CHAPTER 22. COUGH
Jennifer Fournier
DEFINITION AND INCIDENCE
Cough is defined as an explosive expiratory maneuver that, under normal conditions, serves to protect the airways and lungs by clearing inhaled material, excessive mucus, and abnormal substances (Berkow & Fletcher, 1992; Canning, 2006; McCool, 2006). In certain disease states, cough can become excessive, nonproductive, distressing, and potentially harmful to the airway mucosa, and it can be a factor in the spread of infection (Irwin, Boulet, Cloutier et al., 1998; Leach, 2004). Cough is one of the most common symptoms for which the general population seeks medical attention (Beckles, Spiro, Colice et al., 2003; Estfan & LeGrand, 2004; Irwin et al., 1998; Irwin & Madison, 2001; Morice, Kastelik, & Thompson, 2001).
Advanced, progressive diseases that are frequently associated with cough include chronic pulmonary disease, lung cancer, congestive heart failure, and acquired immune deficiency syndrome. In addition, 3% to 35% of people taking angiotensin-converting enzyme (ACE) inhibitors are reported to have cough (Dicpinigaitis, 2006). Cough is also a symptom of other conditions for which patients with advanced illnesses are susceptible, such as the common cold and pneumonia. Few data are available regarding the frequency and severity of cough in the palliative care setting. One study of patients with chronic lung disease and lung cancer in the last year of life showed that 59% of these patients report cough and 46% state that the cough is very distressing (Edmonds, Karlsen, Kahn et al., 2001).
Because cough serves a protective function, an ineffective cough puts patients at risk for complications such as pneumonia and atelectasis (Leach, 2004). Patients with advanced diseases may have difficulty coughing productively due to cachexia and frailty (Estfan & LeGrand, 2004). Also, patients with weakened muscles due to neurological diseases such as cerebrovasular accident, amyotrophic lateral sclerosis, and multiple sclerosis are often not able to cough effectively.
ETIOLOGY AND PATHOPHYSIOLOGY
Pathophysiology
Involuntary cough is a complex process, and it involves the activation and interaction of several subtypes of vagal afferent nerves, including rapidly adapting receptors, mechanoreceptors, C-fibers, and the brainstem. The rapidly adapting receptors are most prevalent in the larynx, main carina, and branching points in the tracheobronchial tree and are activated by chemical (e.g., smoke), inflammatory (e.g., histamine), and mechanical (e.g., foreign body) stimuli, causing bronchospasm and mucus secretion. Bronchospasm and mucus secretion, in turn, stimulate the mechanoreceptors and C-fibers. The cough reflex is integrated in the brainstem where motor output to the larynx, bronchial tree, and respiratory muscles initiates the cough reflex (Canning, 2006; Dicpinigaitis, 2003; Dicpinigaitis & Gayle, 2003; Leach, 2004). An esophageal-tracheobronchial reflex (also mediated by vagal innervation) is thought to cause cough associated with gastroesophageal reflux disease (GERD) from acid reflux that triggers receptors in the lower esophagus (Irwin & Madison, 2001; Poe & Kallay, 2003).
Voluntary cough is mediated via the cortex. Patients can consciously induce cough to clear the airways (Leach, 2004). The ability to initiate cough is especially helpful for patients whose disease process impairs the spontaneous cough reflex.
The cough reflex initiates a deep inspiration (inspiration phase), followed by closure of the glottis and build-up of intrathoracic pressure (compressive phase). Then, the respiratory muscles contract against the closed glottis resulting in forceful expulsion of air and other material as the glottis opens (expiratory phase) (Estfan & LeGrand, 2004; McCool, 2006; Waller & Caroline, 2000).
