Symptoms in the Pharmacy :Respiratory Problems (4)
Cough
Coughing is a protective reflex action caused when the airway is being
irritated or obstructed. Its purpose is to clear the airway so that
breathing can continue normally. The majority of coughs presenting
in the pharmacy will be caused by a viral URTI. They will often
be associated with other symptoms of a cold. The evidence to support
the use of cough suppressants and expectorants is not strong but some
patients report finding them helpful.
What you need to know!
Significance of questions and answers
Age
Establishing who the patient is – child or adult – will influence the
choice of treatment and whether referral is necessary.
Duration
Most coughs are self-limiting and will be better within a few days with
or without treatment. In general, a cough of longer than 2 weeks’
duration that is not improving should be referred to the doctor for
further investigation.
Patients are often concerned when a cough has lasted for, what
seems to them to be, a long time. They may be worried that because
the cough has not resolved, it may have a serious cause.
Nature of cough
Unproductive (dry
, tickly or tight)
In an unproductive cough no sputum is produced. These coughs are
usually caused by viral infection and are self-limiting.
Productive
(chesty or loose)
Sputum is normally produced. It is an oversecretion of sputum that
leads to coughing. Oversecretion may be caused by irritation of the
airways due to infection, allergy, etc. or when the cilia are not working
properly (e.g. in smokers). Non-coloured (clear or whitish) sputum is
uninfected and known as mucoid.
Coloured sputum may sometimes indicate a bacterial chest infection
such as bronchitis or pneumonia and require referral. In these
situations the sputum is described as green, yellow or rust-coloured
thick mucus and the patient is more unwell usually with a raised
temperature, shivers and sweats. Sometimes blood may be present in
the sputum (haemoptysis), with a colour ranging from pink to deep
red. Blood may be an indication of a relatively minor problem such as
a burst capillary following a bout of violent coughing during an acute
infection, but may be a warning of more serious problems. Haemoptysis
is an indication for referral.
Antibacterials/antibiotics are not usually indicated for previously
healthy people with acute bronchitis. Most cases of acute bronchitis
are caused by viral infections, so antibacterials will not help. Two
systematic reviews of antibacterials for acute bronchitis found only
slight benefit, possibly reducing the duration of illness by about half a
day. Some people who have a tendency towards asthma develop a
wheezy bronchitis with a respiratory viral infection. They may benefit
from inhalation treatment used in asthma.
If a person has had repeated episodes of bronchitis over the years
they might have chronic bronchitis (defined as a chronic cough and/or
mucus production for at least 3 months in at least 2 consecutive years
when other causes of chronic cough have been excluded). So careful
questioning is important to determine this.
There is general consensus that antibacterials should be considered
if the person is elderly, has reduced resistance to infection, has
co-morbidity (such as diabetes or heart failure) or is deteriorating
clinically.
In heart failure and mitral stenosis the sputum is sometimes described
as pink and frothy or can be bright red. Confirming symptoms would
be breathlessness (especially in bed during the night) and swollen
ankles.
Tuberculosis (TB)
Until recently thought of as a disease of the past, the number of TB
cases has been rising in the UK and there is increasing concern about
resistant strains. Chronic cough with haemoptysis associated with
chronic fever and night sweats are classical symptoms. TB is largely
a disease of poverty and more likely to present in disadvantaged
communities. In the UK most cases of respiratory TB are seen in ethnic
minority groups, especially Indian and Africans. Human immunodeficiency
virus (HIV) infection is a significant risk factor for the development
of respiratory TB
.
Croup (acute laryngotracheitis)
Croup usually occurs in infants. The cough has a harsh barking
quality. It develops 1 day or so after the onset of coldlike symptoms.
It is often associated with difficulty in breathing and an inspiratory
stridor (noise in throat on breathing in). Referral is necessary.
Whooping cough (pertussis)
Whooping cough starts with catarrhal symptoms. The characteristic
whoop is not present in the early stages of infection. The whoop is the
sound produced when breathing in after a paroxysm of coughing.
The bouts of coughing prevent normal breathing and the whoop
represents the desperate attempt to get a breath. Referral is necessary.
Associated symptoms
Cold, sore throat and catarrh may be associated with a cough. Often
there may be a temperature and generalised muscular aches present.
This would be in keeping with a viral infection and be self-limiting.
Chest pain, shortness of breath or wheezing are all indications for
referral
Postnasal drip
Postnasal drip is a common cause of coughing and may be due to
sinusitis
Previous history
Certain cough remedies are best avoided in diabetics and anyone with
heart disease or hypertension
Chronic bronchitis
Questioning may reveal a history of chronic bronchitis, which is being
treated by the doctor with antibiotics. In this situation further treatment
may be possible with an appropriate cough medicine.
Asthma
A recurrent night-time cough can indicate asthma, especially in
children, and should be referred. Asthma may sometimes present as
a chronic cough without wheezing. A family history of eczema, hay
fever and asthma is worth asking about. Patients with such a family
history appear to be more prone to extended episodes of coughing
following a simple URTI.
