Cough

KEYPOINTS

• Cough may be related to the disease, the treatment or may be unrelated
• Cough can be a distressing symptom for the patient and interfere with sleep
• Using cough suppressants (e.g. codeine, morphine) can bring symptomatic relief and improve quality of life

• Coughing can be very exhausting for both the child and the family

ASSESSMENT

(see Foreword)

• A good clinical assessment is important to try and identify the underlying cause of the cough (e.g. pneumonia, CHF, pleural effusion, asthma, etc.)
• Investigations to consider may include
  • Chest x-ray to assess possible cause

MANAGEMENT

• Consider treatment of the underlying cause (e.g. oncological treatment of tumour, draining of pleural effusion, treatment of infection, gastroreflux disease)

Consider if patient is well enough to benefit

• Simple measures such as moist inhalations or nebulized 0.9% saline can be helpful
• Simple cough suppressant may be tried
• A weak opioid such as codeine 15-30 mg q4h PO or dextromethorphan 30 mg (or higher doses) q4h PO can be used to suppress cough
• Morphine should be used if the cough is not suppressed by codeine or other means. The initial starting dose will depend on the patient’s previous exposure to opioids
  • A dose of morphine 2.5 mg regularly q4h PO (or 1 to 2 mg SC/IV) and a breakthrough or rescue dose every hour, as required (see Breakthrough or Rescue Doses of Morphine) is suitable for an opioid-naive patient
  • A dose of morphine 5-10 mg regularly q4h PO (or 2.5 - 5 mg q4h SC/IV) and a breakthrough or rescue dose every hour, as required (see Breakthrough or Rescue Doses of Morphine) should be used for patients who have already been on codeine
  • For a patient already on morphine an increase in the dose by 20% may improve the cough
• Also consider a trial of dexamethasone 8 mg qAM PO
• Inhaled corticosteroids or sodium cromoglycate may be helpful
• For refractory symptoms consider nebulized local anaesthetics such as lignocaine/lidocaine 5 ml of 2% solution (without adrenaline) prn
• If tenacious secretions are difficult to clear with coughing:
  • Consider using moist inhalations
  • Nebulized hypertonic saline can be effective
  • Try normal saline if this is not available

• Children with persistent non productive cough (like adults) will benefit from opioids
• Codeine
  • Children more than 6 months: 0.5-1.0 mg/kg q4h PO (max 60 mg/dose)
• Morphine
  • Starting doses for opioid naïve infants less than 6 months: 0.01 mg/kg q4h SC/IV, or 0.02 mg/kg q4h PO
  • Starting dose for opioid naïve infants/children more than 6 months: 0.02 mg/kg q4h SC/IV or 0.04 mg/kg q4h PO

PITFALLS/CONCERNS

In patients in the final terminal phase, i.e. hours to days, antibiotics will make little difference to the course of events

PALLIATIVE TIPS

• A bedtime dose of codeine or morphine can help suppress the cough and allow for an undisturbed sleep

SOURCES/REFERENCES

1. Donaldson SH, Bennett WD, Zeman KL, Knowles MR, Tarran R, Boucher RC. Mucus clearance and lung function in cystic fibrosis with hypertonic saline. N Engl J Med 2006;354(3):241-250. http://www.ncbi.nlm.nih.gov/pubmed/16421365
2. Dudgeon DJ. Managing dyspnea and cough. Hematology-Oncology Clinics of North America 2002;16(3):557-577. http://www.hemonc.theclinics.com/issues/contents?issue_key=S0889-8588(00)X0003-2
3. Muers MF, Round CE. Palliation of symptoms in non-small cell lung cancer: a study by the Yorkshire Regional Cancer Organisation Thoracic Group. Thorax 1993;48(4):339-343. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=464429
4. NHS Clinical Knowledge Summaries. Palliative cancer care – cough - management. [Online]. Available from: URL:http://cks.library.nhs.uk
5. Twycross R. Palliative care formulary. 2nd ed. Oxford:Radcliffe Publishing; 2002. p. 59-61.

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