Etiologies and Complications of Cough
There are multiple causes of cough (Table 22-1). Patients with a chronic cough and a normal chest radiograph, who do not smoke, and who are not receiving treatment with ACE inhibitors should be evaluated for upper airway cough syndrome (formerly called postnasal drip syndrome), asthma, nonasthmatic eosinophilic bronchitis, and/or GERD (Irwin, Baumann, Bolser et al., 2006). Aspiration caused by pharyngeal dysfunction is another potential cause of cough.
| ACE, Angiotensin-converting enzyme; COPD, chronic obstructive pulmonary disease; GERD, gastroesophageal reflux disease; UACS, upper airway cough syndrome (formerly postnasal drip syndrome). | ||
| Acute (< 3 wk) | Subacute (3 to 8 wk) | Chronic (> 8 wk) |
|---|---|---|
|
Upper respiratory tract infection (e.g., common cold, bacterial sinusitis)
Lower respiratory tract infection (e.g., bronchitis)
Pneumonia
Exacerbation of asthma, COPD, heart failure
Pulmonary emboli
Environmental irritant
|
Postinfectious:
Pneumonia
Pertussis
Bronchitis
New onset or exacerbation of UACS, asthma, GERD, chronic bronchitis
|
UACS
Asthma
Nonasthmatic eosinophilic bronchitis
GERD
Chronic bronchitis
Bronchiectasis
Nonbronchiectatic suppurative airway disease (bronchiolitis)
Lung tumors
ACE inhibitors
Smoking
Chronic interstitial lung disease
Aspiration
|
The pressures, velocities, and energy required to clear the airways put patients at risk for multiple complications (Box 22-1). Clinicians must be aware of the profound impact cough can have on quality of life and aggressively work to eliminate, or at least minimize, cough.
Box 22-1
• Cardiovascular: hypotension, arrhythmias
• Constitutional: sweating, anorexia, fatigue
• Gastrointestinal: gastroesophageal reflux, herniations
• Genitourinary: urinary incontinence
• Musculoskeletal: strain to rupture of rectus abdominus muscles, diaphragmatic rupture, rib fracture
• Neurological: cough syncope, dizziness, headache, stroke
• Ophthalmologic: rupture of subconjunctival veins
• Psychosocial: self-consciousness
• Respiratory: dyspnea, exacerbation of asthma, laryngeal or tracheobrachial trauma
• Skin: petechiae and purpura, disruption of surgical wounds
*Selected complications. For a more comprehensive listing, see the reference.
Data from Irwin, R.S. (2006). Complications of cough: ACCP evidence-based clinical practice guidelines. Chest, 129(Suppl 1), 54S-58S.
Emergent Conditions Associated with Cough
Superior vena cava (SVC) syndrome is an emergent condition that may present with cough along with dyspnea, hoarseness, dizziness, lethargy, blurred vision, dysphagia, and/or headache. Patients with lung cancer (especially small cell), lung metastasis, and lymphomas are at risk for this syndrome (Beckles et al., 2003). Physical examination may reveal facial and upper extremity edema, arm vein distention, and dilated collateral veins over chest wall, shoulders, and arms (Beckles et al., 2003; Storey & Knight, 2003). Cough can also be a symptom of cardiac tamponade. With this syndrome, cough is accompanied by chest pain, dyspnea, dizziness, orthopnea, and weakness. Patients with lung cancer, breast cancer, leukemia, and lymphoma are at highest risk for cardiac tamponade (Storey & Knight, 2003).
ASSESSMENT AND MEASUREMENT
Both subjective and objective measures should be used to evaluate cough. Subjective measures include patient diaries, visual analog scales, symptom distress scales (these usually measure multiple symptoms and may be disease specific), and general or cough-specific quality of life instruments (Irwin, 2006). Diaries require a motivated patient to maintain for any length of time. Visual analog scales are frequently used and, although they have not been psychometrically tested, they are recommended because they are commonly used and valid and they are likely to yield results that are different from but complementary to results of subjective instruments (Irwin, 2006).
There are three subjective instruments that have undergone extensive psychometric testing: breathlessness, cough, and sputum scale (BCSS), cough quality-of-life questionnaire (Dyspepsia Quality-of-Life Questionnaire [DQLQ]), and the Leicester Cough Questionnaire (LCQ). All three of these instruments use Likert-type scales for patient evaluation; the BCSS has 3 items, the DQLQ has 28 items, and the LCQ has 19 items (French, Irwin, Fletcher et al., 2002; Irwin, 2006). There are several disease-specific scales that include measurement of cough. Most of these have not been as extensively studied but have shown good reliability and validity in small studies. For example, the Lung Cancer Cough Questionnaire (LCCQ) and the Lung Cancer Wheezing Questionnaire (LCWQ) were used in a pilot study to measure these symptoms in patients with lung cancer (Chernecky, Sarna, & Waller, 2004). Use of one of these rating scales may assist clinicians with monitoring cough over time and with evaluating treatment.
