Cough: Information for clinicians

This information is sourced from NICE, PANG and the BNF:

First steps

Treat reversible causes eg:

  • Infection
  • COPD/asthma
  • ACE inhibitors
  • Irritants such as smoking
  • Rhinitis/post nasal drip
  • Gastro-oesophageal reflux disease

If possible, encourage patients with cough to avoid lying on their back because this makes coughing ineffective

Use simple measures first: moist inhalations or taking honey.

Distinguish between a productive and a dry cough to guide symptomatic treatment

Nebulised saline 0.9% 2.5mL q.d.s. can be used for either a dry or productive cough; it may reduce the irritation of dry airways (breathing oxygen or mouth-breathing),  help loosen the normal bronchial secretions and any mucus.

Productive cough

Promotion of an easy, effective cough to clear the mucus should be the aim, unless the patient is dying, and too weak to expectorate.

Antibiotics may be appropriate even in very ill patients as symptomatic treatment even if they do not prevent death.

For patients still able to cough effectively with help:

  • Nebulised 0.9% saline 2.5mL q.d.s. and PRN to loosen mucus
  • Treat any bronchospasm with nebulised salbutamol 
  • Physiotherapy to aid expectoration and teach patients how to cough more effectively
  • If the mucus is very thick carbocisteine could be tried
  • Antitussives should ideally be avoided, but may be helpful at night to aid sleep 

For patients who are dying and too weak to cough:

Dry cough

After treating any reversible cause a dry cough should be suppressed with antitussives (see below)

  • nebulised saline 0.9% 2.5mL q.d.s. may be helpful by reducing the irritation of dry airways (due to oxygen or mouth-breathing) and may loosen the normal bronchial secretions
Drugs used to suppress cough
Treatment Dosage

codeine linctus (15 mg/5 ml)

or codeine phosphate tablets (15 mg, 30 mg)

15 mg to 30 mg, up to 4 doses in 24 hours (watch for constipation)

morphine sulfate oral solution (10 mg/5 ml)

2.5 mg to 5 mg when required every 4 hours

Increase up to 5 mg to 10 mg every 4 hours as required

If unable to swallow

Morphine 10mg/24hrs via syringe pump or 2.5mg-5mg subcut injection

Sources

PANG Guidelines Physical Symptoms and Signs - Cough

Published 16th October 2016

BNF Prescribing in palliative care

Published 1st November 2021

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