Community pharmacy

Cough

Ola Ali Nassr

lecturer
Al-Mustansiriyah University
ola.nassr@uomustansiriyah.edu.iq
 Coughing is:
• body’s defence mechanism to clear the airways of
foreign bodies and particulate matter.
• This is supplemented by cilia in the bronchi that
move mucus and entrapped foreign bodies to be
expectorated or swallowed.
•Cough can be very debilitating to the patient’s
well-being and can also be disruptive to family, friends
and work colleagues
•The British Thoracic Society Guidelines (2019) state
that cough is usually self-limiting and will resolve in 3
or 4 weeks without the need for antibiotics.
• Coughs can be described as:
– productive (chesty) or
– nonproductive(dry, tight, tickly).
– However, many patients will say that they are not
producing sputum, although they may go on to say that
they ‘can feel it on their chest’. In these cases, the cough
is probably productive in nature and should be treated as
such.
Coughs are classified as follows:
• Acute when present for less than 3 weeks
• Subacute when present for 3 to 8 weeks
• Chronic when present for more than 8 weeks
Epidemiology

•In community pharmacy, the figures are high, with at least 24 million visits
per year .
•Schoolchildren experience the greatest number of coughs, with an
estimated 7 to 10 episodes per year (compared with adults, with two to five
episodes per year).

•Acute viral URTIs exhibit seasonality, with a higher incidence seen in the
winter months
 Aetiology
• The vast majority (90%) of URTIs are caused by viruses.
• These include respiratory syncytial virus, rhinovirus and viral influenza.
• The remaining 10% of infections involve bacteria and include
Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus
aureus and Klebsiella pneumonia
• cough reflex is responsible for cough production.
• Receptors located mainly in the pharynx, larynx, trachea and bronchi are
stimulated via mechanical, irritant or thermal mechanisms.
• Neural impulses are then carried along afferent pathways of the vagal and
superior laryngeal nerves, which terminate at the cough centre in the
medulla.
• Efferent fibres of the vagus and spinal nerves carry neural activity to the
muscles of the diaphragm, chest wall and abdomen.
• These muscles contract and are followed by the sudden opening of the
glottis, which creates the cough .
 Clinical features of acute viral cough
•Viral coughs typically present with sudden onset and
associated fever.
•Sputum production is minimal, and symptoms are often worse
in the evening.
•Associated cold symptoms are also often present; these usually
last between 7 and 10 days.
• A duration of longer than 14 days might suggest postviral
cough or possibly indicate a bacterial secondary infection
•A common misconception is that cough with mucopurulent
sputum is bacterial in cause and requires referral.
 Conditions to eliminate
Likely causes
1. Upper airways cough syndrome (UACS)
•This was previously referred to as postnasal drip
•UACS is characterized by a sinus or nasal discharge that flows
behind the nose and into the throat, (i.e., patients describe
something stuck in the throat).
•Patients should always be asked whether they are swallowing
mucus or notice that they are clearing their throat more than
usual.
• Chronic cough is also associated with UACS.
• Allergies are one cause of UACS.
• Coughs caused by allergies are often nonproductive and
worse at night.
• However, there are usually other associated symptoms, such
as sneezing, nasal discharge or blockage, conjunctivitis and
an itchy oral cavity. Cough of an allergic origin might show
seasonal variation; for example, hay fever.
• Other causes include vasomotor rhinitis (caused by odours
and changes in temperature/humidity) and postinfectious
UACS after a URTI.
• If UACS is present, it is better to direct treatment at cause of
the UACS (e.g., antihistamines or decongestants) rather than
just treat the cough. E.g Actified
 2. Acute bronchitis
• Most cases are seen in autumn or winter, and
• symptoms are similar to those of viral URTI, but
patients also tend to exhibit dyspnoea and wheeze.
• The cough usually lasts for 7 to 10 days but can
persist for 3 weeks.
• The cause is normally viral, but is sometimes
bacterial.
• Symptoms will resolve without antibiotic treatment,
regardless of the cause.
• If the person is systemically unwell, referral is
appropriate.
 Unlikely causes
1.Laryngotracheobronchitis (croup)
•Symptoms are triggered by infection with parainfluenza virus
• affects infants aged between 3 months and 6 years and affects
2% to 6% of children.
•it is more common in the autumn and winter months.
•Symptoms occur in the late evening and night.
•The cough can be severe and violent and is described as having a
barking (seal-like) quality.
• In between coughing episodes, child may be breathless and
struggle to breathe properly.
•Typically, symptoms improve during the day and often recur again
the following night, with most children seeing symptoms resolve in
48 hours.
•Standard treatment for children would be oral or intramuscular
dexamethasone
2. Chronic obstructive pulmonary disease ( COPD)
•characterized by destruction of lung tissue and is preferred term
for chronic bronchitis (CB), emphysema and chronic obstructive
airways disease.
•It is characterized by cough, sputum production and increasing
breathlessness; it is treatable although not curable.
•Typical symptoms include chronic cough, breathlessness on
exertion, wheezing and recurrent chest infections.
• Confirmation of the diagnosis is by spirometry testing.
•Patients with established COPD often experience acute
exacerbations marked by a reduction in activities and more
pronounced breathlessness.
•In such cases, the patient requires referral to the GP for potential
antibiotics and steroid therapy.
•A history of smoking is the single most important factor in the
cause of CB
 3. Asthma
• Asthma is a chronic inflammatory condition of the airways
characterized by coughing, wheezing, chest tightness, and
shortness of breath.
• Typically, these symptoms tend to be variable, intermittent,
worse at night, and provoked by triggers (e.g., allergens,
infections, irritant exposure).
•asthma can also present as a nonproductive cough (or
minimally productive) especially in young children, in whom the
cough is often worst at night and recurrent
4. Pneumonia (community-acquired)