Objective measures of cough used in palliative care settings most often involve clinician evaluation of frequency, character, and sputum production. More precise measures that may be used by a consulting pulmonologist for difficult-to-control cough include 24-hour counts of coughing either with an observer (labor intensive) or a monitoring device, use of pharmacological tussigenic challenges to assess the effect of therapy on cough, comparison of airway inflammation indexes in induced sputum samples, and comparison of exhaled nitric oxide levels (Irwin, 2006).
HISTORY AND PHYSICAL EXAMINATION
The etiology of a cough can be determined in 80% of patients with advanced progressive illnesses by a thorough history and physical examination (Waller & Caroline, 2000).
General History
▪ Primary disease and any association between this disease and cough, such as chronic pulmonary obstructive disease (COPD) or lung cancer
▪ Comorbidities, such as GERD, cerebrovasular accident, pulmonary conditions, cardiac conditions, or asthma
▪ Allergies, such as to medications, foods, pets, dust, pollen, or mold
▪ Smoking history, measured in years multiplied by packs per day
▪ Exposures to substances or infections that may affect the respiratory system, such as asbestos, chemical exposure at work, second-hand smoke, or people with respiratory infections
▪ Past surgeries, such as thoracic, thyroid, or esophageal operations
▪ Chemotherapy exposure, including class of drug, dose, and length of treatment
▪ Radiation therapy, including site, length of treatment, and time since treatment
▪ Current medications, noting any recent changes in medications or use of ACE inhibitors
▪ Recent changes in weight, appetite, sleep, voice, activity tolerance, or energy level
Cough Evaluation
▪ Character of cough, such as barking, hacking, brassy, honking, dry, wet, paroxysmal, frequency, intensity
▪ Sputum production, including onset, color, volume, tenacity, and any changes over time
▪ Pain related to cough, including location, severity, and management
▪ Alleviating factors, including rest, positioning, and medications
▪ Influence of positioning (lying, upright) on cough
▪ Temporal patterns, such as constant, nocturnal, only during day, or variable
▪ Effect of cough on quality of life
Physical Examination
▪ Overall appearance
▪ Level of anxiety
▪ Vital signs, especially respiratory rate and depth, and the presence of fever
▪ Skin color (ashen, flushed, pink, cyanotic) and character (cool, hot, diaphoretic, presence of edema or finger clubbing)
▪ Breath sounds: wheezing, rales, rhonchi, crackles, pleural friction rubs, diminished, or absent. Begin and end auscultation at the lung bases to detect atelectasis that may clear with full inspiration (Berry, 2002).
▪ Upper airways: nasal drainage, throat irritation, or sinus congestion
▪ Neck: vein distention, deviated trachea, edema, masses, or enlarged lymph nodes
▪ Chest: shape, vein distention, accessory muscles, retractions, or abnormal percussion sounds
▪ Abdomen: distention, masses, enlarged organs, tenderness, or abnormal sounds
DIAGNOSTICS
Diagnostic studies are used when the etiology is not evident based on the history and physical examination, when empiric interventions for the presumed etiology fail, or when a precise diagnosis will change the planned course of treatment. The clinician must always evaluate the potential benefits and burdens of diagnostic tests.
