• Assess the person to find the cause of the cough.
• Determine what management interventions are appropriate for the person's stage of illness and if appropriate:
• Treat a cough caused by infection. For more information, see Managing cough due to infection.
• Treat the identified cause of coughs not caused by infection. For more information, see Managing a cough of non-infective cause.
• If the cause of the cough is unknown, or treatment of the underlying cause is inappropriate, decide if the cough is dry, moist, productive, or non-productive, and whether the person is able to cough effectively; consider symptomatic treatment.
• Consider management of other physical symptoms, and the psychological, social, and spiritual needs of the person and their family. For more information, see the CKS topic on Palliative cancer care - general issues.

• Ask about:
• The effect on the person's life.
• The features of the cough.
• Associated symptoms.

• Ask about the:
• Impact on the person's quality of life. For more information, see Complications of cough.
• Severity, time of onset, and duration of the cough.
• Pattern and character of the cough, for example [Warrell et al, 2003]:
• Dry cough, persisting over weeks — suggests that the cough is due to the person's cancer.
• Dry cough, barking quality, short lived — pharyngitis, tracheobronchitis, early pneumonia.
• Harsh, hoarse 'croup' sound — laryngitis.
• Prolonged, low 'bovine' cough — left recurrent laryngeal nerve palsy from compression by thoracic lesions (e.g. carcinoma of the bronchus, hilar lymph nodes) causes abductor paralysis of the vocal cords.
• Hard, metallic-sounding 'brassy' cough — tracheal compression from intrathoracic lesions (may be associated with wheeze or stridor).
• Loose cough — secretions moving in the major airways (these may or may not be expectorated).
• Coughing with food or after a meal — aspiration from oesophageal or pharyngeal disease.
• Enquire about associated symptoms:
• Nasal discharge — cough may be caused by post-nasal drip.
• Sputum:
• Purulent sputum — infection.
• Frothy sputum — left ventricular failure, or rarely, alveolar cell cancer.
• Non-infected sputum — jelly-like, white or clear.
• Infected sputum — thick, yellow or green.
• Mucus — large amounts (> 100 mL per day) are produced by people with bronchorrhoea, which can occur as a result of bronchiolo-alveolar cancer, asthma, or tuberculosis.
• Blood — haemoptysis from tumour, or tumour erosion. This is the presenting symptom in 5%, and occurs at some stage in 50%, of people with lung cancer [Warrell et al, 2003].
• Dyspnoea — effusion, lung collapse, lymphangitis carcinomatosa. For more information on causes and management of dyspnoea, see the CKS topic on Palliative cancer care - dyspnoea.

[Twycross and Wilcock, 2001; Warrell et al, 2003; Doyle et al, 2004; Zylicz, 2004]

• This recommendation is based on expert opinion from palliative care and medical literature developed from clinical experience [Twycross and Wilcock, 2001; Warrell et al, 2003; Doyle et al, 2004; Zylicz, 2004].

• Examine the person to help determine the underlying cause of the cough.
• Assess the effectiveness of the cough, and whether it is dry, moist, productive, or non-productive.

• Examination findings that may suggest a specific diagnosis include [Munro, 1995]:
• Decreased chest wall movement — lung collapse, pleural effusion.
• Percussion note — dull on the side of the chest affected by lung collapse, stony dull on the side of pleural effusion.
• Breath sounds — bronchial or 'blowing' quality over areas of consolidation.
• Wheeze/stridor — endobronchial tumour.
• Crepitations — exudate in the bronchioles (e.g. infection, heart failure).
• Assess respiratory rate and effort. If dyspnoea is the predominant symptom, see the CKS topic on Palliative cancer care - dyspnoea.
• Ask the person to cough to assess the effectiveness. (i.e. Is the cough powerful enough to expectorate secretions?)
• Factors leading to ineffective cough in people with cancer include [Twycross and Wilcock, 2001; Doyle et al, 2004]:
• Muscle factors — general debility, weakness of respiratory or abdominal muscles, neurological problems, decreased level of consciousness.
• Airway factors — non-compressible airway (tumour or stent insertion), vocal cord paralysis.
• Mucus factors — reduction of water content of mucus (e.g. reduced fluid intake, drug effects).
• Mucociliary factors — impaired mucociliary function (e.g. smoking, infection).
• Treatment for cough is usually effective if the cause is identified [Doyle et al, 2004].

• This recommendation is based on expert opinion from the medical and palliative care literature [Munro, 1995; Twycross and Wilcock, 2001; Doyle et al, 2004].
• Whether a cough is dry or moist, and its effectiveness, will affect the decision of what symptomatic management is appropriate. For more information, see When to consider symptomatic treatment.