•Bacterial infection is usually responsible for pneumonia

and is most commonly caused by S. pneumoniae (80%
of cases)
•Initially, the cough is nonproductive and painful (first
24–48 hours), but it rapidly becomes productive, with
sputum being stained red.
•The cough tends to be worst at night.
•The patient will be unwell, with a high fever (>38o C),
malaise, headache, and breathlessness and experience
pleuritic pain (inflammation of pleural membranes,
manifested as pain to the sides) that worsens on
inspiration.
• Older patients are often afebrile and may present with
confusion
 5. Medicine-induced cough or wheeze
• A number of medicines may cause bronchoconstriction, which
presents as coughing or wheezing.
•Angiotensinconverting enzyme (ACE) inhibitors are most
commonly associated with cough.
•The incidence might be as high as 16% and time to onset is
variable, ranging from a few hours to more than 1 year after
the start of treatment.
•Cough invariably ceases after withdrawal of the ACE inhibitor
but takes 3 to 4 weeks to resolve.
• Other medications associated with cough or wheeze are
nonsteroidal antiinflammatory drugs (NSAIDs) and beta
blockers.
 Very unlikely causes
•Heart failure
•Bronchiectasis
•Tuberculosis
•Carcinoma of the lung
•Lung abscess
•Spontaneous pneumothorax
•Gastro-oesophageal reflux disease
•Nocardiosis and psychogenic cough
• Patients should not be routinely prescribed
antitussives but instead encouraged to drink
more fluids and told that their symptoms will
resolve in time on their own.
• If recommended, dextromethorphan is the only
agent with any evidence of effectiveness; its side
effect profile and abuse tendency rather than
clinical efficacy may drive this choice.
• On this basis, dextromethorphan would be
first-line therapy and pholcodine second-line
treatment.
 Evidence base for over-the-counter medication
1. Expectorants for wet cough
•Based on studies, guaifenesin is the only expectorant
with any evidence of effectiveness.
•Given its proven safety record, absence of drug
interactions, and the public’s desire to treat productive
coughs with a home remedy, it would seem reasonable
to supply OTC cough medicines containing guaifenesin.
 2.Cough suppressants (antitussives) for dry cough
• Cough suppressants act directly on the cough centre to
depress the cough reflex.
– Codeine
– Pholcodine
– Dextromethorphan

