Download Management of cough in lung cancer

Management of cough
in lung cancer
Clinical guidelines for the management of
cough in lung cancer:
report of a UK Task Group on Cough.
Molassiotis A1, Smith JA2, Bennett MI3, Blackhall
F4, Taylor D5, Zavery B6, Harle A4, Booton R7,
Rankin EM8, Lloyd-Williams M9, Morice AH10.
Epidemiology
• Cough is common symptom
– 23-37% of all cancer patients
– 47-86% in lung cancer
• Not always well managed
• Little evidence to guide practice
• Formation of task group
• Literature reviews
• Peer review by UK committees
• Submitted for publication
Pathophysiology
• Coughing serves to protect airway from
irritants
• Stimuli provoke cough via vagus nerve
through
– chemoreceptors (C fibres)
– mechanoreceptors (A delta fibres)
In lung cancer
• Ulceration of mucosa
– Mechanical stimulation
• Release of inflammatory mediators
– Chemoreceptor stimulation
– Sensitises peripheral nerves
• Also:
–
–
–
–
–
Obstruction
Pleural effusion
Infection
Fistulas
Carcinomatosis
Recommendations
Assessment
• History
– Type of cough (productive / non-productive)
– Trigger factors
– Nocturnal or day time
• Co-morbid conditions
– COPD
– Heat failure
• No validated symptom scale available
Assessment
• Drugs causing cough
– Methotrexate
– Bleomycin
– ACE inhibitors
• Further investigations
– ?CXR
– CT
Treat reversible causes
• COPD / asthma
– Inhaled bronchodilators
– Steroid (prednisolone 30mg daily)
• Infection (bronchietctasis, LRTI)
– antibiotics
• GI reflux
– PPI (omeprazole)
– Metoclopramide or domperidone for non-acid reflux-
Treat the cancer
• Chemo
– Improves symptoms including cough
• External radiotherapy
• Brachytherapy
Symptomatic management
• Linctus
– Glycerol
– Simple linctus
• Trial of steroid
– Prednisolone
– (or dexamethasone)
Centrally acting agents
• Codeine
– 30mg qds
• Morphine or methadone
– If codeine no help
– Morphine 5-10mg bd
• No dose response relationship for cough
Peripherally acting agents
• Antitussive agents
– Levodropropizine,
– Moguisteine
– Levocloperastine
• Local anaesthetic agents
– nebulised bupivacaine
– benzonatate
In general
• Low levels of evidence for these
recommendations
• Peripheral and intermittent approaches
before central and continuous treatment
• In lung cancer
– many patients already on opioids for pain
• Central approaches maximised already
EXPERIMENTAL
Carbamazepine,
Thalidomide, Gabapentin,
Baclofen Amitriptylline
LOCAL ANAESTHETICS
Nebulised Lidocaine
Benzonatate
PERIPHERALLY-ACTING ANTITUSSIVES
Levodropropizine, Moguisteine, Levocloperastine
OPIOIDS
Morphine/Methadone
Dextromethorphan, Codeine, Hydrocodone
CONSIDER ORAL STEROID TRIAL
2 weeks
CANCER SPECIFIC
systemic chemotherapy/RT endobronchial
therapy, PDT, palliative RT
CO-MORBIDITIES
COPD, reflux, asthma, infections