Ask the patient to rate cough frequency, severity and level of associated distress or anxiety. Explore:

Transcription

1 Cough Introduction Cough is a forced expulsive manoeuvre usually against a closed glottis, which is associated with a characteristic sound. It usually has a protective function in maintaining patency and cleanliness of the airways. The impact of cough on patients and relatives is often underestimated. Patients may need symptomatic treatment when cough is persistent, distressing or affecting sleep and/or quality of life. An assessment of the pattern and character of the patient's cough is essential to optimise treatment. Acute cough is defined as duration of <3 weeks, subacute as 3 to 8 weeks, chronic as >8 weeks. For information on the nature of cough, see the Management section. Assessment Ask the patient to rate cough frequency, severity and level of associated distress or anxiety. Explore: o understanding of the reasons for cough o fears (including fear of choking) o impact on: functional abilities (including continence) quality of life families and carers. Clarify: o pattern, character and duration of cough o precipitating/alleviating factors for cough o associated symptoms o occupational history. Look for any potentially reversible causes of cough, such as: o infection o pleural or pericardial effusion o pulmonary embolism o gastro-oesophageal reflux o bronchospasm. Determine if treatment of the underlying disease is appropriate. Seek advice if in doubt. Assess character of sputum and consider sputum culture if necessary. See table 3. Consider chest X-ray. Copyright 2014 NHS Scotland Page 1 of 6

2 Management 1 If stridor is present, seek specialist advice. Give high-dose steroids in divided doses: dexamethasone 16mg orally or subcutaneously, or prednisolone 60mg orally. Consider gastric protection. Consider treating any potentially reversible causes. Optimise current therapy (non-drug management and medication); in particular, ensure adequate analgesia as pain may inhibit effective coughing. Acknowledge fear and anxieties, and provide supportive care. Offer written information and verbal explanation. Consider referral to physiotherapy services if difficulty in expectorating retained secretions. Agree a self-management plan which could include: o cough diary o smoking cessation advice. o improved ventilation such as opening a window, putting on a fan o coping strategies, such as: positioning and posture relaxation controlled breathing technique and effective coughing techniques, eg huffing. Seek specialist advice for the small number of patients who may require suction or a cough assist machine. Specific advice on managing a dry (non-productive) cough A persistent refractory cough may prompt the initial diagnosis of a primary lung malignancy or pulmonary metastases and specific chemotherapy/radiotherapy may be appropriate, depending on histology and fitness. Post-radiotherapy lung damage, pneumonitis and lymphangitis (which can be associated with breathlessness and cyanosis) may respond to steroid therapy. Seek oncology advice. 1 Indicates this use is off licence QT Indicates this medication is associated with QT prolongation Copyright 2014 NHS Scotland Page 2 of 6

3 Table 1 Management of a dry (non-productive) cough Nature of cough Possible cause Potential treatment Onset related to the commencement of medication Rapid onset of cough, associated with dyspnoea Barking cough (short duration) Angiotensin-converting-enzyme (ACE) inhibitors Pleural effusion Pericardial effusion Pulmonary embolism (usually dry cough but may have haemoptysis) Pharyngitis/tracheobronchitis/ early pneumonia Discontinue or switch to alternative medication Consider pleural drainage and pleurodesis Consider pericardiocentesis and pericardiosclerosis Consider merits of anticoagulation with low molecular weight heparin (LMWH) Consider antibiotics, humidify room air Harsh croup (coarse) Laryngitis Humidify room air, advise resting of voice Bovine cough Hard brassy cough (with or without wheeze or stridor) Wheezy cough Recurrent laryngeal nerve palsy (from intrathoracic compression or disease) Tracheal compression from thoracic lesions or nodes, superior vena cava obstruction (SVCO) Airflow obstruction (asthma, chronic obstructive pulmonary disease (COPD)) Cough Table 1. Version 1 May 2014 Consider referral to ear, nose and throat (ENT) for possible vocal cord injection Consider radiotherapy, steroids, stenting (see SVCO section in the Breathlessness guideline) Optimise inhaled therapy, consider steroids Medication In addition to the advice described in Table 1, consider treatment to suppress a dry cough: simple linctus morphine (monitor for side effects including opioid toxicity) o opioid naive 2mg orally, 4 to 6 hourly if required (6 to 8 hourly if frail or elderly) o already on morphine continue and use the existing immediate-release breakthrough analgesic dose (oral if able or subcutaneous equivalent) for the relief of cough. A maximum of 6 doses can be taken in 24 hours for all indications (pain, breathlessness and cough). Titrate both regular and breakthrough doses as required. Specialist referral if symptoms persist for consideration of other treatments. Copyright 2014 NHS Scotland Page 3 of 6

