Cough

Question 1

Classification of Coughs:

Answer 1

-Acute: < 3 weeks; <4 weeks for children
Viral, upper respiratory tract infection, some asthma

-Subacute: 3-8 weeks
Post-infectious, pertussis (whooping cough), bacterial sinusitis, some asthma

-Chronic: >8 weeks, > 4 weeks for children
Drug-induced, cancer-induced, GERD, COPD, smoking, some asthma

Question 2

Purpose and characteristics of Productive cough:

Answer 2

-To expel mucus from the lungs -> wet, chesty
Effective (excretions are expelled), Ineffective (hard to expel excretions)

Question 3

Purpose and characteristics of Non-productive cough

Answer 3

-no physiologic purpose. AKA dry, hacking
-Due to infections, gastroesophageal reflux disease (GERD), medications, and more

Question 4

Complications of Cough

Answer 4

• Exhaustion
• Insomnia -> disturbing others at work or can’t sleep
• Pain
• Hoarseness
• Incontinence -> hint: crossing legs when coughing
• Rib fractures (rare)
• Dysrhythmias (rare)
• Stroke (rare)

Question 5

Patient case: What might cause a Cough other than an infection?

Answer 5

Unresolved GERD, or ACE Inhibitors

Question 6

What is an indicator for ACE Inhibitor-induced Cough?

Answer 6

-Dry, unproductive cough that is persistent and often worse at night
-might be due to the accumulation of bradykinin
-often when starting ACE therapy or dose change
-LISINOPRIL

Question 7

Nonpharmacologic Treatments for Coughs?

Answer 7

-Humidified air
-Lozenges
-Elevate head during sleep
-Stay hydrated

Question 8

Pharmacologic Treatments for Coughs?

Answer 8

-Expectorants
-Antitussives
-Dietary Supplements

Question 9

How do Expectorants work?

Answer 9

-Increase mucin secretion and mucus hydration -> larger volume of mucus -> easier to expel via cough
-API: Guaifenesin, potassium citrate

Question 10

How do Mycolytics work?

Answer 10

-Reduces viscosity of mucus by dissociating the disulfide bonds in mucin

-API: N-acetylcysteine, carbocystein

Question 11

What are the common Non-prescribed Oral Antitussives and Expectorants?

Answer 11

-Codeine, Dextrometorphan, Diphenhydramine (1st Gen), Guaifenesin
-not for kids under age of 2

Question 12

Guaifenesin (Expectorant):

Answer 12

-API of Robitussin and Mucinex
-loosen mucus, and make coughs more productive
-to treat CHEST CONGESTION
-no drug interactions
-not for pregnant women

-take with a glass full of water

Question 13

Doses for Guaifenesin:

Answer 13

12y and older: 200-400mg orally every four hours
6-12y: 100-200mg orally every 4 hours
4-6 y: 100mg every 4 hours
2-4 y: 50-100mg every 4 hours

max dose: adults: 2400mg a day -> 6-12y: 1200mg -> 2-6y: 600mg

Question 14

Who should not be treated with Guaifenesin?

Answer 14

-Patients with a cough that occurs with too much mucus
-patients with asthma bc increased mucus due to Guaifenesin increasing congestion of the airways

Question 15

What are the Antitussives?

Answer 15

-Dextromethorphan (Delsym, DM)
-Codeine (Cheratussin AC)
-Diphenhydramine (Benadryl) -> 1 st Gen Antihistamine

Question 16

Example of a 1st Gen Antihistamine:

Antitussives

Answer 16

-Benadryl
-active ingredient: Diphenhydramine hydrochloride

-it treats runny nose, and itchy nose -> used to prevent congestion to go down the throat, which causes the cough

Question 17

What are the Antitussives?

Answer 17

Try Benadryl, bc it prevents congestion to go down the throat (post-nasal drip)

Question 18

To which patients would Antihistamines be avoided to dispense?

Answer 18

-Breathing problems
-Glaucoma
-Trouble urinating due to enlarged prostate
-Generally older patients

-Side effects: drowsiness, Dizziness, Disturbed coordination, anticholinergic effects

Question 19

Doses of Benadryl:

Answer 19

Adults 12 years and older -> 25-50mg Q 4-6 hours
Children 6-12 years -> 12.5-25mg Q 4-6 hours

max dose: adults: 300mg, 6 and older: 150mg

Question 20

How does Dextromethorphan (f.e. Delsym) work?

