worsened by overhydration

Pharmacologic Therapy

● Cough suppressant (antitussive)

○ Codeine, dextromethorphan, diphenhydramine,

chlophedianol

○ Topical: camphor, menthol

● Expectorant (protussive)

○ Guaifenesin

● Combination products

Cough Suppressants

● Mechanism of Action:

○ Decreases sensitivity of cough receptors

○ Interrupts cough impulse transmission by depressing the

medullary cough center

● Treatment of non-productive coughs

Types of Antitussive Agents

Systemic

Codeine

Dextromethorphan

Diphenhydramine

Chlophedianol

Topical

Camphor

Menthol

Codeine

● MOA: Acts centrally on the medulla to increase the

cough threshold

● Indication: Suppression of nonproductive cough caused

by chemical or mechanical respiratory tract irritation

● Dose: 10-20 mg Q 4-6 hours

● Onset: 15-30 minutes

● Action: 4-6 hours

Codeine Cautions

● Adverse Effects

○ GI: nausea, vomiting, constipation

○ CNS: sedation, dizziness

○ Respiratory depression with overdose

● Drug Interactions

○ Other CNS depressants (i.e. Sedatives, alcohol)

○ Other respiratory depressants (i.e. alcohol)

● Caution

○ Patients with Asthma and COPD (baseline respiratory

depression)

○ Patients at risk for drug abuse/misus

Codeine Abuse/Misuse

● Schedule V substance

● Available without a prescription

● Abuse is not uncommon “purple

drank” “lean”

● Lethal dose ~ 0.5g – 1g

○ Death from respiratory

depression and

cardiopulmonary collapse

Ohio Revised Code 3719.15

● (A) Where a licensed health professional authorized to prescribe

drugs administers or personally furnishes, or where a pharmacist

sells at retail, any medicinal preparation that contains in thirty

milliliters, or if a solid or semisolid preparation, in thirty grams, of

any of the following:

○ (3) Not more than sixty-five milligrams of codeine or of any of its

salts

● Each preparation specified in divisions (A)(1), (2), (3), (4), and (5)

of this section shall in addition contain one or more non-narcotic

active medicinal ingredients in sufficient proportion to confer

upon the preparation valuable medicinal qualities other than those

possessed by the narcotic drug alone.

Codeine OTC Sales

May contain no more than 65 mg of codeine

in 30 mL of solution per Ohio Revised Code

10 mg codeine = 60 mg codeine

5 mL 30 mL

Dextromethorphan

● Mechanism of Action: acts centrally in the medulla to increase

the cough threshold (NMDA receptor antagonist)

● Indication: suppression of nonproductive cough caused by

chemical or mechanical respiratory tract infection

● Dose:

○ 10-20 mg every 4 H

○ 30 mg Q 6-8 H

● Onset: 15-30 minutes

● Peak Effect: 2-3 hours

Dextromethorphan Cautions

● Adverse Effects

○ GI: discomfort, nausea, vomiting, constipation

○ CNS: drowsiness

○ Respiratory depression with overdose

● Drug Interactions

○ Other CNS depressants (i.e. Alcohol, antihistamines)

○ MAOIs may cause serotonergic symptoms

■ Hypertension, fever, arrhythmias, and seizures

Dextromethorphan

Abuse/Misuse

● 1 in 10 American teenagers have abused DXM products

○ More than cocaine, ecstasy, LDS, and meth in this age

group

○ Most common in male adolescents

○ Cheap and easily obtained

○ Hard for parents/guardians to detect DXM abuse

● Causes hallucinatory and dissociative effects

● Euphoric effects “Robo-tripping”

Diphenhydramine

● Mechanism of Action: Nonselective, 1 st gen antihistamine

○ Acts centrally in the medulla to increase the cough threshold

○ Significant sedating and anticholinergic properties

● Indication: suppression of nonproductive cough caused by chemical

or mechanical respiratory tract infection

● Dose: 25 mg Q 4 H

● Onset: 30-60 minutes

● Peak Effect: ~ 2 hours

● Adverse Effects: dizziness, drowsiness, sedation, dryness of eyes &

mucous membranes, blurred vision, urinary hesitancy, constipation

Topical Cough Suppressants

● Camphor and menthol are the only FDA-approved topical

antitussives

● Mechanism of action: Stimulate sensory nerve endings within

the nose and mucosa, creating a local anesthetic sensation

and a sense of improved airflow

● Indication: Cough

● Onset of action: immediate

● Adverse effects: Burning sensation in the mouth, N/V

● Caution: Ingestion of 4 tsp of 5% camphor product has been

shown to be lethal in children

Ointments

Rub on the throat & chest in a thick layer; repeat up to

3x/day. Loosen clothing around throat and chest so vapors

reach the nose & mouth. Cover with a warm, dry cloth. Do

not use in the nostrils, under the nose, by the mouth, on

damaged skin, or with tight bandages

Lozenges

Allow lozenge to dissolve slowly in mouth; repeat hourly

Inhalation

For hot steam vaporizer: place water in vaporizer; place

solution in medication chamber; breathe in the medicated

vapors up to 3x/day

Guaifenesin

● Mechanism of Action: loosens and thins lower

respiratory tract secretions, making minimally

productive coughs more productive

● Indication: symptomatic relief of productive coughs

○ Only FDA approved expectorant

● Dose: 200–400 mg Q 4 H

● Onset: 15-30 minutes

● Adverse Effects: dizziness, headache, N/V, rash,

drowsiness, stomach pain

Cough Combination Products

● Cough medications marketed in

combinations

○ Antitussive w/expectorant

■ Guaifenesin & Codeine

■ Guaifenesin & Dextromethorphan

○ Topical products

■ Camphor, menthol, and other

ingredients (i.e. eucalyptus oil)

● Combined with other cold agents

○ Decongestants, systemic

analgesics, antihistamines, etc.

● Convenient

● Risk of unnecessary drug

Cough Guidelines

● American College of Chest Physicians (ACCP) 2006 cough

guidelines

○ Recommend: combination of 1 st gen antihistamine +

decongestant to treat virus induced post-nasal drip & resolve

resulting cough

○ Recommend: codeine or DXM for short-term symptomatic relief

of cough associated post-infection

○ No mention: guaifenesin for any indication

Special Populations

● Pregnancy

○ Recommend non-drug products first

○ Codeine & DXM (category C)

■ Only if benefits > risks

■ “Probably safe”

● Breast-feeding

○ Unknown if DXM is secreted in breast milk

○ Codeine & diphenhydramine are excreted in

breast milk

■ Excitation, irritability, decreases milk flow

● Elderly

○ More susceptible to codeine, DXM, and

diphenhydramine

Pediatrics

● January 2008 FDA public health advisory

○ Avoid use of OTC cough and cold medication in children < 2 years

○ Potential serious and life threatening AEs

● October 2008 manufacturers voluntarily updated labels

advising non-use in children < 4 years

● FDA 2011 guidelines for liquid nonprescription drug products

that include any type of dispensing device (dropper, cup,

syringe, or spoon).

○ A dosing device be included with all oral liquid nonprescription

products.

○ The device be calibrated to the dose recommended in the

product directions.

○ The device be used only with the product in which it is packaged.

○ The markings remain visible even when the liquid is in the device.

Symptom Treatment

Sore throat Local anesthetics and/or systemic

analgesics

Dry, non-productive cough Cough suppressant

Wet, mucus-producing cough Expectorant

Nasal congestion Topical or systemic

decongestants

Aches and pains Systemic analgesics

Fever Systemic antipyretics