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LITERATURE REVIEW
Management of Cough
BACKGROUND
A population study showed that the prevalence of
Cough is the most effective defense mechanism
cough varied between 3% and 40%.1 An
to eliminate foreign materials, including various
epidemiological survey revealed that 11-18% of the
pathogens from the respiratory tract.1,2 This symptom
general population reported persistent cough. Although
not only affects sick individuals but also healthy
it was not known whether the cough was normal or
individuals. An excessive and persistent cough can be
associated with a disease. This report could be caused by
associated with non-malignant chronic disease, with or
smoking, exposure to urban population or irritants in a
without excessive mucus production. A persistent cough
closed or opened environment, air pollution, or
is hazardous to the patients due to its effect on breathing,
undiagnosed cough-related disease. Around 10-38% of
social activity, and sleeping. Other than that, it can
patients with persistent cough were outpatients in
reduce the quality of life and cause embarrassment while
specialist practices in the United States.2
socializing, and cause syncope, urine incontinence,
muscle pain, insomnia, and fatigue.3
*Corresponding author
E-mail address: poe3_mj@yahoo.com
Definition
A cough is not always an abnormal clinical
symptom.6 It is an explosive expiration to defend the
lungs by increasing secretion and particle cleansing from
the respiratory tract.7 Cough is needed to clean the Figure 1. Diagramatic representation of variable changes
during cough representation: sound, air flow rate, subglottic
respiratory tract from mucus and secretions pressure. Flow rate is negative during inspiration phase, when
(approximately 20-30 ml per day) and the amount of glottis are closed, flow rate is zero and during expiration
respiratory secretion depends on daily exposure to phase, flow rate is positive. Expiration phase is divided into 3
parts: (1) expulsion phase with an explosive first cough sound;
irritants.6 It also protects the respiratory tract from (2) second phase, along with the loss of expulsive flow, the
aspiration of foreign materials occurred due to aspiration sound amplitude also disappears; and (3) third phase, partially
or inhalation of certain particles, pathogens, liquid closed glottis produces regular sound vibrations called second
sound.2,8
accumulation, postnasal drip, inflammation, and
mediators related to inflammation.7
sound amplitudes. Finally, the third phase occurs, which
Cough is started with a series of respiratory
is known as the sound or glottis phase. It is produced by
maneuvers which triggers sudden expulsion from the air,
vibration from a half-closed glottis, which resulted in
creating a characteristic cough sound.2,8 The mechanical
periodic and regular noise.2,8
process of cough is divided into three phases:
1. Inspiration phase: gas inhalation can be at least
50% of tidal volume or as much as 50% of vital Pathophysiology
capacity needed for an effective cough. Stimulation of the reflex arc complex results in
2. Compression phase: glottic closure maintains coughing that begins with an irritation to cough
intrathoracic pressures combined with receptors in the trachea, carina, large respiratory tract
contraction of chest wall muscles, diaphragm, branch, small respiratory tract, and the pharynx.
and abdominal wall. Mechanical and chemical stimuli are responded by
3. Expiration phase: glottis is opened, producing cough receptors in the larynx and tracheobronchial.
expiration airflow and high cough sound and Chemical receptors are sensitive to acid, heat, and
compression on the large respiratory tract. High capsaicin-like compound, which triggers cough reflex
airflow excretes mucus and cleansed the through type 1 vanilloid activation (capsaicin receptor).
respiratory tract.9 These receptors can also be found in the external
The coughing sound produced during the first three auditory canal, eardrum, paranasal sinus, pharynx,
phases is caused by an explosion heard during the diaphragm, pleura, pericardium, and the abdomen. These
expulsion phase. This sound is composed of noise receptors only respond to mechanical stimuli, i.e. to
waves. This phase is accompanied by an intermediate touch or movement.9
phase which occurs when airflow decreases due to
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Figure 2. The pathophysiology of cough reflex and targets for antitussive agents. Pro-tussive stimuli activate the
sensory nerve fibers in the airway and travel through the vagus nerve to the medulla which then ends at the nucleus
tractus solitarius (NTS). The respiratory pattern generator receives message from the second-order neurons, which
modifies the activity of the inspiratory and expiratory motoneurons leading to cough. Antitussives work peripherally
or centrally in pre- and post-synapses.