Cardiovascular
Coughing can be a symptom of heart failure (see p. 60). If there is
a history of heart disease, especially with a persisting cough, then
referral is advisable.
Gastro-oesophageal
Gastro-oesophageal reflux can cause coughing. Sometimes such reflux
is asymptomatic apart from coughing. Some patients are aware of acid
coming up into their throat at night when they are in bed.
Smoking habit
Smoking will exacerbate a cough and can cause coughing since it is
irritating to the lungs. One in three long-term smokers develop a
chronic cough. If coughing is recurrent and persistent, the pharmacist
is in a good position to offer health education advice about the
benefits of stopping smoking, suggesting NRT where appropriate.
However, on stopping, the cough may initially become worse as the
cleaning action of the cilia is re-established during the first few days
and it is worth mentioning this. Smokers may assume their cough is
harmless, and it is always important to ask about any change in the
nature of the cough that might suggest a serious cause.
Present medication
It is always essential to establish which medicines are currently being
taken. This includes those prescribed by a doctor and any bought
OTC, borrowed from a friend or neighbour or rediscovered in the
family medicine chest. It is important to remember the possibility of
interactions with cough medicine.
It is also useful to know which cough medicines have been
tried already. The pharmacist may decide that an inappropriate
preparation has been taken, e.g. a cough suppressant for a productive
cough. If one or more appropriate remedies have been tried
for an appropriate length of time without success, then referral is
advisable.
Angiotensin-converting enzyme (ACE) inhibitors
Chronic coughing may occur in patients, particularly women,
taking ACE inhibitors such as enalapril, captopril, lisinopril and
ramipril. Patients may develop the cough within days of starting
treatment or after a period of a few weeks or even months. The
exact incidence of the reaction is not known and estimates vary
from 2% to 10% of patients taking ACE inhibitors. ACE inhibitors
control the breakdown of bradykinin and other kinins in the
lungs, which can trigger a cough. Typically the cough is irritating,
non-productive and persistent. Any ACE inhibitor may induce
coughing and there seems to be little advantage to be gained
in changing from one to another. The cough may resolve or may
persist; in some patients the cough is so troublesome and distressing
that ACE inhibitor therapy may have to be discontinued. Any patients
in whom medication is suspected as the cause of a cough should be
referred to their doctor. Angiotensin 2 receptor antagonists, which
have similar properties to ACE inhibitors and which do not affect
bradykinin, can be used as an alternative preparation if cough is
a problem.
Coughing is a protective reflex action caused when the airway is being
irritated or obstructed. Its purpose is to clear the airway so that
breathing can continue normally. The majority of coughs presenting
in the pharmacy will be caused by a viral URTI. They will often
be associated with other symptoms of a cold. The evidence to support
the use of cough suppressants and expectorants is not strong but some
patients report finding them helpful.
What you need to know!
- Age (approximate)
- Baby, child, adult
- Duration
- Nature
- Dry or productive
- Associated symptoms
- Cold, sore throat, fever
- Sputum production
- Chest pain
- Shortness of breath
- Wheeze
- Previous history
- Chronic bronchitis
- Asthma
- Diabetes
- Heart disease
- Gastro-oesophageal reflux
- Smoking habit
- Present medication
Significance of questions and answers
Age
Establishing who the patient is – child or adult – will influence the
choice of treatment and whether referral is necessary.
Duration
Most coughs are self-limiting and will be better within a few days with
or without treatment. In general, a cough of longer than 2 weeks’
duration that is not improving should be referred to the doctor for
further investigation.
Patients are often concerned when a cough has lasted for, what
seems to them to be, a long time. They may be worried that because
the cough has not resolved, it may have a serious cause.
Nature of cough
Unproductive (dry
, tickly or tight)In an unproductive cough no sputum is produced. These coughs are
usually caused by viral infection and are self-limiting.
Productive
(chesty or loose)Sputum is normally produced. It is an oversecretion of sputum that
leads to coughing. Oversecretion may be caused by irritation of the
airways due to infection, allergy, etc. or when the cilia are not working
properly (e.g. in smokers). Non-coloured (clear or whitish) sputum is
uninfected and known as mucoid.
Coloured sputum may sometimes indicate a bacterial chest infection
such as bronchitis or pneumonia and require referral. In these
situations the sputum is described as green, yellow or rust-coloured
thick mucus and the patient is more unwell usually with a raised
temperature, shivers and sweats. Sometimes blood may be present in
the sputum (haemoptysis), with a colour ranging from pink to deep
red. Blood may be an indication of a relatively minor problem such as
a burst capillary following a bout of violent coughing during an acute
infection, but may be a warning of more serious problems. Haemoptysis
is an indication for referral.
Antibacterials/antibiotics are not usually indicated for previously
healthy people with acute bronchitis. Most cases of acute bronchitis
are caused by viral infections, so antibacterials will not help. Two
systematic reviews of antibacterials for acute bronchitis found only
slight benefit, possibly reducing the duration of illness by about half a
day. Some people who have a tendency towards asthma develop a
wheezy bronchitis with a respiratory viral infection. They may benefit
from inhalation treatment used in asthma.
