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For the use only of a registered medical practitioner

A cough is a sudden and variable sudden thrust of air from the
lung and through the air passages associated with phonation,
which momentarily interrupts the physiology of breathing,
It is the most common symptom of respiratory disorders
Serves the functions of defending respiratory tract against noxious

Maintains airway patency by removing excessive secretions or foreign body

from air passages1

All children experience coughs and colds.

Coughing in children can be distressing and affects childs sleep,

school performance and ability to play.
Clinical Significance
Cough is cardinal manifestation of respiratory diseases

Pathologic conditions that

irritate the airways,

increase their irritability,

result in their deformation, or

increase the tracheobronchial secretions cause cough

These factors may operate singly or in various combinations
Three Categories of Cough
Acute Cough = < 3 Weeks Duration

Subacute Cough = 3 8 Weeks Duration

Chronic Cough = > 8 Weeks Duration

Differential Diagnosis Acute Cough
Upper Respiratory Tract infections:
-Viral syndromes, sinusitis viral / bacterial
Exacerbation of Chronic Obstructive Pulmonary Disease
Left Ventricular Heart Failure
Foreign Body Aspiration
Common Cold/Viral Rhinosinusitis

Symptoms Nasal Passages
Rhinorrhea, Sneezing, Nasal obstruction, Post
nasal drip

Signs - +/- Fever, +/- throat irritation,

normal chest auscultation
Diagnostic No Laboratory or X-ray
Common Cold/Viral Rhinosinusitis


Antihistamine (H1) + Pseudoephedrine

Treatment Failure

Viral Rhinosinusitis

Bacterial Rhinosinusitis
Viral vs. Bacterial Rhinosinusitis

Viral Bacterial

Most Common Less Common

Treat empirically Treat in cases of treatment failure
Treat for set criteria
Criteria Bacterial Rhinosinusitis

Treatment failure

Two of the following signs or symptoms

1.Maxillary Tooth Ache
2. Purulent Nasal Discharge
3. Abnormal Sinus Trans-illumination
4. Discolored Nasal Discharge

Antihistamine + Pseudoephedrine
Oxymetazoline (Afrin)
Antibiotics against H. influenza and Streptococcus
(Bactrim TMP/Sulfa or Amoxacillin)
Sub-acute Cough 3-8 Weeks
Subacute Cough Differential Diagnosis


Bacterial Sinusitis

Post Infectious Cough
A cough that begins with an acute respiratory tract
infection and is not complicated* by pneumonia

*Not complicated = Normal lung exam

normal chest X-ray
Post Infectious Cough

Post Infectious cough will resolve without


Cause = Postnasal drip or Tracheobronchitis

Chronic Cough
Duration > 8 Weeks

Chronic Cough Differential Diagnosis

Post Nasal Drip (Nose and Sinus Conditions)

Gastroesophogeal Reflux Disease

Chronic Bronchitis from Tobacco

Chronic Obstructive Pulmonary Disease

Left Ventricular Heart Failure

Lung Cancer



Recurrent pulmonary aspiration (congenital anomalies)

Patients Who Present With Chronic Cough Should
Receive a Chest X-ray When Possible
Chest X-ray and Differential Diagnosis

Normal X-ray Abnormal X-ray

Post Nasal drip Tuberculosis

Reflux Disease COPD
Asthma Heart Failure
Chronic Bronchitis Lung Cancer
Cough with Bronchospasm
Some conditions wherein bronchospasm is cause of cough

Epithelial damage caused by infection

Exposure to noxious gases

Chronic bronchitis


Allergic rhinitis

Shields MD. Thorax 2008;63 (Suppl. III) : iii1iii15

Management of cough
Whenever possible, treat the underlying cause1

Specific treatment2
Antibiotics (e.g. macrolide for pertussis)

Asthma therapy

Foreign body removal

Antihistamines and intranasal steroids for an allergic cough in the pollen season

Symptomatic Treatment - 1. Antitussive agents2

2. Mucolytics/ Expectorants3

3. Pharyngeal demulcents3

4. Bronchodilators3
Antitussive agents
Only for dry unproductive cough or when cough is exhausting

Raise threshold of cough centre in CNS

Or Act in respiratory tract to reduce tussal impulses

Or both

Opioids Codeine, Pholcodeine

Side effects Constipation, Drowsiness, Respiratory Depression at higher doses

Nonopioids Dextromethorphan
Advantage - No Constipating Action

Side effects - Headache, Nausea occasionally

Barnes P. The Pharmacological basis of Therapeutics 12th ed; 2011. p. 1057-8 CNS Central nervous system
Tripathi KD . Essentials of Medical Pharmacology, 5th ed; 2003. p 195-198 S/e- Side effects
Antitussive agents
Only for dry unproductive cough or when cough is exhausting

Antihistamines Chlorpheniramine, diphenhydramine,

Mechanism - Relief in Cough due to Sedative and Anticholinergic Action

Side effects - Sedation, Dryness of Mouth

Tripathi KD . Essentials of Medical Pharmacology, 5th ed; 2003. p 195-198

Mucolytics / Expectorants
For Productive Cough
Derivative of alkaloid vasicine from Adhatoda vasaka (Vasaka)

