Palliative Care Guidelines - NHS Lanarkshire

Cough in Palliative CareIntroductionPalliative Care Guidelines: CoughCough has a useful protective function but symptomatic treatment may be indicated when it isdistressing or affecting sleep/ activity.Reversible causes should be identified and treated.Management• Ensure adequate analgesia – pain may be inhibiting effective coughing.• Physiotherapy assessment if difficulty coughing retained secretions.Management of common causes of cough in palliative careCancer related causesTreatmentStridor due to airway obstructionLymphangitis, disease progressionTracheo-oesophageal fistula withaspiration (cough after swallowing)Ineffective cough (eg due to recurrentlaryngeal nerve palsy, weakness, pain)Malignant pleural effusionPneumonitisOther causesSmokingAspirationGastro-oesophageal refluxInfectionACE inhibitorPost-nasal dripCardiac failure, COPD, asthmaMedicationDexamethasone 16mg or prednisolone 60mg (ifdexamethasone not available) orally.Seek oncology/ respiratory medicine advice.Seek oncology advice; consider a trial of steroids.Seek specialist advice – stenting may be possible.Supportive care.Vocal cord injection may help a patient withlaryngeal nerve palsy – refer to ENT.Consider pleural drainage +/- pleurodesis.Seek oncology advice; corticosteroids.Smoking cessation advice if appropriate.Antibiotics if infection, or an antisecretory such ashyoscine butylbromide (see: Last days of life).Proton pump inhibitorProkinetic eg. metoclopramide, domperidone.Antibiotics – see local guidelines.Stop or switch to alternative medication.Nasal decongestant spray, nasal corticosteroid,antihistamine.Optimise treatment.• Simple linctus BP 5ml, 3 times daily.• Nebulised 0.9% sodium chloride 2.5-5ml can help loosen secretions.• Opioid: titrate according to response, monitor for side effects (eg constipation).o Codeine linctus BP (15mg/ 5ml) 5-10ml, 6-8 hourly and/or at bedtime.o Oral morphine liquid 2mg, 6-8hourly or at bedtime.o Methadone linctus (2mg/5ml) 2.5ml at bedtime (specialist advice only).Non-drug• Posture - it is impossible to cough effectively when lying flat.Key References1. Morrice AH. British Thoracic Society recommendations for the management of cough in adults. Thorax 2006;61:1-242. Leach M. Cough. Oxford Textbook of Palliative Medicine, 3 rd Edition 2004, p 899-901© NHS Lothian Issue date: January 2009 Review date: March 20121