- 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
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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/ |
Consider antibiotics, |
Harsh croup (coarse) |
Laryngitis |
Humidify room air, |
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, |
Consider radiotherapy, steroids, |
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.