Mechanism - Depolymerises mucopolysaccharides directly and by liberating

lysosomal enzymes

Side effects - rhinorrea, lacrymation, gastric irritation, hypersensitivity

Metabolite of bromhexine, similar properties

Sodium citrate, ammonium chloride potassium iodide, guaiphenesin, balsam of

Tripathi KD . Essentials of Medical Pharmacology, 5th ed; 2003. p 195-198

Pharyngeal demulcents

Lozenges, cough drops, linctuses containing syrup, glycerine,

Soothen throat

Reduce afferent impulses from inflammed/irritated pharyngeal mucosa

Provide symptomatic relief

Tripathi KD . Essentials of Medical Pharmacology, 5th ed; 2003. p 195-198

Used when element of bronchoconstriction is present

Stimulation of pulmonary receptors may lead to Cough and


1. Relieve cough

2. Improve effectiveness of cough in clearing secretions

E.g. salbutamol, terbutaline

Side effects Most common - muscle tremors; tachycardia and arrhythmias
are less likely

Tripathi KD . Essentials of Medical Pharmacology, 5th ed; 2003. p 195-198

Dilo BM : Composition

Ambroxol may increase Terbutaline sulphate selective

quantity and decrease 2 stimulant - help alleviate
viscosity of tracheobronchial bronchospasm associated with
secretions cough

Menthol increases threshold

Guaiphenesin is an
of cough receptors located in
the respiratory tract
Full prescribing information available on request
For productive cough when associated with Bronchospasm
Children : 3 times a day
6 to 12 years : 1 teaspoonfuls (5 ml)
2 to 6 years : 1/2 teaspoonfuls (2.5 ml)

Prescribing information for DILO-BM Expectorant 01IND06 19/10/06 JK

Abbreviated Prescribing Information of Dilo-BM Expectorant
ACTIVE INGREDIENT: Each 5 ml (one teaspoonful) contains Ambroxol Hydrochloride BP 30 mg, Guaiphenesin IP 50 mg and
Terbutaline Sulphate IP 1.25 mg in flavoured syrup base containing Menthol IP. INDICATIONS: Treatment of productive
cough associated with bronchospasm in conditions such as bronchitis, bronchial asthma, chronic obstructive pulmonary
disease (COPD), bronchiectasis, and emphysema. DOSAGE AND ADMINISTRATION: 3 times daily in following doses:
Adults - 2 teaspoonfuls (10 ml). Children (6 to 12 years) - 1 teaspoonfuls (5 ml). Children (2 to 6 years) - 1/2 teaspoonfuls (2.5
ml). CONTRAINDICATIONS: Hypersensitivity to any of the ingredients. WARNINGS AND PRECAUTIONS: Treat
underlying cause such as specific infection. Caution in patients with hypertension, cardiovascular disease (including
arrhythmias, coronary insufficiency), uncontrolled diabetes mellitus, hyperthyroidism, history of seizures, or in patients who
are unusually responsive to sympathomimetic amines. Patients susceptible to hypokalemia should be monitored. DRUG
INTERACTIONS: Monitor patients receiving concomitant corticosteroids as adverse metabolic effects of terbutaline may be
exacerbated. Hypokalemia with high doses of 2 agonists may result in increased susceptibility to digitalis induced cardiac
arrhythmias. Hypokalemia may be enhanced by concomitant aminophyllin or other xanthines, corticosteroids or diuretics.
Terbutaline reduces serum theophylline concentrations, but may or may not have clinical implications. Dosage may be
increased if respiratory symptoms persist, while monitoring theophylline side-effects and concentration. Other
sympathomimetic bronchodilators or epinephrine (except judicious use of an aerosol adrenergic stimulant bronchodilator)
should not be used concomitantly with terbutaline sulphate. Use with caution in patients treated with monoamine oxidase
(MAO) inhibitors or tricyclic antidepressants. Furazolidone (MAO inhibiting activity) should not be used concurrently.
Patients requiring treatment for both bronchospastic disease and hypertension should not be treated with -blockers for
hypertension as they block pulmonary effect of terbutaline and may produce severe asthmatic attacks in asthmatic patients.
EFFECTS ON ABILITY TO DRIVE AND USE MACHINES: No special precautions required. PREGNANCY: Prescribe only
when potential benefits outweigh risks. ADVERSE EFFECTS: Ambroxol: Dermatological findings (e.g. contact dermatitis,
urticaria, exanthema, itching, pruritic erythema and vesicular eruptions about the nose, upper lips, and cheeks), pharyngeal
soreness and spasm and gastrointestinal findings (e.g. dry mouth, diarrhea, constipation, nausea and vomiting, and
sialorrhea). Guaiphenesisn: Occasional gastrointestinal discomfort, nausea and vomiting with very large doses. Terbutaline:
Most commonly: tremor and nervousness. Others: increased heart rate, palpitations, dizziness, headache, drowsiness,
vomiting, nausea, sweating, and muscle cramps. Effects generally transient and usually do not require treatment. OVERDOSE:
Overdose of terbutaline may lead to significant drop in blood pressure.
Full Prescribing Information available on request from:
GlaxoSmithKline Pharmaceuticals Limited, Dr Annie Besant Road, Worli, Mumbai 400 030 (India).
API/01/VD/Aug 07

Valid upto March 2014