• The appropriateness of investigation and treatment should be weighed against the prognosis, the likely benefit of treatment, and the person's wishes.
• The exact investigations requested will depend on the clinical assessment (e.g. chest X-ray if pleural effusion is suspected).

• It is assumed that individuals with an established diagnosis of malignancy will have been previously referred and investigated in secondary care.
• Investigations which may be carried out in secondary care include:
• Computed tomography/magnetic resonance imaging to assess for lymphangitis carcinomatosa [Ahmedzai, 2004].
• Ventilation/perfusion scan to exclude pulmonary embolism [Ahmedzai, 2004].
• Bronchoscopy, although this is rarely necessary once a diagnosis of cancer is made [Ahmedzai, 2004].
• Swallowing evaluation may be necessary if aspiration is suspected [Estfan and LeGrand, 2004].
• The person's wishes and their stage of illness will determine whether investigations to find the cause of the cough are appropriate [International Association for Hospice and Palliative Care, 2004].

• This recommendation is based on a palliative care guideline [International Association for Hospice and Palliative Care, 2004] and expert opinion from palliative care and medical literature [Ahmedzai, 2004; Estfan and LeGrand, 2004].

• Treat the underlying cause of the cough if possible and appropriate.
• Aim to relieve symptoms:
• Nurse the person in the position that causes least discomfort.
• Avoid smoke or fumes.
• Consider humidifying air.
• Manage dyspnoea if present. See the CKS topic on Palliative cancer care - dyspnoea.
• Consider management of other physical symptoms, and the psychological, social, and spiritual needs of the person and their family.

• The decision to treat the underlying cause of the cough will depend on:
• The wishes of the person.
• The inconvenience and risks of the investigations of the cause.
• The likely benefit of treatments.
• The person's life expectancy.
• Treatment of infection with antibiotics, drainage of effusions, radiotherapy to tumour masses or lymphadenopathy, or stenting of tracheo-oesophageal fistulae may provide symptomatic relief and improved quality of life [Estfan and LeGrand, 2004].
• For more information on the holistic care of the person and their family/carers, see the CKS topic on Palliative cancer care - general issues.

• This recommendation is based on palliative care guidelines [International Association for Hospice and Palliative Care, 2004] and expert opinion from medical and palliative care literature [Ahmedzai, 2004; Estfan and LeGrand, 2004].

• Determine with the person, and their carers and family, what management is appropriate for the stage of illness.
• Options are to treat at home or admit for specialist care (e.g. hospital, specialist cancer centre, or hospice). Factors that may help support a decision on whether or not to admit include:
• Whether or not the person can be managed at home.
• The severity of the illness.
• Comorbidities such as an immunocompromised state.
• Whether the person is responding to treatment at home.
• Whether the person requires treatment of an underlying cause (e.g. radiotherapy to a tumour, drainage of a pleural effusion).
• If the decision is made to treat at home, consider treatment with an appropriate antibiotic.
• Discuss with a specialist if there is uncertainty regarding appropriate treatment or place of management.
• Also consider symptomatic treatment (e.g. to enhance the effectiveness of, or suppress, the cough). For information on symptomatic treatment, see When to consider symptomatic treatment.

• The decision whether or not to treat a chest infection in the terminal phase often causes concern and depends on the individual's circumstances.
• In the terminal phase, antibiotics do not greatly alter the course of events, but their use is justified if it will make the person more comfortable (e.g. by reducing thick, infected sputum).
• Management of symptoms, such as fever and respiratory secretions may be an alternative. (See the CKS topic on Palliative cancer care - secretions.)

[Doyle et al, 2004; Regnard and Hockley, 2004].

• If the decision has been made not to prescribe antibiotic treatment, this will need careful and sympathetic discussion with family or carers, who may perceive this as 'giving up' on their loved one, or leaving them to suffer. 
• If a pleural effusion is suspected, consider referral for drainage [Doyle et al, 2004].
• Consider vocal cord paralysis leading to aspiration in people with recurrent pneumonia [Warrell et al, 2003].

• These recommendations are based on pragmatic advice and expert opinion from medical and palliative care literature [Warrell et al, 2003; Ahmedzai, 2004; Doyle et al, 2004; Estfan and LeGrand, 2004; Regnard and Hockley, 2004].

