1. 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

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

3. 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

4. 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)

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

6. 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

7. Acute cough

8. Acute cough

9. 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

10. 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

11. Chronic cough

12. 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%

13. 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

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

15. 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)

16. 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

17. 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.

19. 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

20. 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

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

22. Mucolytic Sodium Bicarb N-Acetylcysteine N-Acetylcysteine

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

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

25. Expectorant Guaifenesin Terpin hydrate Gliseril guaikolat
Ammonium klorida
Succus liquiritiae
Ipekak

26. 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

27. 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

28. 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.

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

30. 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

31. 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

32. 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)

33. 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     }               

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

35. 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

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