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The cough reflex arc complex consists of: include the sensitivity of RARs to lung collapse or
1. Afferent pathway: sensory nerve fibers (vagus deflation, responsivity of RARs to dynamic changes
nerve branches) located in ciliary epithelia from from lung compliance, and conduction speed (4 to 18
the upper respiratory tract (pulmonary, auricular, meters/second) to maintain continuous lung
pharynx, superior larynx, and gastric) and inflation.9 Mechanical stimuli such as mucus
branches of the heart and esophagus from the secretion or edema increase RARs activity more than
diaphragm. This afferent impulse is directed chemical stimuli such as bradykinin and
diffusely to the medulla. capsaicin.9,10
2. Central pathway (cough center): central 2. C-fibers
coordination area located in the upper part of the Non-myelinated C-fibers are the main afferent nerve
brain stem and the pons. fibers innervating the respiratory tract and lungs. The
3. Efferent pathway: impulses from the cough conduction speed of C-fibers is < 2 meters/second.
center are directed through the vagus, phrenic, This nerve fiber is different from RARs and SARs
and motoric nerves of the spine to the diaphragm because of insensitivity to mechanical stimulus and
and abdominal walls and muscles. lung inflation.9 Citric acid, bradykinin, and capsaicin
Retroambiguus nucleus, derived from the phrenic are stimulants of C-fibers that induce cough.10 These
nerve and other spinal motoric nerves, send stimulants act directly to C-fibers, not through the
impulses to inspiration and expiration muscles, effect on the respiratory tract smooth muscles. E2
and ambiguous nucleus, through the laryngeal prostaglandin, adrenalin, and adenosine sensitize C-
branch of the vagus nerve to the larynx. Mucosa fibers through the direct effect of bradykinin and
and upper respiratory walls (from upper capsaicin to the peripheral nerve end.9
respiratory tract to terminal bronchioles and lung 3. Slowly adapting stretch receptors (SARs)
parenchyma) are the final of the afferent pathway SARs are afferent fibers thought to be involved in
of the vagus nerve.9 the Hering-Breuer reflex, which ends inspiration and
Cough reflex begins with a stimulus to cough starts expiration when the lungs are inflated
receptors. Stimulus from the afferent pathway of sensory sufficiently. The activity of SARs does not change
nerve fibers is divided into three main groups: Ad-fibers upon cough-causing stimulus and SARs is indirectly
or rapidly adapting receptors (RARs), C-fibers, and involved with cough reflex. SARs are highly
slowly adapting stretch receptors (SARs). These nerve sensitive to mechanical stimuli occurring in the lungs
fibers are differentiated by their neurochemical property, during breathing. The activity of SARs increases
anatomic location, conduction speed, physicochemical during inspiration and reaches its peak at the
sensitivity, and adaptation to lung inflation.10 This beginning of expiration. SARs can be differentiated
stimulus is then transmitted to the afferent pathway from RARs based on their conduction potential
through the vagus nerve to the cough center in the activity speed and lack of adaptation to lung
medulla, under control of a higher cortex center. The inflation. SARs are also differently distributed in the
cough center produces efferent signal transmitted to the respiratory tract and mostly found at the end of the
vagus nerve, phrenic nerve, and spinal motoric nerves to intrapulmonary respiratory tract. The activity of
trigger expiration muscles to produce cough.9 SARs causes central inhibition from breathing and
The sensory nerve fibers acting in cough reflex are cholinergic inhibition in the respiratory tract
explained further below: decreases phrenic nerve activity and smooth muscle
1. Ad-fibers or rapidly adapting receptors (RARs) tone of the respiratory tract.9,10
RARs are myelinated nerve fibers with ends
approximately inside or slightly under the Classification
intrapulmonary respiratory tract epithelia and Cough is one of the signs of respiratory and
respond to mechanical changes in the respiratory pulmonary disease. It can be an important indicator for
tract during normal breathing condition. These fibers patients and doctors for early diagnosis and therapy of
respond most to cough stimulus and hold important disease. The American College of Chest Physicians
roles in cough reflex. RARs are differentiated from (CHEST) in 2006 published a guideline on coughing.
other respiratory tract afferent nerve fibers because The guideline classified cough into three groups, i.e.
of their adaptation speed (1-2 seconds) in advanced acute, subacute, and chronic. This classification is
lung inflation. Other distinguishing properties thought to be useful for diagnosis and therapy of cough.
