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  1. 1. DRUGS FOR COUGH Dr.Vijay Bhushanam
  2. 2. Cough (Introduction) • Cough is an explosive expiration, that provides a normal protective mechanism for clearing the tracheo-bronchial tree of secretions and foreign material. • When excessive or bothersome, it is also one of the most common symptoms for which patients seek medical attention. • Reasons for this include discomfort from the cough itself, interference with normal lifestyle, and concern for the cause of the cough, especially fear of cancer.
  3. 3. Mechanism of cough • Coughing may be initiated either voluntarily or reflexively. • As a defensive reflex it has both afferent and efferent pathways. • The afferent limb includes receptors within the sensory distribution of the trigeminal, glossopharyngeal, superior laryngeal and vagus nerves. • The efferent limb includes the recurrent laryngeal nerve and the spinal nerves.
  4. 4. Mechanism of cough (Cont.) • Deep inspiration glottic closure  relaxation of the diaphragm  muscle contraction against a closed glottis  markedly positive intrathoracic pressure narrowing of the trachea  glottis opens at once  the large pressure differential between the airways and the atmosphere coupled with tracheal narrowing produces rapid flow rates through the trachea COUGH • The shearing forces that develop aid in the elimination of mucus and foreign materials.
  5. 5. Etiology of Cough • The most common causes of cough can be categorized according to the duration of the cough. • Acute cough (<3 weeks): URTIs (especially the common cold, acute bacterial sinusitis, and pertussis), pneumonia, pulmonary embolus, and congestive heart failure. • Sub-acute cough (3-8 weeks): post-infectious • Chronic cough (>8 weeks): In a smoker: chronic obstructive lung disease or bronchogenic carcinoma. In a nonsmoker: postnasal drip (sometimes termed the upper airway cough syndrome), asthma, and gastroesophageal reflux.
  6. 6. Types of Cough • Non-productive (dry): No useful purpose, increases discomfort to the patient  needs suppression • Productive (tenacious): Presence of excessive sputum  suppression not desired  needs coughing/clearing out of the sputum
  7. 7. Classification of drugs for Cough • • • • Pharyngeal demulcents: Lozenges, cough drops, linctuses containing syrup, Glycerine, Liquorice Expectorants: 1. Mucokinetics (Bronchial secretion enhancers): Sodium or potassium citrate, Potassium iodide, Guaphenisin (Glyeryl guaiacolate), balsum of Tolu, Vasaka, Ammonium chloride. 2. Mucolytics: Bromhexene, Ambroxol, Acetylcystein, Carbocystein Antitussives (Cough center supressants): a) Opioids: Codein, Pholcodein b) Non-opioids: Noscapine, Dextromethorphan, Chlophedianol c) Antihistaminics:Chlorpheniramine, Diphenhydramine, Promethazine Adjuvant antitussives: Bronchodilators: Salbutamol, Terbutaline
  8. 8. Pharyngeal demulcents • Sooth the throat and reduce afferent impulses from the inflamed/irritated pharyngeal mucosa. • E.g: Lozenges, cough drops, linctuses containing syrup, Glycerine, Liquorice
  9. 9. Expectorants • Increase bronchial secretions or reduce its viscosity, facilitating its removal by coughing • E.g: • Mucokinetics (Bronchial secretion enhancers): Sodium or potassium citrate, Potassium iodide, Guaphenisin (Glyeryl guaiacolate), balsum of Tolu, Vasaka, Ammonium chloride. • Mucolytics: Bromhexene, Ambroxol, Acetylcystein, Carbocystein
  10. 10. Antitussives (Cough center supressants) • These act – in CNS to raise the threshold of cough center (and/or) – peripherally in Respiratory tract to reduce tussal impulse • Should be used only for dry unproductive cough (or) • if the cough is unduly tiring, disturbs sleep (or) • is hazardous (hernia, piles, cardiac ds., ocular surgery etc) • E.g: • Opioids: Codein, Pholcodein • Non-opioids: Noscapine, Dextromethorphan, Chlophedianol • Antihistaminics: Chlorpheniramine, Diphenhydramine, Promethazine
  11. 11. Bronchodilators • Bronchospasm can induce/aggravate cough, especially in individuals with bronchial hyperreactivity • Bronchodilators relieve cough in such individuals • Improve the effectiveness of cough in clearing secretions by increasing the surface velocity of airflow during cough • E.g: Salbutamol, Terbutalin
  12. 12. Antitussive/Expectorant Combinations • AMBRODYL PLUS: Ambroxol, Chlorpheniramine, Salbutamol, Guaphenesin. • ASTHALIN: Salbutamol, Guaphenesin. • ASCORIL-C: Codeine, Chlorpheniramine. • BENADRYL: Diphenhydramine, Ammonium chloride, Sodium citrate, Menthol. • GRILINCTUS: Dextromethorphan, Chlorpheniramine, Guaphenesin, ammonium chloride.
  13. 13. Specific Rx for cough • URTI/LRTI  Appropriate antibiotics • Smoking/Chr. Bronchitis  Cessation of smoking/ avoidance of pollutants • PTB ATT • Post nasal drip due to sinusitis Antibiotics/Nasal decongestants/H1 antihistaminics • Postnasal drip due to allergy Avoidance of precipitating factors/Corticosteroid nasal spray/H1 antihistaminics • GERD H2 blockers/PPIs/Cisapride • ACE inhibitor induced cough  Switch to ARBs/CCBs • Asthmatic cough Inhaled β2 agonists/Ipratropium/Corticosteroids
  14. 14. THANK YOU