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Palliative cancer care - cough - Management
How should I manage a dry cough symptomatically in palliative care?

  • 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.
Clarification / Additional information
  • 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].
Basis for recommendation
  • 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].

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