Symptoms in the Pharmacy :Respiratory Problems (8)
Practical points
Diabeties
In short-term acute conditions the amount of sugar in cough medicines
is relatively unimportant. Diabetic control is often upset during infections
and the additional sugar is not now considered to be a major
problem. Nevertheless, many diabetic patients may prefer a sugar-free
intake for themselves and their children, and many such products
are now available. As part of their contribution to improving dental
health, pharmacists can ensure that they stock and display a range of
sugar-free medicines.
Steam inhalations
These can be useful, particularly in productive coughs. Some clinical
trials indicate benefit and none have found any harm. The steam helps
to liquefy lung secretions and patients find the warm moist air comforting.
While there is no evidence that the addition of medications to
the water produces a better clinical effect than steam alone, some may
prefer to add a preparation such as menthol and eucalyptus or a
proprietary inhalant. One teaspoonful of inhalant should be added
to a pint of hot (not boiling) water and the steam inhaled. Apart from
the risk of scalding, boiling water volatilises the constituents too
quickly. A cloth or towel can be put over the head to trap the steam.
Fluid intake
Maintaining a high fluid intake helps to hydrate the lungs and
hot drinks can have a soothing effect. General advice to patients
with coughs and colds should be to increase fluid intake by around
2 L a day.
Coughs in practice
Case 1
Mrs Patel, a woman in her early twenties, asks what you can recommend
for her son’s cough. On questioning you find out that her
son, Dillip, aged 4, has had a cough on and off for a few weeks. He
gets it at night and it is disturbing his sleep although he doesn’t seem
to be troubled during the day. She took Dillip to the doctor about
3 weeks ago, and the doctor explained that antibiotics were not
needed and that the cough would get better by itself. The cough is
not productive and she has given Dillip some Tixylix before he goes
to bed but the cough is no better. Dillip is not taking any other
medicines. He has no pain on breathing or shortness of breath. He
has had a cold recently.
The pharmacist’s view
This is a 4-year-old child who has a night-time cough of several weeks’
duration. The doctor’s advice was appropriate at the time Dillip saw
him. However, referral to the doctor would be advisable because the
cough is only present during the night. A recurrent cough in a child
at night can be a symptom of asthma, even if wheezing is not present.
It is possible that the cough is occurring as a result of bronchial
irritation following his recent viral URTI. Such a cough can last for
up to 6 weeks and is more likely to occur in those who have asthma or
a family history of atopy (a predisposition to sensitivity to certain
common allergens such as house dust mite, animal dander and pollen).
Nevertheless, the cough has been present for several weeks without
improvement and medical advice is needed.
The doctor’s view
Asthma is an obvious possibility. It would be interesting to know if
anyone else in the family suffers from asthma, hay fever or eczema and
whether Dillip has ever had hay fever or eczema. Any of these features
would make the diagnosis more likely. Mild asthma may present in
this way without the usual symptoms of shortness of breath and
wheezing.
An alternative diagnosis could still include a viral URTI. Most
coughs are more troublesome and certainly more obvious during the
night. This can falsely give the impression that the cough is only
nocturnal. It should also be remembered that both diagnoses could
be correct, as a viral infection often initiates an asthmatic reaction.
Because the diagnosis is uncertain and inhaled oral steroids may be
appropriate, referral to the doctor is advisable.
If, after further history-taking and examination, the doctor feels
that asthma is a possibility, then treatment would be based on the
British Thoracic Society guidelines, which are summarized in the BNF.
Naturally this would only be carried out after full discussion and
agreement with the parents. Many parents are loath to have their
child labeled as an asthma sufferer. The next problem is to prescribe
a suitable inhalation device for a 4-year-old child. This may be an
inhaler with a spacer device or a breath-actuated inhaler or a dry powder
inhaler. It would be usual to try a twice-daily dosage for 2–3
weeks and then review for future management.
The parent’s view
‘I was hoping the pharmacist could recommend something but she
seemed to think Dillip should see the doctor. She didn’t really explain
why though.’
Case 2
A man aged about 25 asks if you can recommend something for his
cough. He sounds as if he has a bad cold and looks a bit pale. You find
out that he has had the cough for a few days, with a blocked nose and
a sore throat. He has no pain on breathing or shortness of breath. The
cough was chesty to begin with but he tells you it is now tickly and
irritating. He has not tried any medicines and is not taking any
medicines from the doctor.
The pharmacist’s view
This patient has the symptoms of the common cold and none of
the danger signs associated with a cough that would make referral
necessary. He is not taking any medicines, so the choice of possible
treatments is wide. You could recommend something to treat his
congested nose as well as his cough, e.g. a cough suppressant and a
sympathomimetic. Simple Linctus and a systemic or topical decongestant
would also be a possible option. If a topical decongestant were
to be recommended, he should be warned to use it for no longer than
1 week to avoid the possibility of rebound congestion.
The doctor’s view
The action suggested by the pharmacist is very reasonable. It may be
worthwhile explaining that he is suffering from a viral infection that is
self-limiting and should be better within a few days. If he is a smoker it
would be an ideal time to encourage him to stop.
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