Chest radiograph is the primary diagnostic tool when the history and physical examination do not clearly define the reason for cough. A chest radiograph is helpful to identify cough-associated problems such as pulmonary malignancy, pneumonia, pulmonary effusion, SVC syndrome, cardiomegaly or congestive heart failure, and cardiac tamponade. Other potential diagnostic procedures to evaluate cough include the following (Estfan & LeGrand, 2004; Irwin et al., 2006; Irwin & Madison, 2001; Martinez-Garcia, Perpina-Tordera, Roman-Sanchez et al., 2005; Olson, 2001; Poe & Kallay, 2003; Saad, Marrouche, Saad et al., 2003; Storey & Knight, 2003; Waller & Caroline, 2000):
▪ Echocardiogram to assist in diagnosing cardiac tamponade and left heart failure
▪ Computed tomography scanning to detect bronchiectasis, tumors, or pulmonary vein stenosis
▪ Barium swallow to observe for fistulas, aspiration, or reflux; bedside swallow to detect dysphagia; and spirometry to detect asthma
▪ Methacholine challenge test for bronchial hyperreactivity to diagnose asthma
▪ Empiric treatment with a proton-pump inhibitor to “diagnose” GERD. (This is more cost-effective, easily tolerated, and readily available than a 24-hour ambulatory esophageal pH monitoring test [Poe & Kallay, 2003].)
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Hospital Core Measures for community-acquired pneumonia requires that blood cultures be drawn before initiating antibiotics for patients hospitalized for pneumonia (JCAHO, 2002). This requirement remains somewhat controversial because, although there is evidence to suggest that those who have blood cultures drawn before antibiotics have a lower mortality, there is no good evidence that it is the act of drawing a blood sample that improves outcomes (Barlow, Lamping, Davey et al., 2003). For patients in palliative care settings, the benefits of blood cultures in determining a course of treatment must be balanced with the burdens of the discomfort and costs associated with blood cultures.
The presence or absence of sputum, characteristics of the sputum, and symptoms associated with the cough may assist in determining its cause (Table 22-2). Bronchitis, pneumonia, and heart failure tend to lead to a productive cough. Coughs due to bronchospasm, pleural effusion, or ACE inhibitors are usually nonproductive. Although the color of the sputum may provide a hint as to cause of the cough, sputum color is due to the concentration of cellular debris, predominantly white cells, present in any inflammatory condition, and is not necessarily indicative of bacterial infection (Slovis & Brigham, 2004). The role of sputum culture and sensitivity in the evaluation of pneumonia is controversial. Some guidelines suggest extensive etiologic testing in all patients, and others recommend sputum studies only if a drug-resistant pathogen is suspected (Pimentel & McPherson, 2003). Sputum cultures are recommended for diagnosis and monitoring of tuberculosis (Irwin et al., 2006).
| Cause | Character of Cough | Sputum | Associated Symptoms |
|---|---|---|---|
| ACE inhibitor-induced | Dry, hacking | Tickling or scratchy sensation in throat | |
| Asthma | Dry, hacking; made worse by cold air, exercise, laughing, allergy exposure; cough may be worse at night | May have thick mucoid sputum, especially at end of an attack; brown plugs may indicate aspergillosis | Episodic wheezing and dyspnea |
| Bronchitis | Productive cough | Mucopurulent; may develop hemoptysis | |
| Bronchiectasis | May initially be dry, but eventually productive of large amounts of sputum | Mucopurulent; may be blood streaked | Breath may have a fetid odor |
| Cancer | Dry to productive | Hemoptysis is common (frank blood or streaked) | |
| CHF | Often dry, may be worse at night | May progress to frothy pink sputum if pulmonary edema | Dyspnea on exertion or orthopnea |
| GERD | Cough worse at night or early in the morning | Substernal burning, indigestion, regurgitation, early morning hoarseness, choking bitter taste in mouth | |
| Laryngitis | Dry, hacking | Hoarseness | |
| Postinfection | Dry | Cough lasting 3-8 wk after an acute respiratory infection | |
| Postnasal drip | Productive | Mucoid or mucopurulent | Tickle in throat, frequent clearing of throat |
| Pneumonia, viral | Dry, hacking |
High fever, chills, malaise, headache, dyspnea; develops 1-2 days after flu-like symptoms
At risk for superimposed bacterial pneumonia
|
|
| Pneumonia, bacterial | Productive | Mucoid or purulent: | High fever, chills, dyspnea, pleuritic chest pain; often preceded by upper respiratory tract illness |
| Streptococcus pneumoniae—rusty or yellow; may be blood streaked | |||
| Klebsiella—sticky, red, and gelatinous (common in chronic alcoholism) | |||
| Tuberculosis | Productive | May develop hemoptysis | Weight loss |
INTERVENTION AND TREATMENT
Treating the Cause
The underlying cause of cough should be treated when possible and when the treatment of the underlying cause will improve quality of living. For example, antibiotics for pneumonia are important to treat the discomforts of cough, dyspnea, and fever as well as to preserve life. In situations when treating pneumonia will not improve quality of living, a decision (in consultation with the patient, family, and interdisciplinary team) may be made to provide aggressive symptom management but not antibiotics.
