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

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

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