Cough

There are two sorts of cough: the useful and the useless. Cough is useful when it effectively expels secretions or foreign material from the respiratory tract, i.e. when it is productive; it is useless when it is unproductive and persistent. Useful cough should be allowed to serve its purpose and suppressed only when it is exhausting the patient or is dangerous, e.g. after eye surgery. Useless persistent cough should be stopped. Asthma, rhinosinusitis, oesophageal reflux or a combination of the last two is the commonest underlying reason for persistent cough. Recently, eosinophilic bronchitis has been recognised as a possibly significant cause; it

Peripheral sites

On the afferent side of the cough reflex: by reducing input of stimuli from throat, larynx, trachea, a warm moist atmosphere has a demulcent1 effect on the pharynx.

On the efferent side of the cough reflex: measures to render secretions more easily removable (mucolytics, postural drainage) will reduce the amount of coughing needed, by increasing its efficiency.

The best antitussive of all is removal of the cause of the cough itself, e.g. treatment of underlying conditions such as asthma, postnasal drip or gastro-oesphageal reflux. In patients with hypertension or cardiac failure, a common cause of a dry cough is treatment with an ACE inhibitor.

1 Latin: demulcere, to caress soothingly.

Central nervous system

Agents may act on:

• the medullary paths of the cough reflex (opioids)

• the cerebral cortex

• the subcortical paths (opioids and sedatives in general).

Cough is also under substantial voluntary control and can be inducible by psychogenic factors (such as anxiety not to cough when it is socially disadvantageous to do so, e.g. during the quiet parts of a musical concert) and reduced by a placebo. Considerations such as these are relevant to practical therapeutics.

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