Pharmacological Treatment
Cough serves a protective mechanism and should not be suppressed unless it is excessive, interferes with sleep and rest, causes discomfort, or otherwise interferes with quality of living. Cough can be triggered by more than one cause and therefore may require more than one treatment at a time (Estfan & LeGrand, 2004; Hanak, Hartman, & Ryu, 2005; Irwin & Madison, 2001). Consider maximal pharmacological treatment to bring the quickest and most complete response (Irwin & Madison, 2000).
Table 22-3 identifies the initial pharmacological treatments for cough due to several different causes based on evidence-based clinical practice guidelines from the American College of Chest Physicians. These should be used as the first-line therapies for these conditions.
| ACE, Angiotensin-converting enzyme; GERD, gastroesophageal reflux disease. | ||
| *All example medications show efficacy versus placebo for ACE inhibitor–induced cough. |
||
| †Routine antibiotics are not recommended for acute bronchitis. |
||
| ‡Prophylactic antibiotics are not recommended for chronic bronchitis. |
||
| §Formerly called postnasal drip syndrome. |
||
| Data from Irwin, R.S., Baumann, M.H., Boulet, LP., et al. (2006). Diagnosis and management of cough executive summary. ACCP evidence-based clinical practice guidelines. Chest, 129(Suppl 1), 1S-23S. | ||
| Cause of Cough | Initial Pharmacological Treatments | Examples |
|---|---|---|
| ACE inhibitor–induced cough | Discontinue ACE inhibitor, if possible; may repeat trial at a later date | Theophylline* |
| Sulindac | ||
| Indomethacin | ||
| Agents of various mechanism to suppress cough if cessation of ACE inhibitor not an option | Amlodipine | |
| Nifedipine | ||
| Ferrous sulfate | ||
| Asthma | Inhaled bronchodilator + inhaled corticosteroid | Albuterol |
| Beclomethazone dipropionate | ||
| Bronchiectasis | Bronchodilator | Albuterol or ipratropium bromide |
| Bronchitis, acute† |
Antitussive medication
β 2-Agonist bronchodilator (if wheezing)
|
Dextromethorphan |
| Albuterol | ||
| Bronchitis, chronic |
Antibiotics only in presence of an acute exacerbation‡
β 2-Agonist bronchodilator and/or anticholinergic bronchodilator
|
Albuterol |
| Ipratropium bromide | ||
| Bronchitis, nonasthmatic eosinophilic | Inhaled corticosteroid | Beclomethazone dipropionate |
| Bronchodilator | Albuterol or ipratopium bromide | |
| Chronic upper airway congestion syndrome§ | Antihistamine + decongestant | Brompheniramine |
| Pseudoephedrine | ||
| Common cold | Antihistamine + decongestant ± antiinflammatory | Brompheniramine |
| Pseudoephedrine | ||
| Naproxen | ||
| GERD | Proton pump inhibitor and/or H 2 antihistamine ± prokinetic | Omeprazole |
| Famotidine | ||
| Metoclopramide | ||
| Lung tumors | Centrally acting cough suppressant | Dihydrocodeine or hydrocodone |
| Postinfectious cough | Bronchodilator | Ipratopium |
Additional medications that may be used to suppress cough include the following:
▪ Guaifenesin, 200 to 400 mg every 4 hours, not to exceed 2400 mg/day, inhibits cough reflex sensitivity in patients with temporary hypersensitive cough receptors by increasing sputum production and decreasing viscosity. It should not be used in patients already suffering from increased secretions or ACE inhibitor cough (Dicpinigaitis & Gayle, 2003; Wynne, et al. 2002).
