Cough Management

• Pharmacologyc
• Non Pharmacologyc
→ Environment Control
(indoor and outdoor)
→ Avoidance
→ Plenty of water for
hydration
 Drugs for Cough
• Depend on the etiology
• Main drugs
– Bronchodilator → bronchoconstriction
– Antibiotic: etiology → bacterial infection
– Anti-inflammation → airway inflammation
• Supporting drugs
– Mucoactive (protussive agent)
– Antitusive ?
 Pharmacologic Therapy
(based on etiology of cough)
Disease Drugs Examples
Asthma Bronchodilator Salbutamol, procaterol,
Fenoterol, terbutaline

Inhaled Steroid Budesonide, fluticason

Rhinosinusitis / Nasal Steroid Mometasone, fluticason

Allergic rhinitis
Anti histamine Cetirizine

Pertussis Antibiotics macrolide Azythromicin, clarythro

Tuberculosis Anti TB RHZE
GERD PPI Omeprazole
 COUGH EFFECTIVENESS
DEPENDS ON
• The ability to generate high velocities of the air
stream
• Dispersion of liquid mucus into the air stream
(misty flow)
• Increase the waves of mucus
• Vibration of the bronchus wall
• The physical property of the mucus

4
McCool FD. Chest 2006;129:48S-53S.
 IMPAIRED OF MUCOCILIARY
• Altered mucus rheology
- increase viscosity, decreased elasticity
- increase secretion

• Ciliary impairment
- primary dyskinesia (genetic defect)
- secondary dyskinesia (infection,
polutants)
 ENHANCED MUCOCILIARY
CLEARANCE
• Physioterapeutic regimen
(postural drainage, positive expiratory
pressure, forced expiration technique,
regular exercise)

• Pharmacological therapies
“mucoactive agent”
 Anticholinergic Opioids
Expectorant
Mucolytic

Anti-inflammatory:
Corticosteroids
Leukotriene
antagonist

15 Bronchodilator

Cough reflex afferent pathway and drug center activity

 MUCOLYTIC
• Drugs that decrease mucus viscosity
Classic mucolytics
- N acetylcystein (NAC): may dissociate mucin disulphide
bonds and other disulphide bond cross-linked gel
components to reduce viscosity
- Erdostein : metabolite act as NAC

Peptide mucolytics
rhDNAse
Break down the highly polymerised DNA and F-actin network
eg. rhDNase proteolytic enzyme that cleaves DNA polymer

Non-destructive mucolytics
Dextran and Heparin
Dissociate or disrupt the polyionic oligosaccharide mucin
network by a mechanism termed “charge shielding”
 Acetylcysteine and carbocysteine for
acute upper and lower respiratory tract
infections in paediatric patients
without chronic broncho-pulmonary
disease (Review)

❑Six trials involving 497 participants

❑They showed benefit for mucolytics
(reduction of cough at day seven)
❑Overall safety was good , very few data were available
in infants younger than two years.
❑Mucolytics acetylcysteine and carbocysteine could be
used for acute URTI and LRTI in pediatric patients

Chalumeau M, 2013
Multicenter, RCT to compare a combination of erdosteine-amox VS
placebo-amox combination in children with ALRI

A total of 158 patients (78 erdosteine group and 80 placebo group) were
treated for 7 +/- 2 days

The severity of cough was decreased by 47% at Day 3 in the

erdosteine group with a statistically significant difference, & still
significant at the final visit.

The decrease in the severity of rales was significantly greater at Day 3

in the erdosteine group than in the placebo group

No important adverse reaction have been observed and also the

biological safety was ensured
To evaluate erdosteine as adjuvant therapy in
rhinosinusitis
RCT, double blind

Complete improvement 78% in treatment, 74.4% in control

There were NO clinically detected serious side effect or
complications
Safety & tolerability
 Anti Tussive and OTC Drugs
• Children are different from adult.
• OTCs (antitussives, antihistamine,
decongestant, analgetics) has no benefit in the
symptomatic control of cough in children.
• OTCs have significant evidence in morbidity and
mortality.
• Only in certain condition anti-tussive can be
given to children with cough, for example for
pertussis.
Schaefer MK. Pediatrics 2008; 121: 783 - 787.
Rimsza ME. Pediatrics 2008; 122: e318 - e322.
Cough Remedies
 Conclusion
• Cough in children is caused by various etiology.
• Age of children and specific pointers of chronic
cough can guide to certain diagnosis
• The management of the cough is based on the
underlying diseases.
• Physicians should aware in prescribing cough
and cold medications which contains antitussive,
anti histamine or other symptomatic drugs
• Mucoactive agent can help to produce effective
cough for clearing the mucous