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

LOCAL ANAESTHETICSNebulised Lidocaine

Benzonatate

PERIPHERALLY-ACTING ANTITUSSIVESLevodropropizine, Moguisteine, Levocloperastine

OPIOIDSMorphine/Methadone

Dextromethorphan, Codeine, Hydrocodone

CANCER SPECIFICsystemic chemotherapy/RT endobronchial therapy, PDT, palliative RT

CO-MORBIDITIESCOPD, reflux, asthma, infections

CONSIDER ORAL STEROID TRIAL2 weeks

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EXPERIMENTALCarbamazepine,Thalidomide, Gabapentin, Baclofen Amitriptylline