89 JURNAL RESPIRASI, MAY 2020, VOL 06 (02); 85-96
Figure 3. Acute cough algorithm for the management of adult patients with cough lasting <3 weeks. Do not forget to
screen for the red flags as potential life-threatening condition. In endemic areas or high-risk populations, consider the
presence of TB. Routinely assess cough severity or quality of life of the patient before and after treatment. Follow
patients 4-6 weeks after initial visit.11
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Figure 4. Subacute cough algorithm for the management of adult patients with cough lasting 3 to 8 weeks. Do not
forget to screen for the red flags as potential life-threatening condition. In endemic areas or high-risk populations,
consider the presence of TB. Routinely assess cough severity or quality of life of the patient before and after
treatment. Follow patients 4-6 weeks after initial visit.11
3. Chronic and persistent cough Chung and Pavord classified chronic cough into
Persistent cough for more than 8 weeks is defined eosinophilic respiratory tract disease responsive to
as chronic cough. The cause of acute and chronic cough corticosteroids, such as bronchial asthma, cough variant
is important because their epidemiology and etiology are asthma (CVA), eosinophilic bronchitis, and steroid-
different. Chronic cough is a common complaint that is resistant disorders such as GERD and postnasal drip
often found in primary and secondary health services. (PND) or rhinosinusitis. Cough is reduced partly or
Chronic cough causes a considerable epidemiological thoroughly in 59% of patients with β agonist inhalation
burden and affects almost 10% of all adult population. followed by inhaled corticosteroid (ICS). CVA is the
Chronic cough is also a significant clinical problem, most frequent cause of chronic cough, which can be
causing the decreased quality of life which is reduced by bronchodilator administration. Patients
challenging for clinicians.13 coughing due to GERD experienced worsening cough
R. S. Irwin in 1977 analyzed and stated that a sound, increased cough (90%), increased appetite (87%),
number of diseases or conditions that cause chronic or and throat cleansing (74%).13,14 Excessive remodeling of
persistent coughing are caused by small anatomical the respiratory tract in bronchial asthma and CVA
locations of cough afferent receptors. Smoking and the causes deformation of the respiratory tract during
use of ACE-inhibitors are only a small part of the cause bronchoconstriction, causing chronic cough.13
of chronic cough. There are three dominant etiologies in Further study on phase I-II from European
most patients that can explain chronic cough: upper Community Respiratory Health Survey (ECHRS)
respiratory tract cough syndrome attributed to various revealed that chronic cough/phlegm is a strong marker
conditions of the nose and sinus, previously known as for individuals with moderate/severe asthma.13 Almost
postnasal drip (PND) syndrome, asthma, and 30% of CVA is reported to develop into bronchial
gastroesophageal reflux disease (GERD).5,12 These three asthma and showed that several types of CVA can be
diagnoses were found in 92-100% of non-smoking predecessors to bronchial asthma. Few types of PNS
patients, not using ACE-inhibitors, and had normal syndromes, such as allergic rhinitis and atopic cough
thorax radiographs. Upper respiratory tract cough also respond to corticosteroid. However, their prognosis
syndrome, asthma, non-asthmatic eosinophilic and impact on the quality of life are different from
bronchitis, and GERD are still the most frequent causes bronchial asthma and it is difficult to decide the duration
in developing regions in the world (where TB is of corticosteroid therapy. Therefore, it is important to
considered as the cause of chronic cough in endemic differentiate cough responsive to corticosteroid from
areas).5 other types of cough.15
Boulet, et al. in 1994 compared the inflammatory
Other than various manifestations of chronic
degree of respiratory tracts on the biopsy tissues of
cough explained above, there is a new clinical concept
bronchus and bronchoalveolar lavage fluid (BALF)
of fungus-associated chronic cough (FACC) defined as a
between non-asthmatic chronic cough and control to
chronic cough related to basidiomycetes in induced
investigate the pathology of the chronic respiratory tract.
