Cough

Scottish Palliative Care Guidelines
Healthcare Improvement Scotland

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, sub-acute as 3 to 8 weeks, chronic as >8 weeks. For information on the nature of cough, refer to the Management section.

Assessment

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

  • Explore:
    • understanding of the reasons for cough
    • fears (including fear of choking)
    • impact on:
      • functional abilities (including continence)
      • quality of life
      • families and carers.
  • Clarify:
    • pattern, character and duration of cough
    • precipitating/alleviating factors for cough
    • associated symptoms
    • occupational history.
  • Look for any potentially reversible causes of cough, such as:
    • infection
    • pleural or pericardial effusion
    • pulmonary embolism
    • gastro-oesophageal reflux
    • 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. Refer to tables in the management sections below.
  • Consider appropriate imaging.

 

General management

  • 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 with PPI or H2 antagonist.
  • 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:
    • cough diary
    • smoking cessation advice
    • improved ventilation such as opening a window, putting on a fan
    • coping strategies such as:
      • positioning and posture
      • relaxation
      • controlled breathing technique and effective coughing techniques, for example 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.

Management of a dry (non-productive) cough

Tables are best viewed in landscape mode on mobile devices

Nature of cough Possible cause Potential treatment
Onset related to the commencement of medication Angiotensin-converting-enzyme (ACE) inhibitors Discontinue or switch to alternative medication
Rapid onset of cough, associated with dyspnoea Pleural effusion Consider pleural drainage and pleurodesis
Pericardial effusion Consider pericardiocentesis and pericardiosclerosis
Pulmonary embolism (usually dry cough but may have haemoptysis) Consider merits of anticoagulation with low molecular weight heparin (LMWH)
Barking cough (short duration) Pharyngitis/ tracheobronchitis/ 
early pneumonia		 Consider antibiotics,
humidify room air
Harsh croup (coarse) Laryngitis Humidify room air,
advise resting of voice
Bovine cough Recurrent laryngeal nerve palsy (from intrathoracic compression or disease) Consider referral to ear, nose and throat (ENT) for possible vocal cord injection
Hard brassy cough (with or without wheeze or stridor) Tracheal compression from thoracic lesions or nodes,
superior vena cava obstruction (SVCO)		 Consider radiotherapy, steroids,
stenting (refer to the SVCO section in the Breathlessness guideline)
Wheezy cough Airflow obstruction - asthma, chronic obstructive pulmonary disease (COPD) Optimise inhaled therapy, consider steroids

Medication

In addition to the advice described the above table, consider treatment to suppress a dry cough:

  • simple linctus
  • †morphine (monitor for side effects including opioid toxicity)
    • opioid naive – 2mg orally, 4 to 6 hourly if required (6 to 8 hourly if frail or in renal/hepatic impairment, start low go slow.)
    • 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.

 

Specific advice on managing a moist (productive of mucus, sputum or saliva) cough

Tables are best viewed in landscape mode on mobile devices

Nature of cough Possible cause Potential treatment
Productive COPD (no infection) Optimise inhaled therapy, consider steroids
Infection, pneumonia or both Consider antibiotics as per local guidelines (assess realistic level of intervention – intravenous (IV) or oral)
COPD exacerbation Consider antibiotics (assess realistic level of intervention – IV or oral) and steroids
Tracheo-oesophageal fistula Consider specialist advice for possible stenting
Aspiration of saliva Antimuscarinics/anticholinergics, antibiotics
Gastro-oesophageal reflux Proton pump inhibitors (PPIs) and prokinetic, for example metoclopramide, QTdomperidone
Cardiac failure Optimise medical management
After food Fatigue or weakness causing poor swallow Assessment by speech and language therapist and dietician
Weak ineffective Motor neurone disease (MND)/ amyotrophic lateral sclerosis (ALS) causing excessive saliva production Consider antisecretory, for example hyoscine to achieve acceptable moisture levels Titrate carefully

Consider suction or cough assist machine
Precipitated by supra pharyngeal secretions Postnasal drip

 

Sinusitis/allergies		 Nasal steroids Nasal decongestant spray, antihistamine, nasal steroids

Character of sputum

Quality of sputum Cause
Purulent Infection
Non-infective, jelly-like, clear Excess saliva or mucus
Bronchorrhoea (Mucus >140ml/day) Broncheo-alveolar cancer, asthma, tuberculosis (TB)

Frothy

 Left ventricular failure, alveolar cell cancer
Blood-stained Infection, including TB, pulmonary embolus, tumour

Medication

  • In addition to the advice described in the table above, consider treatment to aid expectoration:
  • mucolytics - to reduce sputum viscosity, for example carbocisteine as required. Stop if no benefit after a 4 week trial.
  • †nebulised sodium chloride 0.9% 2.5ml 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. Refer to Care in the last days of life guideline.

 

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.

 

Resources

References

Cough in Cancer Patients in Palliative Care in malignant respiratory diseases. In: G. Hanks, Ni. Cherny, Na. Christakis, M. Fallon, S. Kaasa and Rk. Portenoy, E. eds. Oxford Textbook of Palliative Medicine 4th ed. Oxford University Press.

Cough in Palliative Care in non-malignant, end-stage respiratory disease. In: G. Hanks, Ni. Cherny, Na. Christakis, M. Fallon, S. Kaasa and Rk. Portenoy, E. eds. Oxford Textbook of Palliative Medicine 4th ed. Oxford: Oxford University Press.

Bolser, D. C. 2010. Pharmacologic management of cough. Otolaryngologic Clinics of North America, 43(1), pp. 147-55, xi.

Gibson, P. G. and Ryan, N. M. 2011. Cough pharmacotherapy: current and future status. Expert Opinion on Pharmacotherapy, 12(11), pp. 1745-55.

Marks, S. and Rosielle, D. A. 2010. Opioids for cough #199. Journal of Palliative Medicine, 13(6), pp. 769-70.

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. 2010. 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. 2006. 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. 2007. Opiate therapy in chronic cough. American Journal of Respiratory & Critical Care Medicine, 175(4), pp. 312-5.

Wee, B. 2008. Chronic cough. Current Opinion in Supportive & Palliative Care, 2(2), pp. 105-9.

Wee, B., Browning, J., Adams, A., Benson, D., Howard, P., Klepping, G., Molassiotis, A. and Taylor, D. 2012. 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. 780-7.