AUTHOR: Theresa Lowry Lehnen, RGN, PG. Dip. Coronary Care, RNP, BSc, MSc, PG. Dip. Ed (QTS), M. Ed, PhDClinical Nurse Specialist and Associate Lecturer South East Technological University
60 Second Summary
Cough is a common symptom and complaint, particularly during the winter months, and is associated with a wide variety of aetiologies and clinical conditions. A cough can be described as either productive (chesty), where sputum is produced, or non-productive (dry, tickly or irritating), where no sputum is produced. Non-productive coughs may be the result of increased throat irritation due to sensitisation from a virus, and a productive cough results from increased mucosal secretions. Given the vagueness of cough as a presenting symptom, along with the risk of insidious underlying aetiologies and lack of objective tools, a cough should be evaluated and treated as an important clinical symptom, until a benign source is confirmed. Smoking is a leading risk factor for coughs, and additional common causes of an acute cough include acute rhinosinusitis, pertussis, acute exacerbations of COPD, allergic rhinitis, asthma, congestive heart failure, pneumonia, aspiration syndromes, and pulmonary embolism. Specific findings that are common and which may be found in association with a cough include malaise, fatigue, insomnia, lifestyle changes, musculoskeletal chest pain, hoarseness, excessive perspiration, urinary incontinence, syncope, cardiac dysrhythmias, headache, subconjunctival haemorrhage, inguinal herniation, or gastroesophageal reflux. Pharmacological management of coughs and upper respiratory tract infections in the community pharmacy consists primarily of symptomatic relief for the presenting symptoms. Choice of product should be based on patient preference, presenting symptoms, and clinical considerations such as contraindications and potential drug–drug interactions.
A cough is an innate reflex, and important defence mechanism of the lungs that acts as part of the body’s immune system to protect against the entry of foreign materials. Coughing helps expel inhaled particles, irritants, fluids, or microorganisms, and helps clear secretions from the lungs. Cough is a common symptom and complaint, particularly during the winter months, and is associated with a wide variety of aetiologies and clinical conditions. A cough is one of the most common medical complaints, and is the most common symptom for which people seek advice at their community pharmacy. 1, 2 For most people, coughs are self-limiting, however, some coughs can be ominous and indicate serious underlying disease. As there are no objective tools to measure or clinically quantify a cough, evaluation is initially a subjective and highly variable assessment. Given the vagueness of cough as a presenting symptom, along with the risk of insidious underlying aetiologies and lack of objective tools, a cough should be evaluated and treated as an important clinical symptom, until a benign source is confirmed. Globally, cough affects approximately 10% of the adult population, and is associated with impaired quality of life. 3 Coughs are classified as acute, subacute or chronic. A cough is considered ‘acute’ if it is present for less than 3 weeks. A ‘subacute’cough, is one lasting 3 to 8 weeks, most often due to a recent respiratory infection. A cough of greater than 8 week duration is considered a ‘chronic’ cough. 1. 2
A cough can often accompany other symptoms such as rhinorrhoea, fever, sore throat, earache and general aches and pains. Most coughs are selflimiting and will usually self-resolve within 3 weeks, however, it is important for the person to see or be referred to the GP, if the cough lasts more than 3 weeks, or if the person is coughing up blood (haemoptysis). 2 There are many causes of cough, and most are benign. However, cough can also be due to malignancies, nerve injuries, and serious infections, therefore, an inter-professional approach is required when a cough is persistent. 1
Self- limiting coughs, do not usually need to be referred/seen by the GP, and the person should be advised to rest, drink plenty of fluids, stay at home and avoid contact with other people if they have a high temperature, and do not feel well enough to do their normal activities. 7 There is no valid evidence for or against the effectiveness of OTC medicines in acute cough. 8
An acute cough, of less than three weeks’ duration, is often caused by a viral respiratory tract infection, and is one of the most common reasons for accessing healthcare in the community. The most common causes of acute cough in adults are acute viral upper respiratory tract infections (URTIs), such as the common cold. Infections of the lower airways, including acute viral bronchitis, pertussis, and tuberculosis, are also potential causes of acute cough. Acute bronchitis is typically viral in aetiology, but bacterial infection is the source in approximately 10% of cases. Antibiotics are not usually prescribed for coughs, and will only be prescribed if a bacterial infection is present, or the patient is at risk of complications. 1, 2
Smoking is a leading risk factor for coughs, and additional common causes of an acute cough include acute rhinosinusitis, pertussis, acute exacerbations of COPD, allergic rhinitis, asthma, congestive heart failure, pneumonia, aspiration syndromes, and pulmonary embolism. An acute cough is also a main symptom of SARS- CoV-2 (Covid-19) infection, and this must always be considered when a patient presents with a cough, and investigated and treated appropoately.