• Determine with the person, and their carers and family, what management interventions are appropriate for the underlying cause of cough and the stage of illness, for example:
• Treatment of the underlying cause of the cough if possible.
• Referral for treatment of the underlying malignancy if needed (e.g. radiotherapy to a tumour, drainage of a pleural effusion).
• Referral if the cause of the cough is not directly related to the underlying malignancy, but is more appropriately managed in secondary care (e.g. worsening chronic obstructive pulmonary disease).
• Admission to hospital (e.g. acute exacerbation of heart failure).
• If treatment of the underlying cause is not possible, or does not relieve the cough, consider symptomatic treatment (e.g. to enhance the effectiveness of, or suppress, the cough).

• Treatment will depend on the cause:
• The management of malignant causes of cough (e.g. tumour) should involve a specialist in view of the need to tailor treatment to the person's underlying malignancy and co-existing problems, and the large variety of treatments available. These include radiotherapy, aspiration of a pleural effusion, or corticosteroids.
• If drugs (e.g. angiotensin-converting enzyme inhibitors) are thought to be causing the cough, review the person's medication, as it may be appropriate to stop certain drugs or switch to an alternative [Pan-Glasgow Palliative Care Algorithm Group, 2005].
• Bronchorrhoea will necessitate specialist advice, as many different treatments (e.g. radiotherapy, chemotherapy, antimuscarinic drugs, nebulized terbutaline, nebulized indometacin, or octreotide) have been tried with variable success [Doyle et al, 2004].
• There are separate CKS topics which deal with the management of common causes of cough. These will usually be managed in primary care, but in some cases admission to hospital, or secondary care advice may be necessary. For more information, see the CKS topics on:
• Asthma
• Chronic obstructive pulmonary disease
• Dyspepsia - proven GORD
• Heart failure - chronic
• Symptomatic treatment of cough will depend on whether this is appropriate for the person, and whether the cough is dry, moist and productive, or moist and non-productive. For more information, see When to consider symptomatic treatment.

• This recommendation is based on palliative care guidelines [Pan-Glasgow Palliative Care Algorithm Group, 2005] and expert opinion from palliative care literature [Ahmedzai, 2004; Doyle et al, 2004; Estfan and LeGrand, 2004].

• Consider symptomatic treatment if one or more of the following applies:
• The option of treating the underlying cause is not possible or is inappropriate.
• The person remains distressed by symptoms despite treatment of the underlying cause.
• The person is in the terminal phase of life. For information on recognizing the terminal phase, see the CKS topic on Palliative cancer care - general issues.

• This recommendation is based on pragmatic advice and expert opinion from the palliative care literature [Ahmedzai, 2004; Estfan and LeGrand, 2004].
• Cough may be very distressing in the terminal phase of cancer. The act of coughing may cause or aggravate pain, it may disturb sleep, and it can impede communication between people with cancer and their carers [Ahmedzai, 2004].

• Dry cough is usually managed with simple measures and cough suppressants, unless dyspnoea is a feature (see the CKS topic on Palliative cancer care - dyspnoea).
• Determine with the person, and their carers and family, what management interventions are appropriate for the stage of illness and consider:
• Simple measures first:
• Humidify room air.
• Simple Linctus BP.
• A weak opioid cough suppressant if symptom relief is not adequate.
• Pholcodine Linctus BP 10 mL (10 mg) three to four times a day.
• Codeine Linctus BP 5 mL to 10 mL (15 mg to 30 mg) three to four times a day.
• Codeine phosphate tablets 30 mg to 60 mg every 4 hours.
• A strong opioid cough suppressant if cough is persistent.
• Morphine at an initial dose of 5 mg every 4 hours.
• Morphine solution 2.5 mg to 5 mg four times a day up to every 4 hours.
• Seeking specialist advice if all these regimens fail, to discuss:
• Treatment of the underlying cause (e.g. radiotherapy).
• Use of oral corticosteroids.
• Use of a drug with nonspecific cough suppressant activity such as a (nebulized) local anaesthetic.

• With symptomatic management, adopt a stepwise approach [Homsi et al, 2001].
• Boiling water should not be used for moist inhalations because of the risk of scalding [BNF 53, 2007].
• When using an opioid cough suppressant, co-prescribe:
• A regular stimulant laxative (e.g. senna or bisacodyl) with a faecal softener (e.g. docusate or lactulose), or a laxative likely to have both properties (e.g. co-danthramer or co-danthrusate) to prevent opioid-induced constipation. Note: people taking dantron-containing laxatives may experience reddening of the perianal area.
• An anti-emetic (e.g. haloperidol or metoclopramide) should be prescribed [Twycross et al, 2002]:
• Regularly for the first week to prevent opioid-induced nausea and vomiting if the person has experienced nausea with a weak opioid, or
• On standby, for use on an 'as required' basis for a week, in case the person experiences nausea with morphine but has not previously had nausea with a weak opioid.
• Nebulized local anaesthetic options include, 2% lidocaine 5 mL or 0.25% bupivacaine 5 mL every 6–8 hours. However, the use of nebulized local anaesthetics is limited by [Twycross and Wilcock, 2001]:
• An unpleasant taste.
• Oropharyngeal numbness.
• Risk of bronchoconstriction.
• A short duration of action (10–30 minutes).
• In the terminal phase, oral opioid cough suppressants are best when cough is causing distress, or when other symptoms (e.g. pain, dyspnoea, diarrhoea) are also being treated [Homsi et al, 2001].

