12/2/2010
symptoms of
Drug Used for Cough
cough
2 functions:

expel foreign material

remove excess secretions
4 stimuli:

chemical (tobacco smoke)

mechanical (vascular ring)

thermal (cold, dry air)

inflammatory
respiratory disease

cough

sputum (“phlegm”)

haemoptysis (coughing blood)

dyspnoea (breathlessness)

chest pain (pleuritic)

wheeze

stridor
four ways to look at cough

A defense mechanism that helps clear
excessive secretions and foreign material
from airways

A symptom of a pathologic condition or
process

A means of spreading infection

A form of cardiopulmonary resuscitation in a
patient with potentially lethal cardiac
arrhythmia
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symptom characteristics sputum

Cough Sputum
infection/pneumonia

– harsh, dry – volume
– paroxysmal – thick, tenacious thick, green, brown
– loose, productive – thin and watery
– frothy
allergies/inflammatory
– short and – blood stained
suppressed by yellow, pale grey
– mucoid
pain (grey, white, clear)
pulmonary edema
– purulent
(yellow, green) pink, frothy

etiologies of cough Two Basic Types of Cough

acute cough chronic cough
• common cold • postnasal drip
• Productive cough
• acute bacterial sinusitis, syndrome (PNDS),
• pertussis, • asthma, and – Congested, removes excessive secretions
• exacerbations of COPD, • gastroesophageal reflux
• allergic rhinitis and disease (GERD)
asthma; • Nonproductive cough
• less commonly, acute • ACE-inhibitors
cough also can be – Dry cough
associated with serious
conditions such as
– pulmonary embolism,
– congestive heart failure,
– pneumonia

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Treatment of cough
• Treat underlying causes
• Antitussives: dextromethorpan, codeine,
benzonaftate Antitussives
• Expectorants: glycerilguaiacolate, mucolytic
(N-acetylcysteine,erdosteine)
• Acute bronchitis:
- antibiotic NOT indicated
- consider beta agonists, such as salbutamol

Antitussives:
Antitussives: Definition Mechanism of Action
Opioids
• Commonly called: “Cough supressants”
• Suppress the cough reflex by direct action on the
• Drugs used to stop or reduce coughing cough centre in the medulla
Examples:
• Opioid (narcotic) and nonopioid (nonnarcotic) – codeine
– hydrocodone
• Used only for nonproductive coughs (dry
cough)

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Antitussives:
Mechanism of Action
Dextrometorphan
Nonopioids • No classical opiate action!
• Suppress the cough reflex by numbing the – Analgesic, addiction
stretch receptors in the respiratory tract and • Not antagonized by naloxone
preventing the cough reflex from being • Mechanism of antitussive action unknown
stimulated
Examples:
– Dextromethorphan, noskapin

Dextromethorphan Noskapin
• should not be used for cough r/t smoking, • Derivate: benzilisokinolin
asthma or emphysema • Therapeutic dosage: 3-4x/15-30 mg/hr
• adverse effects: dizziness, • <90 mg: respiratory depress (-)
drowsiness & nausea
• Dosage >>>→Histamine release→temporary
– dextromethorphan toxicity
bronchocontriction and hypotension
– should not be used for more than 7
days

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Antitussive: Adverse effects Antitussive : contraindication

• Codeine:
impaired alertness or coordination,
hypersensitivity, dependence; toxic reactions: • pregnancy, lactation, known
euphoria, hyperactivity, nystagmus, hypersensitivity
uncoordinated movements, stupor, shallow
breathing
• DMP:
drowsiness & GI upset; toxic reaction: miosis,
bradycardia, tachycardia, hypotension, narcosis,
seizures, circulatory collapse

Antitussive: Drug interactions

• DMP and MAO (monoamine oxidase)
inhibitors
→ excita;on, hyperpyrexia Expectorants
• Narcotic/opioid antitussive with:
MAO inhibitors, alcohol, and other CNS
depressants
→ poten;a;on of CNS depressive effects

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Expectorants Expectorants
• Used to fascilitate removal of mucus from the
• Ammonium chloride,
lower respiratory tract
• Two types: • guaifenesin/glyceryl guaiacolate (GG),
- mucolytic expectorants: breakdown
• Sodium citrate
the mucus
- stimulant expectorants: increase the overall • Ipecacuanha
volume of mucus produced thereby
enchancing clearance They are unlikely to have any side effects or
interacts with other medicine

Expectorants:
Mechanisms of Action Reflex stimulation
• Reflex stimulation
• Agent causes irritation of the GI tract
• Direct stimulation
• Loosening and thinning of respiratory tract
secretions occur in response to this irritation
Final result: thinner mucus • Example: guaifenesin
that is easier to remove

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Direct stimulation
• The secretory glands are stimulated directly to
Expectorants: Drug Effects
increase their production of respiratory tract
fluids By loosening and thinning sputum and
• Examples:
bronchial secretions, the tendency to cough is
iodine-containing products such as iodinated
glycerol and potassium iodide indirectly diminished

Expectorants:
Expectorants agents
What should we do?
• Precaution: • Expectorants should be used with
liver and renal insufficiency
caution in the elderly or those with
asthma or respiratory insufficiency
• Adverse effects: • Clients taking expectorants should
- GG: drowsiness, nausea, vomiting
receive more fluids, if permitted, to help
loosen and liquefy secretions
• Monitor for intended therapeutic effects

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Mucolytics Mucolytic agents

• drugs that liqueify thick tenacious • Examples:
secretions bromhexin, ambroxol, N-acetylcystein,
• difficulty mobilizing and coughing up hypertonic saline
secretions • Use/ mechanism of action:
– COPD enhance mucolysis by altering molecular
– cystic fibrosis composi;on of mucus → reducing viscosity;
– pneumonia ambroxol: stimulate surfactant production of
– tuberculosis premature infant with respiratory distress
– atelectasis syndromes

Mucolytic agents
mucolytics: acetylcysteine
• mucomyst • Precaution: gastric ulcer
• use of nebulizer • Adverse effects:
- bromhexin → nausea,
• other use: acetamenophen toxicity ↑ serum transaminase level
• caution : compromised coughing - ace;lcistein → bronchial spasm, nausea,
ability ; asthma vomiting, stomatitis,
• breaks S-S bridges in glycoproteins of mucus haemoptysis
→ reduced viscosity of secretions

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ACE inhibitor-induced cough

Dry and hacking

chronic cough occurs in perhaps 10% of
persons taking ACE inhibitor (ACEI) drugs

the cough appears to be a class effect of
the drugs and is not dose-related.

no pulmonary dysfunction appears to result
from ACEI-induced cough.

the pathogenesis of ACEI-induced cough is
unknown, might be due to enhancement of
bradykinin concentrations in the lung tissue

the cough resolves after the drug is
discontinued.
Thank you for Listening
12/2/2010
ACE inhibitor-induced cough
Problem Solving

cough is common in patients with heart failure, many
of whom have smoking-related lung disease

cough is also a symptom of pulmonary oedema,
which should be excluded if a new or worsening
cough develops

ACE inhibitor-induced cough rarely requires
treatment discontinuation

if a very troublesome cough develops (e.g. one
stopping the patient sleeping) and can be proven to
be due to ACE inhibition (i.e. it recurs after ACE
inhibitor withdrawal and rechallenge), substitution
with an AT1-receptor blocker can be considered