A class of blood pressure medication called ACE inhibitors can cause a persistent dry cough in some people. Examples include ramipril, perindopril, and Lisinopril. Approximately 10-15% of people who use this class of blood pressure medication experience a dry cough, and the incidence appears to be higher in women. 9 If the cough is due to the patient taking angiotensin-converting enzyme inhibitor medication, this medicine should be discontinued by the GP, and an aldosteronereceptor blocking medicine started in its place. 1 The 3 most common causes of chronic cough in non-smokers who are not taking an ACE inhibitor are asthma, acid reflux, and postnasal drip. 5
Through careful questioning and the identification of red flags and danger symptoms, the pharmacist can determine whether the patient needs to be referred to the GP or seek urgent medical attention. Individuals presenting to a pharmacy with a cough should be referred to the GP if they;
• Are finding it difficult to breathe
• Are short of breath or have a wheeze
• Are coughing up blood (Haemoptysis)
• Have a hacking cough or cannot stop coughing and it is getting worse
• Have a recurrent nocturnal cough
• Have hoarseness lasting more than 3 weeks
• Have a weak immune system
• Have chest pain
• Have pain on inspiration
• Have asthma or a chronic lung condition
• Have a persistent cough for more than three weeks
• Have green, yellow or rusty coloured phlegm
• Have systemic symptoms e.g. fever, night sweats, unexplained weight loss
• Have a suspected adverse drug reaction
• Have excessive sputum production
• Experience recurrent chest infections
• Experience difficulty swallowing when eating or drinking
• Have symptoms suggestive of whooping cough
• Experience a change in the nature of a smoker’s cough.
Considerations and questions to ask the patient presenting to the pharmacy with a cough
• Age of patient-child, adult or an elderly person?
• Onset (acute or gradual) and duration of cough
• Describe the cough e.g. productive, dry, barking, tickly
• Travel history e.g. recent travel to a TB prevalent area or a recent long-haul flight
• Are there any other symptoms associated with the cough e.g. fever, runny/blocked nose, sneezing and/or sore throat indicates cold or flu
• Are there any red flags/danger symptoms that require a referral to the GP or seek urgent medical attention
• Smoking history including those who have recently quit smoking
• Substance misuse—does the patient display any warning signs of substance misuse or addiction
• Drug history e.g. ACE inhibitors, check for potential drug interactions
• Nocturnal cough e.g. asthma
• Occupational history—is the cough due to the patient’s occupation or an environmental factor?
• Past medical history/comorbidities—is the cough due to an exacerbation of a pre-existing condition e.g. asthma or COPD
• Colour of sputum
Types of presenting cough and OTC pharmacy treatments
Pharmacological management of coughs and upper respiratory tract infections in the community pharmacy consists primarily of symptomatic relief for the presenting symptoms. Choice of product should be based on patient preference, presenting symptoms, and clinical considerations such as contraindications and potential drug–drug interactions. Healthy adults usually do not experience side effects from OTC cough medicines, however, some OTC cough medicines can cause irritability, sleepiness, or dizziness. Side effects may be a concern for people who have health problems, older people, or those who use cough medicines for long periods of time. 5
A cough can be described as either productive (chesty), where sputum is produced, or non-productive (dry, tickly or irritating), where no sputum is produced. 8 Nonproductive coughs may be the result of increased throat irritation due to sensitisation from a virus, and a productive cough results from increased mucosal secretions. During a cold, a cough is often caused by a nasal drip irritating the back of the throat. Steam inhalations can be a useful hometreatment, particularly in productive (chesty) coughs. Hot drinks such as lemon and honey can also provide a soothing effect. Sugar-free versions of cough mixtures are also available for diabetics. 9
In 2011, HPRA restricted the sale of certain cough and cold remedies in Ireland for children under six years of age. Coughs and colds in children are frequent and usually self-limiting, and there is no clear evidence to support the use of these products in children under six. 9 Children under six years should not be given OTC cough and cold medicine containing; 10
• brompheniramine, chlorphenamine maleate, diphenhydramine, doxylamine, promethazine or triprolidine (antihistamines)
• dextromethorphan or pholcodeine (cough suppressants)
• guaifenesin or ipecacuanha (expectorants)
• phenylephrine hydrochloride, pseudoephedrine hydrochloride, ephedrine hydrochloride, oxymetazoline, or xylometazoline hydrochloride (decongestants)
Certain cough remedies however, made with mainly natural ingredients including traditional herbal medicinal products (THRs) are licenced for sale in Ireland, available in pharmacies nationwide, and suitable to use for children over 12 months old. A range of products are specifically formulated for children from 1 year of age, and can be used to treat dry or chesty coughs. It is important to check with the pharmacist which cough remedies are suitable for children under 6 years of age, and if there are any contraindications or possible interactions to its use for each individual child. 9
The best advice for coughs in the under sixes, is to rest and drink plenty of fluids. If the child is over 1 year of age, a warm drink of lemon and honey may be useful. However, honey should not be given to a child under 1 years of age. Most coughs and colds in children under six resolve quickly, however, if the cough is not improving, or there are signs of a bacterial infection, it is advisable to be seen by the GP as an antibiotic may be needed. Over 80% of coughs and colds however, are viral in nature, and antibiotics do not treat viral infections. 9