Antitussives

Answer 20

-Works centrally (in the medulla oblongata) to elevate the
threshold for coughing
-Treats nonproductive coughs
-Coughs with irritation to the respiratory tract

-Case where patients with productive cough are treated with Antitussive (for non-productive cough) -> when they can’t sleep, but only used for the night for them to sleep

Question 21

Dextromethorphan polistirex (long-acting)
Dextromethorphan hydrobromide (short-acting)

Answer 21

-Delysm
-Cough due to minor throat and bronchial irritation, Impulse to cough to help you sleep

-Should not be used with MAOI drugs
-Serotonin syndrome: too much Serotonin -> often caused by 4-5 meds (not an issue with Dextromethorphan alone)
-not allowed for people under 18 - the risk of abuse (get high at very high dose - bottle-wise)

Question 22

What are the symptoms of Serotonin Syndrome?

Answer 22

– Clonus (repeated muscular spasms)
– Overresponsive reflexes
– Mild fever
– Hypertension
– Tachycardia

mild to life-threatening and occur shortly after serotonergic load (drug interaction)

Question 23

How does Codeine work?

Answer 23

-works centrally (in the medulla oblongata) to elevate the
the threshold for coughing -> so sight effects like drowsiness, dizziness

-best OTC product for nonproductive coughs (opioid)

-schedule C-V

Question 24

Codeine phosphate (usually with guaifenesin)

Answer 24

-Brand name: Cheratussin AC
-helps with non-productive cough, should be used short-term (a couple of weeks)

-Side effects:
-drowsiness
-Constipation
–Respiratory depression
–Dizziness
–Hypotension

Question 25

Which patients should NOT get Codeine?

Answer 25

-Ultra-rapid metabolizers of codeine experience a 45% higher median plasma morphine concentration -> it is metabolized by CYP2D6 to morphine -COPD or shortness of breath

Question 26

Why is Codeine available OTC?

Answer 26

-one or more non-codeine products have to be included to be sold OTC -Limits to 200mg codeine per 100mL

Question 27

When can Honey be used?

Answer 27

-Most of the time, but not under the age of 1 -> bc of the risk of agricultural pesticides or Clostridium botulinum spores -May increase salivation, and Calm sensory nerves -antibacterial or anti-inflammatory effects Adverse Effects ?? – Gastrointestinal upset – Nervousness – Insomnia

Question 28

How to treat a young adult with a dry cough mostly at night when laying down?

Answer 28

-The cough could be caused by an allergy -> congestant goes down the throat when laying down -Benadryl (1st gen antihistamine) -> 25-50mg q4-6h for 2 nights and see if it improves -CAUTION: Glaucoma, prostate enlargement, breathing problems -> he is young so no worries

Question 29

CHEST guidelines:

Answer 29

-For adults and pediatrics only use OTC cough and cold meds unless they are shown to make cough less severe -for adults only use NSAIDS for cough unless shown that it makes cough less severe -for pediatrics (1-18y) with cough honey is better than no treatment and better than diphenhydramine, or placebo, but not better than dextromethorphan -for pediatrics with cough avoid using codeine-containing medications bc of the side effects (respiratory distress)

Question 30

When would a combination product of Guaifenesin and Dextromethorphan be considered?

Answer 30

Guaifenesin (for productive cough) Dextromethorphan (non-productive, stops coughing) -> for patients that have productive cough during the day, and cant sleep at night

Question 31

What is the risk when taking Antitussives and antidepressants?

Answer 31

-Serotonin syndrome -intensify the side effects of antidepressants

Question 32

Matching Symptoms with active ingredients:

Answer 32

Night time relief: would rather have 1st Gen Antihistamine bc it makes drowsy (so not in the daytime product) -minor aches, pain, and fever: Acetaminophen (Tylenol) -nasal congestion and sinus pressure: Phenylephrine or Pseudoephedrine -sneezing and runny nose: allergy -> Antihastiamine - Diphenhydramine (Benadryl) -Cough: Dextromethorphan (night) or Guaifenesin -Chest congestion: Guaifenesin (loosens mucus and bronchial secretion), could also be Phenylephrine

Question 33

When would we use 1st Gen Antihistamine?

Answer 33

Non-productive cough, congestion at the back of the throat -> related to viral infection in the upper respiratory tract -counsel on drowsiness -Adult dose: 25-50mg q4-6h

Question 34

When to use Codeine and Dextromethorphan?

Answer 34

Dry and non-productive cough, upper respiratory infection -Codeine: for 18 and older, careful with metabolizers, COPD or shortness of breath; dizziness -Dextromethorphan: not with MAOI drugs, serotonin syndrome, drowsiness, some states only over 18