• This recommendation is based on palliative care guidelines [Kvale, 2006] and expert opinion from the palliative care literature [Ahmedzai and Davis, 1997; Homsi et al, 2001; Twycross and Wilcock, 2001]. Note: CKS were unable to find good quality trial data to support any of the symptomatic treatments recommended in this palliative care population.
• Simple measures enable people with cancer to exert some control over cough treatment, and are often comforting:
• There is little published evidence available on the use of nebulized drugs in the symptomatic management of people with cough (and/or breathlessness) related to malignancy [Ahmedzai, 1997].
• Simple Linctus BP has a high sugar content that simulates saliva production and soothes the oropharynx. The associated swallowing may also interfere with the cough reflex. Any beneficial effect is short lived, so increasing the dose or trying another compound cough mixture is not recommended if there is no benefit [Twycross et al, 2002]. In people with diabetes, consider using a sugar-free cough suppressant.
• With Pholcodine Linctus BP and Codeine Linctus BP, it has been suggested that the licensed doses are probably lower than the doses needed to relieve cough [Fuller and Jackson, 1990].

• Determine with the person, and their carers and family, what management interventions are appropriate for the stage of illness and consider:
• Treatment of infection with an appropriate antibiotic.
• Encouraging expectoration in people with an effective cough mechanism (i.e. those who are able to expectorate secretions):
• Use nebulized saline solution for tenacious secretions (physiotherapy in addition to nebulized saline may be of benefit, however, availability in the community may be limited).
• Use a mucolytic to reduce the viscosity of the secretions.
• Humidifying the air or oxygen (if needed) in people with a dry mouth.
• If a person is at the terminal stage of life and unable to expectorate, consider:
• Drying of secretions, see the CKS topic on Palliative cancer care - secretions.
• Using morphine as a cough suppressant.

• With symptomatic management, adopt a stepwise approach [Homsi et al, 2001].
• Whether or not treatment to loosen secretions or encourage expectoration is considered will depend on the stage of the person's illness and the effectiveness of their cough.
• Use of nebulized saline can result in the production of copious liquid sputum and this makes it unsuitable for those who are unable to expectorate [Davis, 1997].
• If considered appropriate, nebulized 0.9% saline solution should be given as 2.5 mL to 5 mL four times a day [Ahmedzai and Davis, 1997; Twycross and Wilcock, 2001; Twycross et al, 2002].
• Cough suppressants should be avoided except in situations such as when the cough is distressing in a dying person who is too weak to expectorate. Cough suppressants may help to ensure sleep at night and to prevent exhaustion during the day [Twycross and Wilcock, 2001].
• When using an opioid cough suppressant, consider the need to prevent opioid-induced constipation, nausea, and vomiting.

• This recommendation is based on palliative care guidelines [Lothian Palliative Care Guidelines Group, 2004] and expert opinion from the palliative care literature [Ahmedzai and Davis, 1997; Twycross and Wilcock, 2001; Ahmedzai, 2004]. Note: CKS were unable to find good quality trial data to support any of the symptomatic treatments recommended in this palliative care population.
• Body positioning is important as coughing is not effective when supine (lying on the back).
• In the terminal phase, oral opioid cough suppressants are best when cough is causing distress, or when other symptoms (e.g. pain, dyspnoea, diarrhoea) are also being treated [Homsi et al, 2001]. Morphine can be used to suppress a productive cough at the end of life, and morphine solution offers more flexibility because the dose can be titrated upwards against symptoms.
• There is little published evidence on the use of nebulized drugs in the symptomatic management of people with cough (and/or breathlessness) related to malignancy [Ahmedzai, 1997].
• A very small trial (n = 8) found use of nebulized saline for approximately 5 minutes prior to chest physiotherapy in people with bronchiectasis may give more benefit than use of nebulized saline alone [Sutton et al, 1988].
• Mucolytic treatments may help to reduce the viscosity of the secretions [Davis, 1997].
• Humidifying the air or oxygen can help people with a dry mouth as they may have a reduction in tracheobronchial mucus which can cause difficulty with expectoration [Ahmedzai, 2004].