Over the counter cough and cold medicines can be considered for children aged 6-12 years, after the basic principles of best care have been tried, but treatment should be restricted to 5 days or less. Children should not be given more than one brand of cough or cold preparation at a time because different brands may contain the same active ingredients. Care should always be taken to give the correct dose. 10 Steam inhalations, used safely under adult guidance can help loosen nasal and chest congestion and make it easier for a child to expel built-up mucus. A humidifier can be used to keep the air moist and clear, and products such as vapour rub or balms containing essential oils such as eucalyptus can also help loosen nasal and chest congestion. 11
OTC Cough Treatments 8
Opioid derivatives are commonly sold as cough suppressants / antitussives to suppress the cough reflux from the medulla in the brain stem to provide relief from frequent coughing. Common drugs include dextromethorphan, pholcodine, dihydrocodeine, and codeine. Preparations may be sold as syrups, medicated lozenges, tablets or capsules. There is limited quality evidence for the benefit of these agents, however, consumer demand can be high. Caution should be taken with preparations that may cause drowsiness such as codeine and dihydrocodeine. Dextromethorphan has been implicated in serotonin toxicity and should not be given to patients taking other drugs known to contribute to serotonin toxicity. Patients presenting with a non-productive cough who are known to have asthma should not be given cough suppressants as these may contribute to respiratory depression or mask signs and symptoms of asthma flare-ups. Narcotic cough suppressants may be subject to abuse and misuse and this must be considered when supplying. In order to combat abuse and misuse, some formulations contain laxatives such as sorbitol to discourage consumption of supratherapeutic doses. 5
Productive coughs present as a cough where mucus is expectorated when coughing. Medication licensed for the management of productive coughs fall into two categories: expectorants (protussives) and mucolytics. Like antitussives, these drugs come as syrups, medicated lozengers, tablets or capsules. Expectorants, such as guaifenesin, stimulate the secretion of mucus in the airways and reduce adhesion to improve the efficacy of coughing in clearing mucus. Mucolytics, for example, bromhexine, act to thin the mucus to facilitate easier clearance. Mucolytics and expectorants are sometimes sold in combination products to provide a synergistic effect in aiding cough management. Similar to antitussives, quality evidence for the clinical efficacy of expectorants and mucolytics is limited. 5
Cough Suppressants (Antitussives) 8
• Indicated for the symptomatic relief of non-productive (dry, tickly or irritating) coughs
• e.g. codeine, pholcodine, dextromethorphan
• Codeine and pholcodine are opioid cough suppressants, whereas dextromethorphan is a non-opioid cough suppressant
• Codeine, pholcodine and dextromethorphan all carry the potential for abuse, however, pholcodine and dextromethorphan have a lower abuse potential compared to codeine
• Codeine can cause sedation and constipation
• Patients should be advised of the possibility of sedation occurring with pholcodine or dextromethorphan
• Cough suppressants should be used with caution in asthmatics
• Codeine-containing OTC liquid medicines should not be used for cough suppression in children and young people less than age 18 years of age
• OTC cough and cold medicines containing dextromethorphan and pholcodine should not be used in children under 6 years of age
• Pholcodeine is contraindicated in bronchiectasis- bronchiolitis in children; chronic bronchitis- COPD in adults; and in patients at risk of respiratory failure 10
Expectorants 8
• Indicated for the symptomatic relief of productive coughs
• e.g. guaifenesin, ammonium chloride, ipecacuanha, squill
• There is little evidence on the effectiveness of expectorants. More likely they serve as a placebo effect, however, some report them as being useful in alleviating cough symptoms
• Guaifenesin has no known clinically significant drug interactions
• OTC cough and cold medicines containing guaifenesin and ipecacuanha should not be used in children under 6 years of age
Antihistamines 8
• Antihistamines used in cough and cold preparations include first-generation antihistamines such as diphenhydramine, promethazine and triprolidine
• Antihistamines dry up the nasal and bronchial secretions and are indicated for the relief of cough and/or nasal symptoms e.g. rhinorrhoea, and sneezing
• Antihistamines can cause anticholinergic adverse effects such as dry mouth, constipation, blurred vision, urinary retention, exacerbation and precipitation of acute angle-closure glaucoma and should not be recommended in patients with glaucoma or prostate enlargement
• Antihistamines cause sedation and may be suitable to recommend where the cough is disturbing sleep
• OTC cold/cough preparations containing brompheniramine, chlorpheniramine, diphenhydramine, doxylamine, promethazine, and triprolidine should not be used in children under 6 years of age
Demulcents 8
Demulcents relieve irritation of the mucous membranes by forming a protective film. Demulcents such as simple syrup or honey are non-medicated alternative for cough syrups. These ingredients are included in many cough syrups and may increase salivation and the secretion of pulmonary mucus. These are safe to use in children and other populations where medicated syrups or lozenges are contraindicated. 5
• Demulcent cough preparations coat and soothe the back of the throat and they contain soothing ingredients such as glycerol, syrup and/or honey.
