Zen Ahmad, dr., SpPD-KP Tempat/Tanggal Lahir : Palembang, 8 Maret 1962 Pekerjaan : Staf Penyakit Dalam RS Dr. M. Hoesin/FK UNSRI Riwayat Pendidikan : Internis tahun 2000 Konsultan Paru tahun 2005

Update management patient with cough Zen Ahmad FK UNSRI/RSMH Palembang

Defenition and terminology Cough is a forced expulsive manoeuvre, usually against a closed glottis and which is associated with a characteristic sound Acute cough and Chronic cough Acute: a cough lasting less than 3 weeks Chronic: a cough lasting more than 8 weeks Dry cough and Productive cough

Afferent impulses to cough centre (medulla) Mechanism of cough Stimulation of mechano-or chemoreceptors (throat, respiratory passages or stretch receptors in lungs) Afferent impulses to cough centre (medulla) Efferent impulses via parasympathetic & motor nerves to diaphragm, intercostal muscles & lung Increased contraction of diaghramatic, abdominal & intercostal (ribs) muscles noisy expiration (cough)

Diagnostic of cough Anamnestic Physical examination Radiologic Chest radiograph CT scan Sinus imaging Bronchoscopy Spirometry Bronchial provocation testing Echocardiogram 24th esophageal pH monitoring

Acute cough Acute cough is the commonest new presentation in practice care, most commonly associated with viral URTI Acute cough is normally benign and self-limiting It is the commonest symptom associated with acute exacerbations and hospitalisations with asthma and COPD Indications for further investigation include haemoptysis, prominent systemic illness, suspicion of inhaled foreign body, suspicion of lung cancer. Patients report benefit from various over-the-counter preparations; there is little evidence of a specific pharmacological effect

Acute cough

Acute cough

Treatment of acut cough Viral infection Antiviral Neuramidase inhibitors Amantadin Anti inflamatory NSAID Corticosteroid Inflamation Peripherally acting Local anaesthetic Demulcents Expectorants, mucolytics Cooling, warming agents VR1 antagonist Airway sensory receptors Centrally acting Opioids Dextromethorpan Sedatives Central Nervous system Respiratory muscle Cough

Chronic cough Cough accounts for 10% of respiratory referrals to secondary care. Most patients present with a dry or minimally productive cough Decrement in quality of life is comparable with severe COPD The presence of significant sputum production usually indicates primary lung pathology In chronic cough a heightened cough reflex is the primary abnormality

Chronic cough

Chronic cough Commonest causes of chronic cough in adults UACS due to a variety of rhinosinus conditions Asthma GERD NAEB In 5 prospective studies from the western, these 3 diseases singly/combination caused 92-96% of the chronic coughs in non-smokers who were not on ACE inhibitors and who had normal CXR The prevalence of NAEB as a cause outside of the western hemisphere has ranged from 0 to 33%

Investigative protocol management of chronic cough Initial clinical assessment History; PE; Spirometry; Reversibelity; CXR Possible diagnosis ? No Yes Sequential 8 week trial for the commonest causes of cough 8 week trial of appropriate th/ No No Treatment successful Other possible diagnosis Yes Yes 8 week trial of appropriate th/ Yes Continue th/ Th/ trial success No Investigational protocol

Treatment of chronic cough 1st generation antihistamine-decongestant Inhaled bronchodilator Inhaled corticosteroid A leukotriene receptor antagonist Anti-reflux therapy Acid suppression therapy Pokinetic therapy

Treatment of chronic cough Antitussive, incorporates with mucolytic and/or inhibitory effects on the cough reflex itself This therapy only reduce the frequency/intensity of coughing on a short-term basis These drugs do not resolve the underlying pathophysiology responsible for the coughing “There is no evidence that this therapy can prevent coughing” Because of the success of specific therapy, suppressant therapies are necessary only in specific situations When the etiology of cough is unknown When specific therapy requires a period of time before it can work When specific therapy will be ineffective (ex: inoperable lung cancer)

Treatment of chronic cough Some protussive agents are effective in increasing cough clearance (amiloride in CF; hypertonic saline in bronchitis) but their long-term effectiveness has not been established In acute or chronic cough not due to asthma, albuterol is not recommended In patients with neuromuscular impairment, protussive pharmacologic agents are ineffective and should not be used In chronic bronchitis, agents that have been shown to alter mucus characteristics are not recommended for cough suppression. In cough due to URI or chronic bronchitis, the only inhaled anti-cholinergic agent that is recommended for cough suppression is ipratropium bromide

Action of Antitussives at the cough receptor RAR, rapidly adapting receptor; NK, neurokinin; LTD4, leukotriene D4; VR1, vanilloid receptor; GABA, g-aminobutyric acid; NTS, nucleus tractus solitarius.

