for pharmacists, how to make differential diagnosis & recommendations for mild ailments in community pharmacy

1. Responding to
symptoms
LectuRe 2
cough

2. RespiRatoRy
system

4. Background :
General review of the anatomy of the respiratory tract :
1- upper respiratory tract :
Nasal cavity :
-Is the internal portion of the nose
-Connected to the pharynx
-Function is :
1- filters out large dust particles
2- Warms and moisten incoming air

5. Pharynx :
Divided into 3 sections :
1- nasopharynx : exchange air with the nasal cavity and
move the particle matters towards the mouth
2- oropharynx
3- laryngopharynx : both serve as common pathway for
air and food
Larynx ( voice box )
This is a short passage that connect the pharynx with the
trachea

6. Lower respiratory tract :
Trachea & bronchi :
The trachea connects the larynx with the bronchi
The bronchi divided and sub divided into bronchioles
The terminal bronchioles give rise to alveoli where
gaseous exchange take place .
they acts as defense mechanism , cilia on the surface
of cells beat upwards in organized waves of contraction ,
thus expelling foreign bodies

7. cough :

8. Definition :
Coughing is a protective reflex action caused when the
airway is being irritated or obstructed .
Its purpose is to clear the airway so that breathing can
continue normally
The majority of coughs presenting in the pharmacy will
be caused by viral infections , they will be often
associated with other symptoms of cold

9. Cough may be classified as:
1- productive cough : phlegm is produced
2- dry cough : no phlegm production
Cough is most commonly associated with other respiratory tract
infections

10. What you need to know :[ differential diagnosis ]
1- Age (approximate ) baby , child, adult …
-This will influence the choice of treatment and whether referral is
necessary

11. 2- Duration :
Most cough are self limited and will be better within a few days
without treatment.
-Cough longer than 2 weeks’ duration that is not improving should
be referred to the doctor for further investigation.
-Cough more than 3 months suggests tuberculosis or carcinoma

12. 3- Nature ( dry or productive ):
Dry cough : in this type no sputum is produced .
Usually caused by viral infection and self limited
Productive cough : sputum is normally produced
Over secretion may be caused by irritation of the airways due to
infection ,allergy , ….etc

13. Sputum colour :
-Mucoid ( clear & white ) is normally of little consequence and
suggests that no infection is present
-Yellow , green or brown sputum , normally indicates infection ,
however mucopurulent sputum is probably caused by bacterial infection
such as bronchitis or pneumonia and required referral to GP. In this case
the patient is generally unwell and has raised temperature (fever )
-Heamoptysis: blood in the sputum , this may be rusted coloured
(pneumonia ) or pink but thin and frothy ( left ventricular failure ) , or dark
red ( carcinoma )

14. 4- periodicity :
-Adults with recurrent cough might have chronic bronchitis
especially if they smoke ( smoking cessacion will help reduce
cough symptoms and complications )
-Recurrent cough in children who have family history of eczema ,
asthma or hay fever should be referred that they may required
further investigations and pulmonary function tests (e.g peak
expiratory flow assessment )

15. 5- Associated symptoms
( cold , sore throat , fever ) may be associated with a cough
There may be a raised temperature and muscular aches ( this would be in
keeping with viral infections
Shortness of breath , wheezing are all indicator of refer
tuberculosis ( TB):
Chronic cough with hemoptysis associated with chronic fever and night sweats

16. croup (acute laryngotacheitis ) :
-Usually in infants
-The cough has a harsh barking quality
-It develop one day or two after the onset of cold like symptoms
-Often associated with difficulty in breathing and an inspiratory stridor
( noise in throat on breathing in ) referral is necessary
asthma :
-Recurrent night time cough can indicate asthma especially in children
and should be referred
-A family history of aczema , asthma ,hay fever

17. cardiovascular :
-Coughing can be symptom of heart failure
-Patients may complain of productive ,frothy cough which may have pink –tinged
sputum
smoking habits :
-Smoking will exacerbate a cough and can cause coughing since it is irritating the
lung
-Smokers may assume their cough is harmless , it is always important to ask
about any change in the nature of the cough that might suggest a serious cause
carcinoma of the lung :
-Possibility increase in long term cigarette smokers who had have cough for
several months
-Sputum with blood
-Weight loss
-Fatigue
-Dyspnea

18. Angiotensin-converting enzyme inhibitors (ACE inhibitors ):
-Patients taking ACEI (enalapril, captopril, lisinopril , ramipril ) may complain of
chronic dry cough
-Patients may develop cough within days of starting treatment or after period of
few weeks or months

19. When to refer :
1- cough for 2 weeks or more with no improvement
2- sputum ( yellow, green , pink , blood stained )
3- chest pain
4- shortness of breath
5- wheezing
6- barking cough
7- recurrent nocturnal cough in children
8- suspected adverse drug reaction

20. Management :
-The choice of treatment depend on the type of cough
-They are many types :
1-cough suppressant ( for dry cough ):
-Mainly the opiate derivatives ( codeine , phlocodeine , dextromethorphan )
-They act centrally so the main side effect is sedation ( advice patient not to
drive or operate machines )
-Can cause respiratory depression ( contraindicated for asthmatic )
-Dextromethorphan can be given for children older than 1 year but generally
not recommended for children less than 5 years

