Cough: Information for clinicians

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:

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)

 

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

Recommended Resources

PANG Guidelines Physical Symptoms and Signs - Cough

Published 16th October 2016

NICE CKS Palliative care - cough

Published 1st February 2024

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