4 Specific advice on managing a moist (productive of mucus, sputum or saliva) cough Table 2 Management of a moist cough Nature of cough Possible cause Potential treatment Productive COPD (no infection) Optimise inhaled therapy, consider steroids After food Weak ineffective Precipitated by supra pharyngeal secretions Infection, pneumonia or both COPD exacerbation Tracheo-oesophageal fistula Aspiration of saliva Gastro-oesophageal reflux Cardiac failure Fatigue or weakness causing poor swallow Motor neurone disease (MND)/amyotrophic lateral sclerosis (ALS) causing excessive saliva production Postnasal drip Sinusitis/allergies Consider antibiotics (assess ceiling of treatment intravenous (IV) or oral) Consider antibiotics (assess ceiling of treatment IV or oral) and steroids Consider specialist advice for possible stenting Antimuscarinics/ anticholinergics, antibiotics Proton pump inhibitors (PPIs) and prokinetic, eg metoclopramide, QT domperidone Optimise medical management Assessment by speech and language therapist and dietician Consider antisecretory, eg hyoscine to achieve acceptable moisture levels. Titrate carefully. Consider suction or cough assist machine. Nasal steroids Nasal decongestant spray, antihistamine, nasal steroids Cough Table 2. Version 1 May 2014 Medication In addition to the advice described in Table 2, consider treatment to aid expectoration: mucolytics - to reduce sputum viscosity, eg carbocisteine. Stop if no benefit after a 4 week trial. nebulised sodium chloride 0.9% 2.5 to 5ml as required - to help loosen secretions. When a patient with a moist cough reaches end of life, drying of secretions may be necessary. Copyright 2014 NHS Scotland Page 4 of 6

5 Practice Points Non-drug management techniques that help patients and families cope are essential. Using a self management plan can help with symptom relief. As the illness progresses, medication to relieve cough may become more necessary. Starting opioids at a low dose and titrating carefully is safe and does not cause respiratory depression in patients with cancer, airways obstruction or heart failure. Patient and carer advice points There are many causes of cough. Some coughs require very specific treatments. Encourage discussion to permit alleviation of associated fears or symptoms, eg incontinence. Table 3 Character of Sputum Quality of sputum Cause Purulent Non-infective, jelly-like, clear Bronchorrhoea (Mucus >100ml/day) Frothy Blood-stained Infection Excess saliva or mucus Broncheo-alveolar cancer, asthma, tuberculosis (TB) Left ventricular failure, alveolar cell cancer Infection including TB, pulmonary embolus, tumour Cough Table 3. Version 1 May 2014 Resources Palliative care drug information Macmillan Cancer Support Roy Castle Lung Foundation Cancer Research UK Marie Curie cancer care Chest Heart and Stroke Scotland British Lung Foundation British Heart Foundation NHS Inform, Long-term health conditions and mental health NHS Inform palliative care zone My Condition, My Terms, My Life Self Management Patient.co.uk website Copyright 2014 NHS Scotland Page 5 of 6

6 References 2010a. Cough in Cancer Patients in Palliative Care in malignant respiratory diseases In: G. Hanks, Ni. Cherny, Na. Christakis, M. Fallon, S. Kaasa andrk. Portenoy, E. eds. Oxford Textbook of Palliative Medicine 4th ed. Oxford Oxford University Press. 2010b. Cough in Palliative Care in non-malignant, end-stage respiratory disease. In: G. Hanks, Ni. Cherny, Na. Christakis, M. Fallon, S. Kaasa andrk. Portenoy, E. eds. Oxford Textbook of Palliative Medicine 4th ed. Oxford: Oxford University Press. Bolser, D. C Pharmacologic management of cough. Otolaryngologic Clinics of North America, 43(1), pp , xi. Gibson, P. G. and Ryan, N. M Cough pharmacotherapy: current and future status. Expert Opinion on Pharmacotherapy, 12(11), pp Marks, S. and Rosielle, D. A Opioids for cough #199. Journal of Palliative Medicine, 13(6), pp Molassiotis, A., Smith, J. A., Bennett, M. I., Blackhall, F., Taylor, D., Zavery, B., Harle, A., Booton, R., Rankin, E. M., Lloyd-Williams, M. and Morice, A. H Clinical expert guidelines for the management of cough in lung cancer: report of a UK task group on cough. Cough, 6, pp. 9. Morice, A. H., Mcgarvey, L. and Pavord, I Recommendations for the management of cough in adults. Thorax, 61(suppl 1), pp. i1-i24. Morice, A. H., Menon, M. S., Mulrennan, S. A., Everett, C. F., Wright, C., Jackson, J. and Thompson, R Opiate therapy in chronic cough. American Journal of Respiratory & Critical Care Medicine, 175(4), pp Wee, B Chronic cough. Current Opinion in Supportive & Palliative Care, 2(2), pp Wee, B., Browning, J., Adams, A., Benson, D., Howard, P., Klepping, G., Molassiotis, A. and Taylor, D Management of chronic cough in patients receiving palliative care: review of evidence and recommendations by a task group of the Association for Palliative Medicine of Great Britain and Ireland. Palliative Medicine, 26(6), pp a. Authors: Kin-Sang Chan, Doris M. W. Tse, Michael M. K. Sham, and Anne Berit Thorsen. 2010b. Author: Richard M. Leach. Copyright 2014 NHS Scotland Page 6 of 6