COUGH

About 30% of patients with advanced cancer admit to some cough, but as a troublesome symptom it is surprisingly uncommon.

Persistent coughing can cause anorexia, nausea or vomiting, insomnia, musculo-skeletal pain, cough fracture of a rib, exhaustion or cough syncope.

A recurrent laryngeal nerve palsy (usually due to a bronchial carcinoma) causes vocal cord paralysis and a “bovine” cough. The normal expulsive force of the cough is lost and the patient may need help to cough up tenacious sputum. (see Hoarseness)

Cough productive of sputum is easier to manage than a dry cough. The usual causes are bronchitis, pulmonary infection or lung abscess.

Rarely an alveolar cell carcinoma can produce large volumes (500cc to 1,000cc) of clear watery sputum (bronchorrhea).

Left ventricular failure can develop (due to an infarct or arrythmia), causing frothy sputum, orthopnea, nocturnal cough, tachycardia, gallop rhythm and fine basal crepitations. It responds to diuretics.

If sputum is green and infected, sputum culture and antibiotics may be indicated. A broad spectrum antibiotic can be started while awaiting results of sputum culture.

Physiotherapy 2 or 3 times a day, shaking or gently percussing the chest with forced expiration can help loosen sputum, and is a useful form of active therapy. There is no place for postural drainage in very ill patients. (see Physical Therapy)

Other treatments that are sometimes useful include steam inhalations, expectorants and mucolytics.

Dry cough – A persistent irritating cough without sputum production can be difficult to manage. The usual causes are bronchospasm, pleural effusion or bronchogenic carcinoma.

Management options:

1. Bronchodilators

2. Pleural aspiration

3. Radiotherapy

4. Steroids

5. Humidified air

6. Soothing syrup

7. Opioids

8. Nebulized lidocaine

1. Bronchospasm can cause a troublesome cough. There may be no history of asthma and no audible wheeze. Peak flow rate may be reduced although it may be intermittent (nocturnal coughing, for example). Treatment includes albuterol (by nebulizer or inhaler), slow-release aminophylline or steroids. (see Dyspnea)

2. A pleural effusion can occasionally present as a cough due to diaphragmatic irritation. It is confirmed by chest x-ray and treated by aspiration. (see Pleural Effusion)

3. Radiotherapy may be indicated if there is a large untreated carcinoma.

4. Oral steroids (dexamethasone 4mg to 8mg per day) can reduce wheeze and may reduce cough due to a large bronchial abscess.

5. A humidifier can help. Dry air and irritants like cigarette smoke worsen coughing.

6. Simple linctus (5mg to 10mg 4 times a day) can reduce pharyngeal irritation.

7. Opioids are the most powerful central cough suppressants. Codeine linctus 5ml to 10ml 4 times a day may be sufficient. Oral morphine starting with 2.5mg every 4 hours, and increasing to 5mg, 10mg or 20mg every 4 hours will suppress cough in patients not already taking morphine. For patients already taking morphine, methadone linctus (2mg in 5ml) 3 times a day can sometimes help to reduce cough (for unknown reasons).

8. Nebulized lidocaine 2% can bring dramatic relief, used for 10 minutes every 2 to 6 hours (maximum of 10ml per 24 hours). Numbness of the mouth may persist for about 30 minutes after each treatment, therefore the patient must be told not to eat or drink for this time.

Terminal phase coughing – If the patient is too weak to cough up secretions, atropine 0.6mg up to 4 times a day can reduce distressing bubbling without causing sedation. For terminal bubbling use scopolamine 0.4mg IM every 4 hours. Suction is occasionally helpful if the patient is distressed by tenacious sputum at the back of the throat, but repeated suction is distressing and should be avoided. (see Terminal Phase)

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.