• Scenario: Assessment of cough: covers the potential causes of cough in palliative cancer care, and the history, examination, and investigations which may be necessary to elicit the cause of the cough.
• Scenario: Known cause of cough: covers the palliative cancer care management of a person with cough of known cause, including infection.
• Scenario: Symptomatic treatment: covers the palliative cancer care management of a person with cough of unknown cause, including symptomatic management of dry and moist cough.

• Ask about the:
• Impact on the person's quality of life.
• Severity, time of onset, and duration of the cough.
• Pattern and character of the cough, for example:
• 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.
• Dyspnoea — effusion, lung collapse, lymphangitis carcinomatosa. For more information on causes and management of dyspnoea, see the CKS topic on Palliative cancer care - dyspnoea.

In depth

• Examine the person to help determine the underlying cause of the cough:
• Decreased chest wall movement — lung collapse, pleural effusion.
• Percussion note — dull in the case of lung collapse, stony dull in the case 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 present, see the CKS topic on Palliative cancer care - dyspnoea.
• Assess the effectiveness of the cough, and whether it is dry, moist, productive, or non-productive.

In depth

• Weigh the appropriateness of investigation and treatment against the prognosis, the likely benefit of treatment, and the person's wishes.
• The exact investigations requested will depend on the clinical assessment.

In depth

• Treat the underlying cause of the cough if possible and appropriate.
• Aim to relieve symptoms (e.g. 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 psychological, social, and spiritual needs.

In depth

• 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 more information, see Scenario: Symptomatic treatment.

In depth

• 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). For more information, see Scenario: Symptomatic treatment.

In depth

• 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. See the CKS topic on Palliative cancer care - general issues.

In depth

• Use simple measures first — humidify room air, Simple Linctus BP.
• If symptom relief is not adequate, use a weak opioid cough suppressant — Pholcodine Linctus BP 10 mL (10 mg) three to four times a day, or Codeine Linctus BP 5 mL to 10 mL (15 mg to 30 mg) three to four times a day, or codeine phosphate tablets 30 mg to 60 mg every 4 hours.
• If cough is persistent, use a strong opioid cough suppressant — morphine in an initial dose of 5 mg every 4 hours, or morphine solution 2.5 mg to 5 mg four times a day up to every 4 hours.
• If all these measures fail, seeking specialist advice.
• If dyspnoea is a feature see the CKS topic on Palliative cancer care - dyspnoea.

In depth

• Treat infection, if present, with an appropriate antibiotic.
• In people with an effective cough mechanism and tenacious secretions — use nebulized saline solution (physiotherapy in addition may be of benefit), or a mucolytic.
• In people with a dry mouth — humidifying the air or oxygen (if needed).
• 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), or using morphine as a cough suppressant.

In depth

• For people with a moist cough and tenacious secretions, nebulize 0.9% saline solution 2.5 to 5 mL four times a day. If greater relief is required, gradually increase nebulizer use up to every 2 hours. Review after 48 hours.

In depth

• If the person is already taking a strong opioid such as morphine, do not use pholcodine. Use an as required dose of morphine.
• Pholcodine Linctus BP 10 mg may be taken three to four times a day.
• Pholcodine is mildly sedative — warn people to avoid activities where drowsiness may be detrimental.
• If pholcodine is ineffective, switch to morphine solution 5 mg to 10 mg every 4 hours and 'as required'.

In depth

• If the person is already taking a strong opioid such as morphine, do not use codeine. Use an as required dose of morphine.
• Codeine linctus BP 5 mL to 10 mL (15 mg to 30 mg) may be taken three to four times a day.
• If a dose requiring a large volume of linctus is required, consider using codeine phosphate tablets (off-licence use). Codeine phosphate tablets can be taken in a dose of 30 mg to 60 mg three to four times a day.
• If codeine is ineffective, switch to morphine solution 5 mg to 10 mg every 4 hours and 'as required'.

In depth

• For someone not already taking an opioid, a dose of 2.5 mg — every 4 hours and as required.
• For someone in whom a weak opioid (e.g. codeine or pholcodine) was ineffective, use a dose of 5 mg to 10 mg — every 4 hours and as required.
• After 1–2 days, calculate the total dose given over 24 hours, and use this to recalculate the 4-hourly dose. (The new 4-hourly and 'as required' dose is a sixth of the new total daily dose.)
• Repeat this process every 1–2 days until the cough is controlled.
• Once a stable dose has been reached, consider converting to modified-release morphine.
• For someone already taking a strong opioid such as morphine, use an 'as required' dose of morphine.
• If an 'as required' dose relieves cough, either increase the regular daily dose by 30–50% every 2–3 days until symptoms are controlled or adverse effects prevent further dose increases, OR continue to use additional morphine as required. If the total daily dose is increased, recalculate the 'as required' dose.
• If an 'as required' dose of morphine does not relieve cough, there is little point continuing to increase the dose.
• Some people with cough but no pain can benefit from a dose of morphine at bedtime to prevent cough from disturbing sleep.

In depth