1. Pharmaceutical guidelines of patients with pathology of breathing organs. Symptomatic treatment of COUGH

2. Cough is a forceful expulsion of air from the lungs
It is normally a protective reflex for removing foreign bodies, environmental irritants, or accumulated secretions from the respiratory tract.
The cough reflex involves central and peripheral mechanisms. Centrally, the cough center in the medulla oblongata receives stimuli and initiates the reflex response (deep inspiration, closed glottis, buildup of pressure within the lungs, and forceful exhalation). Peripherally, cough receptors in the pharynx, larynx, trachea, or lungs may be stimulated by air, dryness of mucous membranes, or excessive secretions.

3. Cough
A cough is productive when secretions are expectorated; it is nonproductive when it is dry and no sputum is expectorated.
Cough is a prominent symptom of
respiratory tract infections (the common cold, influenza, bronchitis, pharyngitis, pneumonia)
chronic obstructive pulmonary diseases (emphysema, chronic bronchitis).
asthma, acid reflux into the esophagus (gastroesophageal reflux disease), sinusitis, postnasal drip, bronchitis, cigarette smoking, tuberculosis, hypersensitivity pneumonia (inflammation of the lung from exposure to certain environmental chemicals), and even lung cancer. Therefore, a persistent cough or a cough that is associated with chest pain, fever, weight loss, or blood-tinged or discolored sputum should be evaluated by a doctor.

4. Cough Dry Wet Laryngitis Acute viral diseases Dry pleurisy Bronchitis
Smoking cough
In the beginning of diseases:
Acute bronchitis
Pneumonia
Lung abscess
Tuberculosis
Lung cancer
Wet
Acute viral diseases
Bronchitis
Pneumonia
Tuberculosis
Bronchiectatic disease

5. Threatning symptoms
Cough with increasing intensity that lasting above week
Cough accompanied by long steading (weeks) hyperthermia 38 °C
Cough accompanied by hyperthermia above 38 °C during 3 days or more
Cough accompanied by dyspnea and thorasic pain on breathing
Cough of pus
Blood spitting
Cough with pronounced dyspnea
Cough and weakness and weight loss
Excessive sweating, shivering
Sudden attack of severe cough
Severe cough during an hour without any interval
Abundant expectoration of sputum

6. Antitussives
Antitussive agents suppress cough by depressing the cough center in the medulla oblongata or the cough receptors in the throat, trachea, or lungs.
Centrally acting antitussives:
narcotics (eg, codeine, hydrocodone) and non-narcotics
(eg, dextromethorphan).
Locally acting agents (eg, throat lozenges, cough drops) may suppress cough by increasing the flow of saliva and by containing demulcents or local anesthetics to decrease irritation of pharyngeal mucosa.
Flavored syrups are often used as vehicles for other drugs.

7. Indication for use of antitussives
a dry, hacking, nonproductive cough that interferes with rest and sleep.
It is not desirable to suppress a productive cough because the secretions need to be removed. Although antitussives continue to be used and some people report beneficial effects, some research studies indicate that cough medicines are no more effective than placebos in children or adults.

8. Expectorants
Expectorants are agents given orally to liquefy respiratory secretions and allow for their easier removal.
Guaifenesin is the most commonly used expectorant. It is available alone and as an ingredient in many combination cough and cold remedies, although research studies do not support its effectiveness and many authorities do not recommend its use.

9. Expectorants
Other expectorants (hot beverages, potassium iodide, and ipecac) stimulate production of watery mucus.

10. Mucolytics
Mucolytics are administered by inhalation to liquefy mucus in the respiratory tract. Solutions of mucolytic drugs may be nebulized into a face mask or mouthpiece or instilled directly into the respiratory tract through a tracheostomy.
Sodium chloride solution and acetylcysteine (Mucomyst) are the only agents recommended for use as mucolytics.

11. Mucolytics
Acetylcysteine is effective within 1 minute after inhalation, and maximal effects occur within 5 to 10 minutes. It is effective immediately after direct instillation.
Oral acetylcysteine is widely used in the treatment of acetaminophen overdosage

12. Mucolytics
expectorants like bromhexine or ambroxole may effectively decrease viscosity of bronchial secretions

13. Ambroxol
Ambroxol is a clinically proven systemically active mucolytic agent. When administered orally onset of action occurs after about 30 minutes. The breakdown of acid mucopolysaccharide fibers makes the sputum thinner and less viscous and therefore more easily removed by coughing. Although sputum volume eventually decreases, its viscosity remains low for as long as treatment is maintained.

14. Ambroxol (cont’d) Indications
All forms of tracheobronchitis, emphysema with bronchitis pneumoconiosis, chronic inflammatory pulmonary conditions, bronchiectasis, bronchitis with bronchospasm asthma. During acute exacerbations of bronchitis it should be given with the appropriate antibiotic.
Contraindications
There are no absolute contraindications but in patients with gastric ulceration relative caution should be observed.

15. Types of cough medications available OTC for the temporary relief of cough due to a cold
oral cough suppressants,
oral expectorants,
topical (externally applied) medicines

16. Oral cough suppressants
Codeine and hydrocodone are narcotic oral cough suppressants that require a doctor's prescription. Dextromethorphan is an oral cough suppressant that is available OTC. Dextromethorphan is chemically related to codeine and acts on the brain to suppress cough, but does not have the pain-relieving and addictive properties of codeine. Diphenhydramine is another non-narcotic medication that acts on the brain to suppress cough. It is also an antihistamine.

