Coughs and sore throats-Module 147
Coughs and sore throats are common minor ailments. But with a variety of different causes and symptoms, treating them is not as easy as you might think
• the different types of cough
• when cough treatments should be used
• how to manage a sore throat, and the different ingredients available in lozenges
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Cough and sore throat are two of the most common ailments you will encounter in the pharmacy. Most coughs and sore throats are caused by a virus that has infected the respiratory tract, such as the common cold or flu. On average, adults experience two to three sore throats per year and most colds will be accompanied by a cough.
Coughs
A cough is a protective reflex action that helps clear the airways of mucus and irritants such as dust and smoke. In most cases it is a sign of infection, inflammation or irritation.
There are two main types of cough: dry and productive/chesty.
A dry cough feels like a persistent tickling in the back of the throat and is non-productive, meaning that no mucus is coughed up from the lungs. Dry coughs happen when the throat and upper airways become inflamed and swollen – the brain thinks this inflammation is an obstruction and tries to clear it with coughing.
In contrast, a productive or chesty cough is one that produces mucus (also known as phlegm or sputum). This thin, clear fluid is cleared from the lungs and brought up with each cough.
Colds and flu viruses tend to target the throat or windpipe – known as the upper airways – whereas lower respiratory tract infections such as bronchitis and pneumonia affect the airways deeper down in the lung.
Coughs can also be classified as either acute, subacute or chronic based on how long they last. Acute coughs last for less than three weeks and are usually caused by a respiratory tract infection.
Subacute coughs last anywhere from three to eight weeks. Chronic coughs persist for more than eight weeks and should always be referred to the pharmacist. Around 10-20 per cent of adults suffer from chronic coughing.
Possible causes include:
smoking
rhinitis
asthma
gastro-oesophageal reflux disease (GORD)
a side effect of ACE inhibitors – drugs used to treat heart failure and hypertension.
In children, a persistent cough can also be a sign of a more serious condition such as whooping cough. Symptoms to look out for include intense hacking bouts of coughing, a characteristic ‘whoop' sound, production of thick phlegm and vomiting (in infants and young children). If you have any suspicions that a customer's symptoms may be due to whooping cough, always refer the patient to the pharmacist.
Customers with the following symptoms should also be referred to the pharmacist before recommending an OTC cough remedy:
• green, yellow or rust-coloured phlegm – this suggests a bacterial infection
• blood in the phlegm
• shortness of breath or wheezing
• painful cough
• fever lasting more than 72 hours
• difficulty swallowing.
Cough treatments
OTC treatments for cough include cough suppressants, expectorants, demulcents and antihistamines.
Cough suppressants
Cough suppressants – also known as antitussives – act on the ‘coughing centre' in the brain to block the cough reflex. Examples include pholcodine and dextromethorphan.
These products are best for treating dry, tickly coughs. They generally have few side effects and are safe to take with other medications. However, it is important not to recommend them to customers with productive, chesty coughs – suppressing this type of cough will stop phlegm being cleared from the airways, making breathing more difficult and increasing the chance of a secondary bacterial infection.
Expectorants
A wide range of expectorant cough medicines is available containing active ingredients such as guaifenesin, ipecacuanha, ammonium chloride and squill. They are used to treat productive, chesty coughs.
Expectorants work by stimulating bronchial secretions to increase production of thin, watery fluid. This helps dilute and loosen the thick, sticky mucus in the airways, allowing it to be cleared by coughing. Expectorant cough medicines only contain small quantities of the active agent, so are unlikely to cause side effects
or interact with other drugs.
Demulcents
Demulcents such as glucose, glycerine and honey form a protective coating over the throat and help ease the irritation that causes coughing. These products give short-term relief from dry, irritating, tickly coughs.
Antihistamines
Antihistamines help to dry up secretions and suppress coughs. Examples include diphenhydramine and promethazine. They are most suitable for treating dry coughs. The antihistamines in cough medicines are often ‘sedating', which means they cause drowsiness and can help aid sleep (which may be disrupted by coughing). These products are best taken in the evening.
Patients should be advised to avoid driving or operating heavy machinery if affected by drowsiness. If a customer says they are taking other medicines, particularly antidepressants or drugs that cause drowsiness, check with your pharmacist as interactions may occur with antihistamines.
Because many cough medicines contain sugar, it is important to ask if a customer
has diabetes before recommending a product. Sugar-free options are available, so consult your pharmacist for advice on dealing with diabetic patients.
Also refer to your pharmacist for the best way to treat coughs in young children. OTC cough and cold medicines are not suitable for children under six years of age.
Some cough medicines also contain paracetamol to help relieve the pain and fever associated with colds and flu. Always check first if a product has paracetamol in it and – if it does – remind customers not to exceed the recommended dose or take it with other paracetamol-containing products.
In most cases, a cough will clear up on its own within two weeks. Cough medicines should not be taken for any longer than this. Any cough lasting longer than two weeks, or getting progressively worse, needs to be checked by a GP.
