Cough

Key messages

Definition and prevalence

Cough is a prevalent symptom in palliative care, particularly among patients with advanced respiratory diseases, including interstitial lung disease (ILD), lung cancer, and chronic obstructive pulmonary disease (COPD). It is typically classified as either productive or non-productive, with its presence often indicating airway irritation, infection, tumour invasion, or as a side effect of treatments such as chemotherapy and radiotherapy. [1,2] Studies suggest that up to 70% of patients with lung cancer experience cough as a distressing symptom at some point during their illness, highlighting its widespread impact in this population. [3,4]

In patients with ILD, cough is particularly challenging due to the disease's progressive nature, where it occurs in nearly 85% of cases, significantly affecting the patient's quality of life. This symptom not only contributes to physical discomfort but also exacerbates fatigue and sleep disturbances, which can further deteriorate the patient’s overall condition. [5,6] Moreover, in palliative care settings, the presence of cough can often lead to increased anxiety and social isolation, as patients may avoid social interactions due to the stigma or physical discomfort associated with persistent coughing. [2,7] These factors underscore the importance of early and effective management strategies to alleviate the burden of cough and improve the quality of life for patients in palliative care.

Assessment

Assessing cough in palliative care involves a comprehensive approach that focuses on identifying the underlying causes, evaluating the severity, and understanding the impact on the patient’s overall quality of life. The assessment begins with a detailed clinical evaluation, including a thorough patient history and physical examination. Clinicians aim to pinpoint the primary cause of the cough, which could range from infections and tumour growth to airway obstruction or side effects from treatments like chemotherapy and radiation therapy. [1,2] Diagnostic tools such as chest X-rays, CT scans, and spirometry are often utilised to further investigate persistent or severe cases of cough, ensuring that the treatment plan is appropriately targeted. [3,5]

In addition to the physical assessment, it’s crucial to consider the psychological impact of cough on the patient. Persistent cough can be distressing, contributing to anxiety, depression, and social withdrawal, especially in terminally ill patients who may feel a loss of control over their symptoms. [4,8] Tools like patient-reported outcome measures (PROMs) and visual analogue scales (VAS) are valuable for assessing the severity and impact of cough from the patient’s perspective. Regular reassessment is essential, as the nature of the cough may evolve over time, particularly in progressive diseases like ILD or lung cancer, necessitating adjustments in the management strategy. [2,7]

Non-pharmacological treatment

Non-pharmacological treatments play a valuable role in managing cough in palliative care, particularly when pharmacological options may not be sufficient or preferred by patients. Humidification therapy can help maintain airway moisture, potentially reducing irritation and the frequency of coughing. This approach is often useful for patients with dry cough, which can be aggravated by environmental factors or oxygen therapy. [1,7] Devices like humidifiers or nebulisers might provide moisture directly to the respiratory tract, offering relief for some patients. [7]

Chest physiotherapy may also be an effective non-pharmacological strategy, especially for patients with productive coughs where mucus clearance is important. [2,5] Techniques such as postural drainage, percussion, and vibration could assist in mobilising secretions, making it easier for patients to clear their airways. This approach could be particularly beneficial for chronic obstructive pulmonary disease (COPD) and bronchiectasis. [5]

Addressing the psychological aspects of cough is equally important. Persistent cough can contribute to anxiety and stress, which might exacerbate the symptom. Cognitive-behavioural therapy (CBT) and relaxation techniques have shown promise in helping patients manage the psychological burden of chronic cough, potentially improving overall well-being. [4,8] Additionally, environmental modifications such as maintaining a smoke-free environment and optimising humidity levels could reduce cough triggers. [1,3] Some patients report relief through complementary therapies like acupuncture and aromatherapy, which may be beneficial when included in a holistic care plan, particularly when conventional treatments are insufficient. [3]

Pharmacological treatment

Pharmacological interventions are central to managing cough in palliative care, especially when non-pharmacological methods are insufficient. Opioids, particularly low-dose morphine, are frequently used to suppress the cough reflex. Morphine works by reducing the sensitivity of the cough reflex in the brainstem, making it effective in managing refractory cough in patients with lung cancer or interstitial lung disease (ILD). [3,5] In the context of palliative care, opioids are carefully titrated to balance effective symptom control with the minimisation of side effects. While respiratory depression is a potential concern, it is less of an issue when opioids are managed by experienced palliative care teams who adjust doses to provide significant symptom relief without compromising respiratory function. [3,5]

Corticosteroids are another important class of medications used when inflammation contributes to cough, such as in cases of airway obstruction from tumours or exacerbations of chronic obstructive pulmonary disease (COPD). Prednisone and dexamethasone are often prescribed to reduce airway inflammation and oedema, which can alleviate cough by improving airway patency and reducing irritation. [1,2] These medications are valuable in palliative care for their ability to rapidly reduce symptoms, though long-term use must be carefully managed to avoid complications like immunosuppression, hyperglycaemia, and osteoporosis. [1,2]