3. Demulcents
•Demulcents, such as simple linctus and honey, are
pharmacologically inert and are used on the theoretical basis
that they reduce irritation by coating the pharynx and thus
prevent coughing.
• However, there is no evidence for their efficacy
 4. Antihistamines
•could reduce some of the symptoms of a cold: runny nose
(rhinorrhoea) and sneezing.
•These effects are due to anticholinergic action of antihistamines.
•The older drugs (e.g. chlorphenamine (chlorpheniramine),
promethazine) have more pronounced anticholinergic actions than
the non-sedating antihistamines (e.g. loratadine, cetirizine,
acrivastine).
•Therefore non-sedating antihistamines are less effective in
reducing symptoms of a cold.
•Antihistamines are not so effective at reducing nasal congestion.
• Some (e.g. diphenhydramine) may also be included in cold
remedies for their supposed antitussive action or to help the
patient to sleep.
• Evidence indicates that antihistamines alone are not of
benefit in the common cold but that they may offer limited
benefit for adults in combination with decongestants,
analgesics and cough suppressants.
 Interactions:
•The problem of using antihistamines, particularly the older types (e.g.
chlorphenamine), is that they can cause drowsiness.
• Alcohol will increase this effect, as will drugs such as benzodiazepines or
phenothiazines that have the ability to cause drowsiness or CNS depression.
•Antihistamines with known sedative effects should not be recommended for
anyone who is driving, or in whom an impaired level of consciousness may be
dangerous (e.g. operators of machinery at work).
• Because of their anticholinergic activity, the older antihistamines may
produce the same adverse effects as anticholinergic drugs (i.e. dry mouth,
blurred vision, constipation and urinary retention).
•These effects are more likely if antihistamines are given concurrently with
anticholinergics such as hyoscine or with drugs that have anticholinergic
actions such as tricyclic antidepressants or bladder antispasmodics (e.g.
oxybutynin)
 Interactions
•Alcohol
•Hypnotics
•Sedatives
• Betahistine
• Anticholinergics
Side effects
• Drowsiness (driving, occupational hazard)
• Constipation
• Blurred vision
•Urinary symptoms
• Confusion
Cautions
• Closed-angle glaucoma
• LUTS in men Epilepsy Liver disease
Children under 6 years old

•In March 2009, an important statement was issued by the Medicines

and Healthcare products Regulatory Agency (MHRA), which says:
•The new advice is that parents and carers should no longer use
over-the-counter (OTC) cough and cold medicines in children under
6.
– There is no evidence that they work and
– they can cause side-effects, such as allergic reactions, effects on
sleep or hallucinations.
– The risks of side-effects are reduced in older children. This is
because they weigh more, get fewer colds and can say if the medicine
is doing any good.
• Antitussives: Dextromethorphan and pholcodine
• Expectorants: Guaifenesin and ipecacuanha
• Nasal decongestants: Ephedrine, oxymetazoline, phenylephrine,
pseudoephedrine and xylometazoline
• Antihistamines: Brompheniramine, chlorphenamine, diphenhydramine,
doxylamine, promethazine and triprolidine
• Children aged between 6 and 12 years can still use these preparations,
but with an advice to limit treatment to 5 days or less.
• The MHRA rationale was that for children aged over 6 years, the risk
from these ingredients is reduced because:
• they suffer from cough and cold less frequently and consequently
require medicines less often; with increased age and size,
• they tolerate the medicines better; and
• they can say if the medicine is working.
• Simple cough remedies (such as those containing glycerine, honey or
lemon) are still licensed for use in children. Alternatively, for children
over the age of 1 year, a warm drink of honey and lemon could be given.
• Remember that all aspirin-containing products are contraindicated in
all children under the age of 16. This includes oral salicylate gels. WHY?
• A NICE guideline says that antibacterials should be considered
if:
• the person Is systemically very unwell
• Is at high risk of serious complications because of a
pre-existing co-morbid condition such as heart, lung,
kidney, liver or neuromuscular disease, or
immunosuppression
• Is older than 65 years of age with two or more of the
following, or older than 80 years with one or more of
the following:
– ◦ Hospital admission in the previous year
– ◦ Type 1 or type 2 diabetes mellitus
– ◦ Known congestive heart failure
– ◦ Use of oral corticosteroids
 Prevention of colds and flu
• Pharmacists should encourage those in at-risk groups to have an
annual flu vaccination.
• In the United Kingdom, the health service now provides
vaccinations to
• all patients over 65 years and
•those below that age who have chronic respiratory disease
(including asthma), chronic heart disease, chronic renal failure,
chronic neurological disease, and diabetes mellitus or
immunosuppression due to disease or treatment.
• Pregnant women and people living in long-stay residential care
are also advised to have immunization
•Increasing attention is being paid to ways of reducing
transmission of flu, and this also applies to colds.
•Routine handwashing with soap and water for at least 20
seconds reduces the transmission of cold and flu viruses.