• Examples include paediatric simple linctus, simple linctus, glycerine, lemon and honey linctus
• Indicated for the symptomatic relief of cough
• They are pharmacological inert, and used mainly for their placebo effect
• Demulcent cough preparations are inexpensive, and are safe to recommend for the elderly, children and pregnant women
Traditional Herbal Remedies (THRs)
Herbal medicines are popular in the treatment of minor medical conditions, including coughs. Herbal medicinal products on the Irish market must be either authorised or registered with the HPRA. Effective regulation of herbal medicines is considered necessary in order to ensure that safe products of appropriate quality continue to be available in pharmacies and other outlets. If an herbal medicinal product does not meet the criteria for registration as a traditional herbal medicinal product (THMP), it can still be granted a marketing authorisation (MA) in the same way as nonherbal medicines. 11
Herbal medicines are those with active ingredients made from plant extracts such as leaves, roots and flowers. Like conventional medicines, herbal medicines have an effect on the body, and can be potentially harmful if not used correctly. While traditional herbal remedies are safe to use for most people, some herbal medicines may not be suitable for certain individuals including; those taking other medicines; people with serious health conditions, such as kidney or liver disease; people who are undergoing surgery; pregnant or breastfeeding women; some older people and children. 12
There are a wide variety of herbal remedies available for coughs in pharmacies. Consumers should check for a traditional herbal registration (THR) marking on the product packaging, which means the medicine complies with quality standards relating to safety and manufacturing, and provides information about how and when to use it. It is always important to check with the pharmacist if traditional herbal remedy products for coughs or other illnesses are suitable, and if there are any contraindications or possible interactions with its use for the individual person. 12
Consumers should also be made aware that THR products are intended for conditions that can be self-medicated and which do not require medical supervision such as minor coughs, colds and general aches and pains. Using THR products for more serious conditions could be harmful, especially if there is delay in individuals seeking medical advice. Claims made for THR products are based on traditional use, and not on evidence of the products effectiveness. 12
Other Important OTC Cough Treatment Considerations 8
• Cough/cold preparations containing sodium: Check sodium content and assess whether the cough/cold preparation is suitable for the patient e.g. low sodium diet, renal impairment, cardiovascular disease
• Cough/cold preparations containing alcohol: Check alcohol content and assess whether the cough/cold preparation is suitable for the patient. Is there a history of alcohol abuse? Is the patient taking an existing medicine that may interact with the alcohol present in the cough/cold preparation? Who is it for, e.g. child, pregnant or breastfeeding woman?
• Recommend a sugar-free cough/cold preparation over one containing sugar in children or people with diabetes
• Do not recommend a cough/ cold preparation containing illogical combinations such as an antitussive and expectorant
• Check that the cough/cold preparation is age-appropriate
Medical Devices for Coughs
A range of medical devices for coughs and respiratory symptoms are available at pharmacies nationwide, including humidifiers, inhalers, and nebulizers among other products. A nebulizer is a type of breathing device that can be used to inhale medicated vapours. While not always prescribed for a cough, nebulizers may be used to relieve coughs and other symptoms caused by respiratory illnesses. Steam mist humidifiers release soothing vapour into the air to help provide temporary relief from cough and congestion. The warm mist helps reduce respiratory discomfort by increasing humidity levels to help the individual breathe better and sleep more comfortably. Prescribed inhalers are available for a number of respiratory conditions associated with cough such as asthma and COPD. The GP or Pharmacist should be consulted on the most suitable medical devices for coughs and respiratory symptoms.
References available on request
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