▪ Hydrocodone (5 to 10 mg orally every 4 to 6 hours), codeine (10 to 20 mg orally every 4 to 6 hours), and dextromethorphan (10 to 30 mg orally every 4 hours, maximum 120 mg/day) are centrally acting antitussives (Estfan & LeGrand, 2004; Waller & Caroline, 2000; Wynne et al., 2002). Antitussives should not be used for chronic coughs related to asthma or emphysema because they will raise airway resistance (Dicpinigaitis & Gayle, 2003).
▪ Benzonatate, 100 mg orally every 8 hours (may increase to every 4 hours, maximum dose 600 mg/day), deadens the afferent stretch receptor sites in the airways. Side effects may include gastrointestinal upset, sleepiness, pruritus, dizziness, rash, headache, and constipation (Estfan & LeGrand, 2004; Wynne et al., 2002).
▪ Lidocaine, 1 to 2 ml of 1% to 2% solution via a nebulizer up to four times a day, is reported to be effective when other measures fail, but there are no controlled clinical trials to support the use of this intervention. Patients must not take anything by mouth for 1 hour post–nebulized lidocaine, to prevent aspiration.
▪ Prednisone, 40 to 60 mg/day orally, 10 to 14 days and then slowly tapered to the lowest dose or dexamethasone 4 mg/day orally may decrease inflammation, reduce bronchospasm, or reduce edema (Storey & Knight, 2003; Waller & Caroline, 2000; Wynne et al., 2002).
For thick secretions that are difficult to expectorate, albuterol 0.5 ml in 2.5 ml of saline via nebulizer helps to loosen secretions (Waller & Caroline, 2000). Adequate fluid intake also helps to lessen the viscosity of secretions.
An anticholinergic, such as hyoscyamine, 0.125 to 0.25 mg sublingually every 4 to 6 hours as needed, or glycopyrrolate, 1 to 2 mg orally two or three times daily or 0.1 to 0.2 mg intravenously every 4 to 6 hours as needed, may decrease cough and secretions due to aspiration and at end-of-life (Estfan & LeGrand, 2004; Kee & Hayes, 2003; Waller & Caroline, 2000). Symptoms of cardiac tamponade can be managed with analgesics, anxiolytics, and oxygen when patients are nearing the end of life. Steroids may be helpful in reducing the edema of SVC syndrome (Storey & Knight, 2003).
Nonpharmacological Treatment
Physiotherapy and Breathing Techniques
▪ Encourage an effective cough in patients who have difficulty raising secretions. Have the patient sit upright, take a deep breath and hold it for 2 to 3 seconds, and then cough.
▪ Manually or mechanically assisted cough may reduce respiratory complications in patients with neuromuscular diseases and expiratory muscle weakness (McCool & Rosen, 2006). Consult a respiratory or physical therapist. Avoid using this technique in patients with airflow obstruction, such as those with COPD.
▪ Expiratory muscle training may be helpful to people with neuromuscular weakness (McCool & Rosen, 2006).
▪ Huffing may assist patients with COPD and cystic fibrosis to clear sputum (McCool & Rosen, 2006).
Interventional Therapies
▪ Radiation therapy can be effective in relieving tumor-induced cough in patients who have an expected prognosis that is sufficiently long (Storey & Knight, 2003). Short-course radiotherapy (one or two fractions) has been shown to be effective in decreasing symptoms in non–small-cell lung cancer patients. Longer courses should be reserved for patients with good performance status and longer life expectancy (Macbeth, Toy, Coles et al., 2001).
▪ Thoracentesis followed by pleurodesis or use of an indwelling pleural drainage catheter (e.g., Pleurx) relieves cough and dyspnea associated with malignant pleural effusions. Talc, bleomycin, and doxycycline are the most commonly used chemical sclerosing agents (Covey, 2005).
▪ Pericardiocentesis can provide quick relief of symptoms of cardiac tamponade, when appropriate, based on expected prognosis. Pericardial window with drainage and sclerosis can prevent recurrence in the patient who is a good surgical candidate (Storey & Knight, 2003).