sputum. FACC manifests in: (i) chronic cough, (ii) fungi
Samples from cough patients had relatively higher
inflammatory cells than control (especially mononuclear found in sputum, especially basidiomycetes, and (iii)
cells) and showed epithelial desquamation, submucosal good clinical response to antifungal treatment. Previous
fibrosis, inflammation of the mitochondria, dilatation of studies detected basidiomycetes in 39 sputum samples
smooth endoplasmic reticulum, and increased activity of (22.8%) from 171 chronic cough patients. There are
nucleus metabolism. There was no insignificant three types of FACC: (i) single colonization of
differences compared to the etiology of chronic cough basidiomycetes (pure-FACC), (ii) sensitization of
(PND and GERD). Mast cells are found in the BALF of basidiomycetes (allergic fungal cough, AFC), and (iii)
non-asthmatic cough patients compared to control. A colonization and/or sensitization of basidiomycetes other
recent study by Niimi, et al. also found that mast cell than a chronic cough, such as CVA, atopic cough, upper
hyperplasia is a characteristic in non-asthmatic chronic respiratory cough syndrome, and hypersensitive cough
cough patients.13 syndrome.3,16
92 JURNAL RESPIRASI, MAY 2020, VOL 06 (02); 85-96
Figure 5. Chronic cough algorithm for the management of adult patients with cough lasting > 8 weeks. Do not forget
to screen for the red flags as potential life-threatening condition. In endemic areas or high risk populations, consider
the presence of TB. Routinely assess cough severity or quality of life of the patient before and after treatment. Follow
patients 4-6 weeks after initial visit.11
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Other chronic cough causes often found in • penetration through the blood-brain
children and occur without underlying medical disease barrier and retention to the nerve system
or response to medical therapy are psychogenic cough, causes the longer working duration of this
habit cough, or tic cough. Nevertheless, these disorders antitussive.4,6,10
should be differentiated from other chronic coughs such • GABA (γ-aminobutyric acid) is an
as refractory chronic cough, upper respiratory cough inhibitory neurotransmitter in the central
syndrome, vocal cord dysfunction syndrome, and nervous system also found in the lungs.
hypersensitive cough syndrome. To date, there is no According to Ryan, et al., Gabapentin
guideline in differentiating these types of cough.17 produces a suppressive effect on cough
reflex in the center.6,10
Treatment • Local anesthesia such as lidocaine,
1. Pharmacology benzonatate, bupivacaine, and mexiletine
Causal therapy should be preferred if feasible. has been investigated to suppress
If not, however, in cases such as in acute respiratory coughing. It is the most effective
infection due to virus or only effective if postponed antitussive, but its use is still controversial
(such as TB), symptomatic therapy can be and becomes the last resort in patients
considered along with therapy to causes underlying with irritative cough. Local anesthesia
the cough.5 interrupts electrophysiological activity on
cough receptors and afferent receptors
Central antitussive (e.g. during bronchoscopy). Local
a. Opioids, such as morphine and codeine, works administration reversibly inhibits the
centrally on the cough center. Opioid-type action potential of vagus-pulmonary
antitussive has side effects and a higher risk of afferent nerve. This activity is thought to
addiction. Opioids are recommended as an be caused by inhibition to the voltage-
effective symptomatic therapy in disturbing dry gated sodium channel.6,10
cough. It is less effective for cough caused by • Diphenhydramine, a first-generation
common cold.5,6,10 antihistamine H1, is approved in several
• Codeine is mostly used and often countries (including England and the
considered as a basic antitussive. It is United States) as an over-the-counter
activated by CYP2D6 into morphine, (OTC) antitussive. It is reported to reduce
which then undergoes glucuronidation. cough reflex sensitivity in patients with
The degree of metabolism may vary cough due to URTI.4
dramatically due to a significant genetic
• Butamirate is widely used in Europe as an
difference in cytochrome P450 which
OTC antitussive. A cross-over placebo-
depends on the monooxygenase activity.
controlled study revealed that none of the
A fast metabolizer patient changes most
34 subjects who finished the study
codeine into morphine through the liver,
causing toxicity potential. Meanwhile, in experienced significant improvement after
slow metabolizer, only a few of the drugs the administration of butamirate.4
are converted, reducing drug
effectivity.4,6,10 Peripheral Antitussive
b. Non-opioid antitussive is preferable for acute • Levodropropizine is a non-opioid agent
cough due to lower potential of misuse and that works in the peripheral nervous
addiction than its opioid counterpart.5 system. This drug modulates sensory
• Dextromethorphan significantly neuropeptides in the respiratory tract and
suppresses acute cough. The effect is is given orally. A clinical trial on adults in
shown in the administration of a single 30 Indonesia indicated that levodropropizine
mg dose compared to placebo in six had better antitussive effect compared to
studies. Dextromethorphan has a
placebo and morclofone and was equal to
relatively slow onset and reaches its peak
cloperastine.5,6
after two hours of administration. Slow
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• Menthol is produced by Mentha arvensis. A study showed that dornase alfa reduced viscosity
Menthol inhalation suppresses cough and adhesion of respiratory tract secretions and long-
reflex and can be prescribed as crystal term use could increase pulmonary function, reduced
BPC or in a special capsule, although the damage to lung function, and reduced the need for
suppressive property is brief.4,7 hospitalization and antibiotic therapy.6
• Throat lozenges can also reduce cough
and flu symptoms through relieving Antibiotic
activity on the mucosal membrane. The Antibiotic is only effective to cough caused by a
effect of throat lozenges is widely bacterial infection, marked by purulent sputum (e.g.