Sore throats
The majority of sore throats are caused by infection with viruses or bacteria. Common cold viruses are responsible for 25 per cent of all sore throats. The bacteria Streptococcus accounts for a further one in 10 adult cases and a third of sore throats in children. Other possible infectious causes include the influenza virus, herpes simplex type one (the virus that causes cold sores) and candida (the yeast that causes thrush).
Once an infection has taken hold, it causes redness and swelling at the back of the throat and in the tonsils. This inflammation results in the pain of a sore throat.
Less commonly, sore throats can result from a non-infectious cause such as:
• irritation – such as from cigarette smoke, coughing or mucus in the back of the throat
• GORD
• inflammation of the skin in the mouth (oral mucositis) – a side effect of cancer treatment rare conditions such as Kawasaki disease or leukaemia.
One third of sore throats will have no obvious cause.
Patients should be referred to the pharmacist if their sore throat has lasted more than five days or is accompanied by coloured spots on the throat, tonsils or tongue, fever, stiff neck, rash or difficulty breathing or swallowing.
These symptoms may indicate a more serious underlying infection such as tonsillitis or meningitis.
Customers taking other prescription medicines such as carbimazole should be referred to the pharmacist immediately. One of the more serious side effects of carbimazole, a treatment for an overactive thyroid gland, is bone marrow suppression – signs of which include infection and
sore throat.
Treating a sore throat
Simple sore throats usually resolve on their own within three to seven days. In the meantime, you can recommend from the range of OTC products available to help ease pain and discomfort.
Most sore throat treatments are formulated as lozenges or pastilles that target the affected area directly.
Sucking throat sweets has the added advantage of increasing saliva production, which itself helps to lubricate and moisten the throat.
Most pastilles and lozenges contain demulcent ingredients to soothe inflamed membranes and relieve irritation. Examples include glycerine and honey, which can be taken safely by most people.
However, as many throat lozenges have a high sugar content, customers with diabetes should be referred to the pharmacist. Sugar-free versions of most products are available.
Antibacterials
Many sore throat lozenges contain additional antiseptic agents – such as benzalkonium, hexylresorcinol and tyrothricin – to help fight the underlying infection as well as relieve symptoms.
These are beneficial when treating sore throats with an obvious infectious cause.
Local anaesthetics
Found in some lozenges and also available as throat sprays, anaesthetic agents such as benzocaine numb the pain and are particularly useful for customers with difficulty swallowing due to a sore throat.
These products are not suitable for children or elderly people and should not be used for more than five days.
Analgesics and anti-inflammatories
Conventional painkillers such as paracetamol and ibuprofen provide effective relief from sore throat pain and inflammation. Specialised lozenges are also available containing the NSAID flurbiprofen in combination with honey and lemon.
For customers complaining of a very inflamed throat, you can suggest gargling with soluble aspirin dissolved in water. Neither ibuprofen or aspirin are suitable for patients with a previous peptic ulcer or liver or kidney problems, and aspirin should never be given to children under 16 years of age.
Antibiotics are not generally recommended for the treatment of sore throats, but may be needed if there is a severe infection (such as tonsillitis) or for patients with weak immune systems or certain underlying medical conditions.
In these cases, a 10-day course of the antibiotic penicillin V is usually prescribed. Erythromycin or clarithromycin are effective alternatives for penicillin-allergic patients.
Self management
As well as OTC treatment advice, you can suggest self-care tips that can help customers cope with their coughs and sore throats.
Inhaling steam from a bowl of hot water with a towel over the head loosens phlegm and is particularly good for chesty coughs. Some oils can be added to the water can help relief nasal congestion.
Advise customers to keep warm and get plenty of rest. To keep hydrated, it is important to drink eight to 10 glasses of fluid a day – hot drinks with lemon and honey are particularly soothing for sore throats. Gargling with warm salt water can also help ease pain and inflammation in the throat.
By increasing their intake of vitamin C and zinc customers can boost their immune system which, together with frequent handwashing, may help prevent infection with cough and sore throat-causing viruses in the future.
Stopping smoking can also improve cough and sore throat symptoms.
Key points
• Patients with a dry cough should take a cough suppressant, or antitussive, while those with a chesty cough should take an expectorant
• You should refer patients with painful coughs, discoloured sputum (especially if there is blood) or difficulty breathing to the pharmacist
• Always ask the patient if they are on any other medication – particularly for diabetes, as many cough syrups contain sugar
• Most sore throats ease within three to seven days, and treatment focuses on making the patient as comfortable as possible with lozenges.
Evaluation
• Look at the cough preparations available in your pharmacy. Do you know their main ingredients, and which products to recommend to whom?
• Keeping hydrated is especially important when you are ill. Why?
• There are several causes of sore throat. Check you know about the differences between them, and ask the pharmacist to go through points you are unsure about.Look at the cough preparations available in your pharmacy. Do you know their main ingredients, and which products to recommend to whom?
• Keeping hydrated is especially important when you are ill. Why?
• There are several causes of sore throat. Check you know about the differences between them, and ask the pharmacist to go through points you are unsure about.