17. Oral cough suppressants
Dextromethorphan and diphenhydramine can be used to relieve a dry, hacking cough. They are not generally used to suppress a productive cough
Cough suppressants are sometimes used to suppress even productive coughs if they are especially bothersome and prevent restful sleep.

18. Oral expectorants
Guaifenesin is an oral expectorant that is believed to increase the leaking of fluid out of the lung tissue and into the airways. This action thins (liquefies) the thick mucous in the airways and facilitates the clearing of the mucous by coughing. Clearing of mucous from the airways decreases cough.

19. Topical medications
Camphor and menthol are topical cough medications. Camphor and menthol ointments are rubbed on the throat and the chest as a thick layer. The anesthetic action of their vapors is believed to relieve cough. They are also available as products for steam inhalation. Menthol is also available as lozenges and compressed tablets.

20. ANTICOUGH MEDICATIONS. GUIDELINES
These drugs may relieve symptoms but do not cure the disorder causing the symptoms.
An adequate fluid intake, humidification of the environment, and sucking on hard candy or throat lozenges can help to relieve mouth dryness and cough.

21. ANTICOUGH MEDICATIONS. GUIDELINES
The patient should take medications as prescribed or as directed on the labels of OTC preparations. Taking excessive amounts or taking recommended amounts too often can lead to serious adverse effects.
The patient should take cough syrups undiluted and avoid eating and drinking for approximately 30 minutes. Part of the beneficial effect of cough syrups stems from soothing effects on pharyngeal mucosa. Food or fluid removes the medication from the throat.

22. Use in Children
Most infections are viral in origin and antibiotics are not generally recommended.
For bronchitis, which is almost always viral, antibiotics are not usually indicated unless pneumonia is suspected or the cough lasts 10 to 14 days without improvement.

23. ANTICOUGH MEDICATIONS. GUIDELINES (cont’d)
Adverse effects
Excessive suppression of the cough reflex with antitussives(inability to cough effectively when secretions are present):
This is a potentially serious adverse effect because retained secretions may lead to atelectasis, pneumonia, hypoxia, and respiratory failure.

24. ANTICOUGH MEDICATIONS. GUIDELINES (cont’d)
Adverse effects:
Nausea, vomiting, constipation, dizziness, drowsiness, pruritus, and drug dependence: associated with narcotic agents. When narcotics are given for antitussive effects, however, they are given in relatively small doses and are unlikely to cause adverse reactions.

25. ANTICOUGH MEDICATIONS. GUIDELINES (cont’d)
Drug interactions
Drugs that increase antitussive effects of codeine: CNS depressants (alcohol, antianxiety agents, barbiturates, and other sedative-hypnotics) - Additive CNS depression. Codeine is given in small doses for antitussive effects, and risks of significant interactions are minimal.

26. ANTICOUGH MEDICATIONS. GUIDELINES (cont’d)
drug interactions
Drugs that alter effects of dextromethorphan:
MAO inhibitors - This combination is contraindicated. Apnea, muscular rigidity,
hyperpyrexia, laryngospasm, and death may occur.

27. ANTICOUGH MEDICATIONS. GUIDELINES (cont’d)
Anticough agents that include codeine, Dextromethorphan, butamirat are not recommended for using in kids (to 2 years of age), during pregnancy and lactation
Agents that include glaucini hydrochloridum may provoke decreasing of arterial blood pressure in kids
Anticough agents that include Dextromethorphan may cause CNS and breathing depression if using in hight doses or for a long period
Anticough agents that include butamirat, dextromethorphan may cause weakness, sleepiness, dizziness

28. Mucolytics & expectorants GUIDELINES
Ambroxol is contraindicated in first term of pregnancy
Acetylcysteine may cause pulmonary hemorrage, liver and kidney function disturbances, may provoke attack of asthma in patients with BA
Acetylcysteine solution don’t use in one syringe with antibiotics
Bromhexine and ambroxole may increase liver transaminase activity

29. Mucolytics & expectorants GUIDELINES (cont’d)
Bromhexine and ambroxole are not combined with codeine including drugs
Bromhexine and ambroxole stimuly surfactant synthesis, making better alveolar cells function, and help clearing of mucous from the airways

30. Mucolytics & expectorants GUIDELINES (cont’d)
Bromhexine don’t use in kids to 3 years age
Expectorants don’t combine with drugs that supress cough reflex
Expectorants don’t combine with drugs that dehydrate organism (diuretics, laxatives)
Expectorants with reflective mechanism of action (thermopsis) may provoke vomiting and are contraindicated in patients with ulcer disease

31. Mucolytics & expectorants GUIDELINES (cont’d)
Expectorants show their clinical efficiency on 6-7 days of treatment
In the first 2-3 days of reception of expectorants a cough and separation of sputum can increase: these phenomena testify to efficiency of preparation
At presence of acute inflammatory process herbal expectorants are preferable
At an overdose or prolonged reception of preparations, containing iodides, the origin of iodism is possible: rrhinitis, somnolence, swelling; hyperthyroidism - tachicardia, tremor, insomnia, diarrhea are possible (more frequent at persons after 40 years)
Plant decoctions and extracts render not only coughing up action, but also the regenerations of the damaged mucous membrane of bronchial tubes promote due to the contained microelements, vitamins and biogenic stimulators