If a person has had repeated episodes of bronchitis over the years
they might have chronic bronchitis (defined as a chronic cough and/or
mucus production for at least 3 months in at least 2 consecutive years
when other causes of chronic cough have been excluded). So careful
questioning is important to determine this.
There is general consensus that antibacterials should be considered
if the person is elderly, has reduced resistance to infection, has
co-morbidity (such as diabetes or heart failure) or is deteriorating
clinically.
In heart failure and mitral stenosis the sputum is sometimes described
as pink and frothy or can be bright red. Confirming symptoms would
be breathlessness (especially in bed during the night) and swollen
ankles.
Tuberculosis (TB)
Until recently thought of as a disease of the past, the number of TB
cases has been rising in the UK and there is increasing concern about
resistant strains. Chronic cough with haemoptysis associated with
chronic fever and night sweats are classical symptoms. TB is largely
a disease of poverty and more likely to present in disadvantaged
communities. In the UK most cases of respiratory TB are seen in ethnic
minority groups, especially Indian and Africans. Human immunodeficiency
virus (HIV) infection is a significant risk factor for the development
of respiratory TB
.
Croup (acute laryngotracheitis)
Croup usually occurs in infants. The cough has a harsh barking
quality. It develops 1 day or so after the onset of coldlike symptoms.
It is often associated with difficulty in breathing and an inspiratory
stridor (noise in throat on breathing in). Referral is necessary.
Whooping cough (pertussis)
Whooping cough starts with catarrhal symptoms. The characteristic
whoop is not present in the early stages of infection. The whoop is the
sound produced when breathing in after a paroxysm of coughing.
The bouts of coughing prevent normal breathing and the whoop
represents the desperate attempt to get a breath. Referral is necessary.
Associated symptoms
Cold, sore throat and catarrh may be associated with a cough. Often
there may be a temperature and generalised muscular aches present.
This would be in keeping with a viral infection and be self-limiting.
Chest pain, shortness of breath or wheezing are all indications for
referral
Postnasal drip
Postnasal drip is a common cause of coughing and may be due to
sinusitis
Previous history
Certain cough remedies are best avoided in diabetics and anyone with
heart disease or hypertension
Chronic bronchitis
Questioning may reveal a history of chronic bronchitis, which is being
treated by the doctor with antibiotics. In this situation further treatment
may be possible with an appropriate cough medicine.
Asthma
A recurrent night-time cough can indicate asthma, especially in
children, and should be referred. Asthma may sometimes present as
a chronic cough without wheezing. A family history of eczema, hay
fever and asthma is worth asking about. Patients with such a family
history appear to be more prone to extended episodes of coughing
following a simple URTI.
Cardiovascular
Coughing can be a symptom of heart failure (see p. 60). If there is
a history of heart disease, especially with a persisting cough, then
referral is advisable.
Gastro-oesophageal
Gastro-oesophageal reflux can cause coughing. Sometimes such reflux
is asymptomatic apart from coughing. Some patients are aware of acid
coming up into their throat at night when they are in bed.
Smoking habit
Smoking will exacerbate a cough and can cause coughing since it is
irritating to the lungs. One in three long-term smokers develop a
chronic cough. If coughing is recurrent and persistent, the pharmacist
is in a good position to offer health education advice about the
benefits of stopping smoking, suggesting NRT where appropriate.
However, on stopping, the cough may initially become worse as the
cleaning action of the cilia is re-established during the first few days
and it is worth mentioning this. Smokers may assume their cough is
harmless, and it is always important to ask about any change in the
nature of the cough that might suggest a serious cause.
Present medication
It is always essential to establish which medicines are currently being
taken. This includes those prescribed by a doctor and any bought
OTC, borrowed from a friend or neighbour or rediscovered in the
family medicine chest. It is important to remember the possibility of
interactions with cough medicine.
It is also useful to know which cough medicines have been
tried already. The pharmacist may decide that an inappropriate
preparation has been taken, e.g. a cough suppressant for a productive
cough. If one or more appropriate remedies have been tried
for an appropriate length of time without success, then referral is
advisable.
Angiotensin-converting enzyme (ACE) inhibitors
Chronic coughing may occur in patients, particularly women,
taking ACE inhibitors such as enalapril, captopril, lisinopril and
ramipril. Patients may develop the cough within days of starting
treatment or after a period of a few weeks or even months. The
exact incidence of the reaction is not known and estimates vary
from 2% to 10% of patients taking ACE inhibitors. ACE inhibitors
control the breakdown of bradykinin and other kinins in the
lungs, which can trigger a cough. Typically the cough is irritating,
non-productive and persistent. Any ACE inhibitor may induce
coughing and there seems to be little advantage to be gained
in changing from one to another. The cough may resolve or may
persist; in some patients the cough is so troublesome and distressing
that ACE inhibitor therapy may have to be discontinued. Any patients
in whom medication is suspected as the cause of a cough should be
referred to their doctor. Angiotensin 2 receptor antagonists, which
have similar properties to ACE inhibitors and which do not affect
bradykinin, can be used as an alternative preparation if cough is
a problem.
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