discussed in the fifth American Cough in suppurative bronchitis, bronchiectasis,
Conference in 2015. Most delegates exacerbated COPD, purulent rhinitis, and sinusitis).
agreed on the effectivity of throat It is not indicated for acute bronchitis.4,6
lozenges, but no studies expressed the
effect.4,7 2. Non-Pharmacology
Respiratory tract cleansing may be disrupted in
Expectorant patients with cough mechanism abnormality (e.g.
Expectorant reduces irritation to cough receptors by muscle weakness), mucus rheological changes (e.g.
increasing mucus accumulation through “coughing cystic fibrosis), and mucociliary clearance changes
up”. It is the most frequently used drug for (e.g. bronchiectasis). Various efforts in increasing
respiratory diseases in German (e.g. ambroxol and respiratory clearance are performed to increase
N-acetyl cysteine). In chronic obstructive pulmonary pulmonary mechanism and gas exchange and to
disease (COPD) and bronchiectasis cases, prevent atelectasis and infection, albeit lacking
expectorant is recommended to relieve cough due to evidence on benefits.6,7 Cough and huffing are forced
thick secretion production. Many patients reported expiration maneuvers and examples of ways to
the effectivity of expectorant in acute bronchitis cleanse respiratory tract secretions.18
cases.4 Cough physiotherapy is a technique to:
The following describes several examples of 1. Increase effectivity of cough with effective cough
expectorant: technique,
• Ambroxol, a bromhexine active metabolite, is 2. Suppress productive cough involuntarily,
the most popular medicine in German. It also 3. Instruct patients to increase the use of
shows other antitussive effects other than physiotherapy tools such as acapella.7
expectorant. Several other interventions such as huffing can
• Pholcodine and guaifenesin are also used as an also be performed with the help of health workers
expectorant. (directed maneuver), though other interventions can
• Ammonium chloride is an acid-producing salt be performed without help.18 Huffing is an expiration
that is considered to provide an expectorant technique through the mouth with the opened
effect in loosening phlegm.4,6 esophagus, unlike cough. It helps cleanse phlegm
from the respiratory tract for relief. Huffing is
Mucolytic conducted by rapidly squeezing air in the lungs and
Mucolytic drugs non-selectively reduce let it out through the open mouth and esophagus like
viscosity and elasticity of respiratory tract secretion when trying to blow glass. We use the abdominal
by reducing polymer network that is responsible for muscles to help ejecting air out without force to
the gel-like structure of mucus or sputum. Classic avoid wheezing and shortness of breath. Huffing is
mucolytic disrupts mucin polymer by breaking always followed by breathing control.18,19
disulfide bond connecting mucin monomer There are two huffing techniques available to
covalently into a long and rigid oligomer or by help eliminate phlegm from the lungs:
dispersing tangled mucin through breaking the bond 1. Small-long huff or medium-volume huff
of hydrogen ions or van der Waals.6 This technique helps excrete phlegm from the
The only mucolytic approved in the United lower chest. Take a short to moderate breath,
States and Canada is dornase alfa. This drug is then let the air out rapidly until the lungs feel
given through inhalation with a dose of 2.5 mg/day. empty.18,19
95 JURNAL RESPIRASI, MAY 2020, VOL 06 (02); 85-96
18. Pontifex E, Williams MT, Lunn R, et al. The Effect 19. Bott J, Blumenthal S, Buxton M, et al. Guidelines
of Huffing and Directed Coughing on Energy for the Physiotherapy Management of the Adult,
Expenditure in Young Asymptomatic Subjects. Medical, Spontaneously Breathing Patient. Thorax
Aust J Physiother 2002; 48: 209–213. 2009; 64: i1 LP-i52.