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Cough in palliative care patients is often caused by infection, pleural effusion, or the direct effects of malignancy on the lung or airways. Co-morbidities such as Chronic Obstructive Pulmonary Disease (COPD) and cardiac failure may also contribute, and should be optimised.  Antibiotic treatment of infection may sometimes give good palliation of infected secretions.

 

The investigation and management of cough may differ depending on the person’s illness stage and wishes for treatment. Active treatment of malignancy as appropriate with surgery, chemotherapy or radiotherapy, or by drainage of pleural effusion, may effectively treat coughing in patients who are well enough. [1] The following information relates to the symptomatic management of cough. 

 

What is known 

• There is little evidence to support the use of the most common medications that are used to suppress coughing in palliative care patients, nor have they been studied in the palliative care population [2]. Most commonly used are weak opioids (as in over the counter cough syrups) and strong opioids (morphine and other opioid agonists). [1]
• There is some evidence to support the use of mucolytic agents in COPD, however they have not been studied in the palliative care setting. [3]
• Nebulised lignocaine or other local anaesthetics have sometimes been used empirically in palliative care patients with refractory cough. No high level evidence was found to support its use in the palliative care setting.

What it means in practice

• Symptomatic management of coughing is needed when treating the underlying cause is not appropriate or not possible, or has been ineffective; or in a patient who is distressed.
• Symptomatic treatment of cough is largely empirical. Centrally acting opioids can be titrated for a cough which is distressing. Management of secretions can involve antimuscarinic medications and / or, when appropriate, antibiotics.
• A moist cough in a dying patient can be managed with antimuscarinic medications. Treatment of mucopurulent sputum with antibiotics may sometimes provide palliation by reducing the volume of secretions and cough [4].

Finding out more
Guidelines

• Chronic cough due to lung tumours: ACCP evidence—based clinical practice guidelines (Kvale 2006)
• Cough suppressant and pharmacologic protussive therapy: ACCP evidence-based clinical practice guidelines (Bolser 2006)

Link to prescribing information
NB Prescribing information may not yet have been updated to include the most recent evidence.

• Online Palliative Medicine Handbook 
  Click on “Notes on Prescribing”
  This prescribing information is from the UK and some medications may not be available in Australia
• Therapeutic Guidelines for Palliative Care
  An Australian source of prescribing information not available directly online through CareSearch, but can be accessed online in most hospitals, or purchased.

Overview articles

• Breathlessness, cough and other respiratory problems (Davis 1997)

Related CareSearch pages 
Respiratory secretions 
Haemoptysis

References 

1. Kvale, P. Chronic cough due to lung tumours: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 suppl):147S-153S
2. Smith SM, Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database of Systematic Reviews. 2008 Jan 23(1):CD001831.  
3. Poole PJ, Black PN. Mucolytic agents for chronic bronchitis or chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. 2006 Jul 19;(3):CD001287. 
4. Spruyt O, Kausae A.  Antibiotic use for infective terminal respiratory secretions. Journal of Pain and Symptom Management. 1998 May;15(5):263-4. 

This page was created on 29 April 2008 and is due for April 2010