Antitussives such as dextromethorphan, codeine, and benzonatate are used to directly suppress the cough reflex, particularly in patients experiencing dry, non-productive coughs that disrupt sleep and reduce quality of life. [3,7] These medications are particularly useful when cough is not associated with the need to clear secretions. Bronchodilators such as albuterol and ipratropium are also employed, particularly in patients with obstructive airway diseases like COPD, where bronchospasm is a primary contributor to cough. By relaxing the bronchial muscles, bronchodilators can improve airflow and reduce the frequency of coughing episodes, enhancing overall respiratory comfort. [2,4]

Equity and access

Equity and access to effective cough management in palliative care are influenced by various social, cultural, and economic factors. Aboriginal and Torres Strait Islander peoples often encounter challenges due to geographic isolation and limited availability of culturally safe healthcare services. The integration of traditional healing practices and the involvement of community leaders in care planning are essential to improving access and ensuring effective symptom management for conditions like cough within these communities. [9] Culturally appropriate care models that align with the preferences and needs of these populations can significantly enhance health outcomes and the overall quality of care provided. [9]

For culturally and linguistically diverse (CALD) populations, barriers such as language differences, varying cultural perceptions of illness, and reliance on traditional remedies can delay or complicate the management of cough in palliative care. [9,10] Health literacy remains a critical issue, as patients from CALD backgrounds may not fully understand their conditions or the available treatments, leading to underutilisation of effective therapies such as opioids. [10] Addressing these challenges requires the provision of multilingual resources, the employment of culturally competent healthcare professionals, and the integration of traditional practices into care plans, which can bridge gaps in understanding and ensure that patients receive culturally respectful and effective care. [9,10]

People living in rural and remote settings also face significant barriers to accessing palliative care, including essential services for managing symptoms like cough. Geographic isolation and a shortage of specialised healthcare providers make continuous and comprehensive care challenging. [6] While telemedicine offers a promising solution to bridge these gaps by providing remote consultations, its effectiveness is dependent on reliable internet access and the patient's comfort with digital tools. [6] Similarly, prisoners and people experiencing homelessness often struggle to access consistent palliative care. The prison environment can limit access to specialised care, leading to poor symptom control, while the transient nature of homelessness complicates the delivery of continuous care, resulting in unmanaged symptoms like cough. [11,12] To improve access for these underserved groups, targeted interventions such as mobile health units, dedicated palliative care programs within correctional facilities, and the expansion of telehealth services are crucial. [6,11,12]

Care context

Approaches to the management of cough in palliative care tend to vary across different settings with each setting presenting its own set of challenges and opportunities for symptom control. In hospital settings, the availability of advanced diagnostic tools and multidisciplinary teams can be beneficial for managing acute and severe symptoms, particularly in patients with complex conditions such as lung cancer or interstitial lung disease. [3] However, hospitals may not always provide the most comfortable environment for patients, especially those who are vulnerable to heightened anxiety in clinical settings. Striking a balance between effective symptom management and patient comfort can be challenging in these environments, where the clinical atmosphere might contribute to patient discomfort. [13]

In residential aged care homes, managing cough often requires a more adaptive approach, particularly given the high prevalence of comorbidities among elderly residents. These settings might emphasise non-pharmacological strategies, such as positioning and environmental modifications, to manage cough. [5] The effectiveness of care in these care homes may be enhanced by regular assessments and collaboration with external palliative care teams, which can help ensure that care plans are adjusted as needed to meet the evolving needs of residents. [6] In home-based care, the approach to managing cough is often more personalised, with care plans tailored to the patient's preferences and lifestyle. This setting could be particularly beneficial for patients with chronic conditions, where the familiarity of home might reduce anxiety and improve overall comfort. However, the success of home-based care typically depends on the involvement and capacity of family caregivers, who are often supported by healthcare providers through telemedicine to manage symptoms like cough effectively. [6,13]

Implications for families and carers

The management of cough in palliative care can have various implications for families and carers, who often play a central role in providing day-to-day care and ensuring the patient’s comfort. This role can be physically and emotionally demanding, particularly in home-based care settings, where carers are directly responsible for managing symptoms like persistent cough. The physical demands include continuous monitoring and administering treatments, which may contribute to fatigue and stress, particularly when the cough is severe or disrupts the patient’s overall well-being. [13] Additionally, the emotional burden of witnessing a loved one’s discomfort can lead to feelings of helplessness and anxiety. [6]

Supporting carers in managing these challenges is important. Carers benefit from appropriate education and ongoing support from healthcare providers, including understanding the underlying causes of the cough, administering medications effectively, and using non-pharmacological strategies such as positioning and environmental modifications. Regular communication between carers and healthcare providers, possibly through telemedicine, is important to address emerging concerns and make necessary adjustments to care plans. [13]

The well-being of carers is closely linked to the quality of life of the patient. When carers feel supported and competent in managing symptoms like cough, this can enhance the patient’s comfort and overall well-being. [3] Conversely, insufficient support could lead to carer burnout, potentially affecting the quality of care provided. [6] Recognising and addressing the needs of carers as part of a holistic palliative care approach is important to maintaining both carer well-being and patient care quality. Access to respite care, mental health support, and community resources can help carers manage their responsibilities more effectively and continue to provide compassionate care. [6,13]