First steps
Treat reversible causes eg:
- Infection/aspiration
- COPD/asthma
- ACE inhibitors
- Irritants such as smoking
- Rhinitis/post nasal drip
- Gastro-oesophageal reflux disease
- Pleural effusion
If possible, encourage patients with cough to avoid lying on their back as 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 - 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) and help loosen the bronchial secretions.
Productive cough
Promotion of an 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 - careful decision making needed
For patients still able to cough effectively:
- Nebulised 0.9% saline 2.5mL -5ml q.d.s. and PRN to loosen mucus
- Treat any bronchospasm (wheeze) with nebulised salbutamol
- Physiotherapy to aid expectoration and teach patients how to cough more effectively
- If the mucus is very thick carbocisteine can be tried to loosen secretions
- Antitussives should ideally be avoided, but may be helpful at night to aid sleep
For patients who are dying and too weak to cough:
- antitussives (see below)
- antimuscarinic drugs to dry secretions - eg buscopan.
Dry cough
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)
After treating any reversible cause a dry cough should be suppressed with antitussives (see below)
Drugs used to suppress cough
| Treatment | Dosage |
|
Simple linctus Honey in warm water |
10mls tds |
|
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) (Oramorph) |
5 mg to 10 mg every 3 hours as required. Lower doses in frail elderly |
|
If unable to swallow |
2.5mg-5mg subcut injection PRN Morphine 10mg/24hrs via syringe pump |