Lifestyle Changes
▪ Smoking cessation, even after lung cancer diagnosis, decreases cough over time. Be aware that cough may temporarily increase after quitting due to the return of cilial action and the ability to expectorate toxins from the lungs (Brunton, Carmichael, Colgan et al., 2004; Dweik, 2002; Garces, Yang, Parkinson et al., 2004; Wynne et al., 2002). Clinicians should provide smoking cessation support and guidance and discuss the use of medications to lessen the effects of nicotine withdrawal.
▪ Patients with GERD should follow an antireflux diet that includes no more than 45 grams of fat per day and no coffee, tea, soda, chocolate, mints, citrus products, or alcohol. They should also stop smoking and limit vigorous exercise that increases intraabdominal pressure (McCool & Rosen, 2006).
▪ Care should be taken with feeding the patient with dysphagia. The patient should be well rested before meals. Place the patient in a high-Fowler’s position while eating and maintain a semi-Fowler’s position for 30 minutes after meals. Keep suction equipment within reach and be prepared to perform a Heimlich maneuver. A dietary consult may be helpful to provide instruction on foods and liquids that are less likely to be aspirated by patients with dysphagia, such as thickened beverages.
PATIENT AND FAMILY EDUCATION
Patients need to be reminded that cough is a protective mechanism and should not be suppressed without careful consideration and that self-treatment for cough should not exceed 1 week without seeking professional advice. Encourage patients and caregivers to discuss alternative or home remedies for cough with the clinician before starting these therapies so that they can be evaluated for any potentially harmful consequences or side effects. Instruct patients and caregivers on the proper use of medications and other interventions.
When appropriate, teach patients to keep a cough diary or to use a visual analog scale to rate the severity and frequency of cough as a means to monitor the effectiveness of interventions. Encourage the patient to notify the clinician if the interventions are not effective, if the patient is experiencing any untoward effects, or if the patient develops a fever or worsening of cough.
Teach patients and caregivers to wash hands frequently, to avoid people with infectious respiratory symptoms, and to get an annual influenza vaccine. Remind patients to cover their mouth and nose when coughing and to promptly wash hands afterward.
Encourage patients to take in adequate fluids to keep secretions loose. If the patient has a chronic cough related to GERD, provide verbal and written instructions about appropriate dietary recommendations.
Instruct patients and caregivers on the benefits of smoking cessation and the appropriate use of medications to prevent nicotine withdrawal.
EVALUATION AND PLAN FOR FOLLOW-UP
The most important measure of the success of treatment for cough is the patient’s subjective evaluation. The use of visual analog scales to rate severity and frequency of cough assists in evaluating the effectiveness of interventions over time. The goal is to maximize patient comfort while promoting optimal respiratory functioning.
Mr. T., a 72-year-old man with stage IV lung cancer, was admitted to hospice home care when his oncologist sadly informed him that the chemotherapy was doing more harm than good and that there was no more curative treatment available. One week later, he arrived at the hospice inpatient unit alert and experiencing cough, dyspnea on exertion, and heightened anxiety. He is accompanied by Mrs. T. and their three grown children.
The interdisciplinary team works with Mr. T. to manage his anxiety and dyspnea with lorazepam and his cough with hydrocodone syrup. Two days after admission, the nursing assistant reports to the advanced practice nurse that Mr. T.’s voice sounded hoarse after his morning bath and that he was coughing more and his face looks a little swollen. Further examination shows distended neck veins, facial and bilateral upper extremity edema, and a worsening cough. A clinical diagnosis of superior vena cava syndrome is made based on these symptoms. After consultation with Mr. T. and his family, a radiation therapy consult is obtained and two radiation treatments are ordered to begin immediately. The clinician also orders dexamethasone 4 mg orally every day. Two days after radiation therapy, Mr. T.’s symptoms of superior vena cava syndrome are subsiding and he reports less cough, dyspnea, and anxiety. Mr. T. is discharged back home, where the home care staff would assume the care of Mr. T. and his family.
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