21. 2- Expectorants (productive cough )
-These are ammonium salts , ipecacuanha , guaifensine
-Guaifensine should be recommended as first-line treatment fr productive
cough

22. Practical points :
1- insulin dependent diabetics :
-Should be asked to monitor their blood glucose frequently because insulin
requirements increased during acute infections.
-May prefer low or sugar free syrups although the effect in blood sugar Is
non-significant
2- alternative delivery routes :
-Lozenges now are available to treat cough , it is more practical than syrups

23. 3- steam inhalation :-
-Advice patient for steam inhalation especially in productive cough . It helps
liquefy lung secretions
4- fluid intake :
- maintaining a high fluid intake helps to hydrates the lung and hot drinks
can have soothing effects

24. A Cough Suppressants
1. Codeine/pholcodine
Both are effective cough suppressants.
Pholcodine has several advantages over the codeine, in that:
a) It produces fewer side effects (at OTC doses codeine can cause
constipation and at higher doses, respiratory depression)
b) Pholcodine is less liable to abuse.
For these reasons, codeine is best avoided in the treatment of children’s
coughs and should never be used in children under a year old.

25. • Both pholcodine and codeine can induce drowsiness, although in
practice this does not appear to a problem. Nevertheless it is sensible to
give an appropriate warning.
• Codeine is well known as a drug of abuse and many pharmacists
choose not to recommend it.
• Dose:
Pholcodine can be given at a dose of 5 mg to children over 2 years.
Adults may take doses of up to 15 mg up to 3-4 times daily.
The drug has a long half-life and may be more appropriately given as a
twice daily dose.

26. 2. Dextromethorphan
This is an effective but less potent cough suppressant than codeine and
pholcodine.
It is non-sedating and has few side effects.
Occasionally drowsiness has been reported, but, as pholcodine, this does not
seem to be a problem in practice.
Dextromethorphan can be given to children of 2 years and over.
Dextromethorphan was generally thought to have a low potential for abuse.
However, there have been rare reports of mania following abuse and
consumption of very large quantities, and pharmacists should be aware of this
possibility if regular purchase is made

27. 3. Demulcents
Preparations such glycerine, lemon and honey are popular and
useful for their soothing effects.
They don’t contain active ingredients and are safe in children
and pregnant women.
Their pleasant taste makes them suitable for children but their
high syrup content preclude their use in diabetics.

28. B -Expectorants
Two mechanisms have been proposed for expectorants:
They may act directly by stimulating bronchial mucus secretion,
leading to increased liquefying sputum, making it easier to cough up.
They may act indirectly via irritation of the GIT which has a subsequent
action on the respiratory system causing increased mucus secretion.
The latter theory has less evidence.
.

29. Cough remedies – other constituents
1. Antihistamines
Examples used in OTC include diphenhydramine and
promethazine.
In theory, they reduce the frequency of coughing and have a
drying effect on secretions, but in practice they also induce
drowsiness. ( may be useful in nocturnal cough )
Combinations of antihistamines with expectorants are illogical
and best avoided.

30. A combination of antihistamine and cough suppressant may be useful
in that antihistamines can help to dry up secretions, and when the
combination is given as a night-time dose if the cough is disturbing sleep, a
good night’s sleep will invariably follow – one of the rare occasions when a
side effect proves useful.
The non-sedating antihistamines are less effective in symptomatic treatment
of coughs and colds because of their less pronounced anticholinergic
actions.

31. 2. Sympathomimetics
Examples include pseudoephedrine and phenylpropanolamine.
These are commonly included in cough and cold remedies for their
bronchodilatory and decongestant actions.
Phenylpropanolamine is a weaker bronchodilator than ephedrine
and pseudoephedrine.
They may be useful in productive coughs.

32. All three have a stimulant effect which lead to a sleepless night if
taken close to bedtime.
These drugs can cause raised blood pressure, stimulation of the heart
and alterations in diabetic control.
Oral sympathomimetics should not be recommended for patients with
diabetes, coronary heart disease (angina), hypertension and
hyperthyroidism

33. Practical Points
A. Diabetics
Current thinking is that in short-term acute conditions, the amount of sugar
in cough medicines for short-term use is relatively unimportant.
Diabetic control is often upset during infections and the additional sugar is
not now considered to be a major problem.
Nevertheless many diabetic patients may prefer a sugar-free product, as
will many other customers who wish to reduce sugar intake for themselves
and for their children.
As part of their contribution to improving dental health, pharmacists can
ensure that they stock and display a range of sugar-free medicines.

34. B. Steam inhalations
These can be very useful, especially in productive cough.
The steam helps to liquify lung secretions, and patients find the warm
moist air comforting.
While there is no evidence that the addition of medications to the water
produces better clinical effect than steam alone, some may prefer to add a
preparation such as menthol and eucalyptus.
One teaspoonful of inhalation should be added to a pint of hot (not
boiling) water and inhaled. Apart from the risk from scalding, boiling water
volatilizes the constituents too quickly.
A cloth/towel can be put over the head to trap the steam.

35. C. Fluid intake
Maintaining a high fluid intake helps to hydrate the lungs and hot
drinks can have soothing effect.
General advice with coughs and cold should be to increase fluid intake
by around 2 litres a day.

36. Thank
you