Mucolytic and expectorant 95% water, 2% glycoproteins Gel layer-high viscosity from goblet cells Sol layer – low viscosity from sub mucosal glands Goblet and sub-mucosal glands increase secretion when irritated Vagal stimulation will also increase sub-mucosal gland secretion Mucolytic Expectorant

Mucolytic Increased Mucus Production Viscosity of mucus Ciliary effectiveness Mucus plugs Airway Resistance Infections Mucolysis is needed in diseases in which there is increased mucus production Cystic Fibrosis COPD; Asthma Bronchiectasis Pneumonia

Mucolytic N-Acetlycysteine Erdosteine Carbocistein Bromheksin Ambroxol Pulmozym (Dornase Alpha or DNAse) Sodium bicarbonat

Mucolytic Sodium Bicarb N-Acetylcysteine N-Acetylcysteine

Mucolytic Erdostein Bromhexine Ambroxol Carbo cistein Guaiphenesine N-acetyl cystein Vestein + Vostrine Vectrine Woods expec Transbroncho Bisolvon Bisolvon extra Broncholit Edotin Epexol Fluimucil Mucohexin

Side effect of mucolytic Rare Nausea Vomiting Stomach pain Diarrhea Headache Vertigo Allergic reaction

Expectorant Guaifenesin Terpin hydrate Gliseril guaikolat Ammonium klorida Succus liquiritiae Ipekak

Antitussive Obat penekan atau penghambat batuk Central antitussive Dependent Opioid Codeine Independent Levorphanol drivat: Dextromethorphan Amido: Pentoxyverine Piperidin: Cloperastine Morpholine: fominoben ,Promolate Eprazinone , zipeprol Peripheral antitussive local anesthesia action: narcotine, benzonatate Alleviative action: extractum glycyrrhizae liquidum

Treatment of chronic cough Relatively few drugs are effective for non-specific suppression of cough It is recommended that suppressants be guided by specific knowledge of the disorder causing cough Mucolytic agents are not consistently effective to ameliorate cough in patients with bronchitis Zinc preparations are not recommended for cough due to cold Peripheral (levodropizine, moguisteine), central antitussive (co-deine, dextromethorphan) can be useful in chronic bronchitis but have little efficacy in patients with cough due to URI In patients with chronic or acute bronchitis, peripheral cough suppressants, are recommended for the short-term symptomatic relief of coughing Opioids are useful in lung cancer

Codeine One of the strongest cough suppressants known It suppresses coughing by direct action on the cough centre in the medulla oblungata, and also decreases the rate and/or tidal volume of respiration. Increases tolerance to pain, decreasing discomfort, but the pain still is apparent to the patient Is combined with acetaminophen (Tylenol) or aspirin for more effective pain relief.

Codeine Dangerous side effects can occur when alcohol is combined with codeine Codein Phenyltoloxamine Guaiphenesin Paracetamol Codipront + Codipront cum expec Coditam

Codeine; side effects Light-headedness Dizziness Nausea Vomiting Respiratory depression Sedation Tolerance and physical dependence with frequently repeated administration Euphoria Allergic reactions, constipation, abdominal pain, rash and itching Suppress secretion of bronchial gland and movement of cilia

Dextromethorphan Non-sedating opiate and has been shown to suppress acute cough Suppresses the cough reflex by a direct action on the cough center in the medulla There is a dose response, and maximum cough reflex suppression occurs at 60 mg and can be prolonged Care must be taken in recommending dextromethor- phan at higher doses since some combined prepara- tions contain other ingredients such as paracetamol

Dextromethorphan Onset and duration of action: Usually within one-half hour, after 10- to 20-mg doses every 4 hours or 30 mg every 6 to 8 hours Elimination: Primarily renal (excreted as unchanged dextromethorphan and demethylated metabolites, including dextrorphan) Risk-benefit should be considered in this conditions Asthma    (impair expectoration; increase airway resistance) COPD, Productive Cough (inhibition of cough reflex may lead to retention of secretions ) DM (some DXM products contain sugar and impair blood glucose control) Hepatic function impairment  (metabolism of DXM may be impaired) Respiratory depression (DXM may make this condition worse)

Dextromethorphan: Side effect Dizziness Drowsiness Nervousness Restlessness GI problems: Nausea; Vomiting; Stomach pain; Constipation Headache Toxic psychosis (hyperactiv, visual/auditory hallucinations) has been reported after ingestion of 300 mg or more Respiratory depression (very high doses) DXM dependence, especially in high doses prolonged use     }               

Dextromethorphan Dextro metorphan Phenylpropanolamine Brompheniramine Pseudoepedrin Triprolidine Chlorpheniramin Parasetamol Actiped + Alpara Alco plus DMP Valved DM Tuzalos Sanaflu + Decolgen Panadol Lacoldin Dextral

Sedative antihistamines First generation antihistamines with sedative properties suppress cough but also cause drowsiness They may be a suitable treatment for nocturnal cough Brompheniramine Difenhidramin

Bromhexine Brompheniramine Dextrometorphan Pseudoephedrine Triprolidine Guaiphenesine Actiped + Actiped expec Alco plus DMP Woods Woods expec Benadryl DMP Bisolvon Decolgen