How should cough medicine be chosen?😷😷😷

Cough is one of the body's important defense mechanisms against pathogens. It clears respiratory secretions and substances that are harmful to the respiratory tract. However, severe and frequent cough can seriously affect the patient's life and work. According to the course of the disease, cough can be divided into chronic cough (>8 weeks), subacute cough (3 to 8 weeks) and acute cough (<3 weeks). According to the volume of sputum, it can also be divided into dry cough and wet cough (sputum volume > 10 ml per day). There are different treatment options for different types of coughs. Therefore, the following will introduce the different types of cough medicines.

1. The patient had frequent and severe cough, less or no sputum volume, no itchy throat, nasal congestion, runny nose, belching, acid reflux and other symptoms.

For this type of patients, it is recommended to use only single-ingredient antitussives. Antitussives can be divided into peripheral antitussives and central antitussives. Commonly used in clinical are dextromethorphan, pentoxyverine and phenproperine.

1. Dextromethorphan is a commonly used antitussive drug in clinical practice. Its effects are similar to codeine, but without the hypnotic and analgesic effects. Therapeutic doses generally have no inhibitory effect on the respiratory center and are not addictive. Adults are orally administered three times a day, 15 to 30 mg each time.
2. Pentoxyverine also has antispasmodic and anticonvulsant properties. It should be used with caution in patients with cardiac insufficiency and glaucoma. Adults are orally administered three times a day, 25 mg each time.
3. Phenproperine is a non-narcotic antitussive that inhibits peripheral afferent nerves. It also has some central cough-relieving effects. Adults are orally administered three times a day, 20 to 40 mg each time.

Phenproperine is the first choice for patients with severe cough, followed by dextromethorphan. Phenproperine or pentoxyverine is recommended for patients with an irritating dry cough. Phenproperine is indicated for patients with a cough that occurs mainly during the day. Dextromethorphan is used for patients who cough mainly at night. Studies have pointed out that the same dose of codeine and dextromethorphan have similar effects in reducing the frequency of chronic cough, but the antitussive effect of codeine is not as strong as dextromethorphan. In addition, dextromethorphan had no significant effect on treating nocturnal cough in children.

2. Patients with cough and phlegm or phlegm that is difficult to cough up.

The use of antitussives alone is not suitable for this type of patients, especially strong antitussives such as codeine. They reduce the secretion of the bronchial glands. It makes mucus thick and difficult to cough up. Not only can it worsen the infection, it can even increase the risk of choking. Therefore, mucolytics or expectorants (eg, acetylcysteine, ambroxol, ammonium chloride, bromhexine) should be the mainstay of treatment for this type of patient. Expectorant therapy enhances the clearing effect of cough on airway secretions. They increase phlegm discharge and enhance the antitussive effect. 

Ambroxol and bromhexine are mucolytics. Bromhexine is metabolized into ambroxol in the human body. It reduces the viscosity of secretions and promotes ciliary movement in the airways. In addition, it can increase the concentration of antibacterial drugs in the respiratory tract. 

• Ambroxol: Adults take 30-60 mg orally three times a day. 
• Bromhexine: Adults take 8-16 mg orally three times a day.

Acetylcysteine can reduce the viscosity of the patient's sputum. Adults take 600 mg orally once or twice a day, or 200 mg (granules) three times a day.

3. Patients with dry cough or low sputum production and nasal symptoms such as runny nose and/or nasal congestion and sneezing.

This cough is usually caused by a cold or rhinitis. Antihistamines or decongestants can significantly relieve cough symptoms in these patients. However, caution should be exercised when prescribing these medications for children. Central or peripheral antitussives can be used in patients with severe cough. First-generation antihistamines (chlorpheniramine), decongestants (ephedrine, pseudoephedrine), and antitussives (codeine, dextromethorphan, pholcodine) are used to treat the common cold with cough. Medications containing codeine are contraindicated for children under 18 years of age. Drugs containing ephedrine and pseudoephedrine should be used with caution in patients with hypertension and heart disease.

4. Patients cough with shortness of breath or wheezing but no nasal symptoms.

It is recommended to treat this type of patient with drugs that suppress bronchospasm and relieve cough during asthma attacks, such as aminophylline and methoxyphenamine. When patients use aminophylline, lincosamides (clindamycin, lincomycin), macrolides (clarithromycin, erythromycin, roxithromycin), quinolones (ciprofloxacin, norfloxacin, ofloxacin), tetracyclines (doxycycline, minocycline). They inhibit the excretion of aminophylline and cause aminophylline poisoning. Azithromycin and moxifloxacin can be used in combination with aminophylline because they have no obvious interaction.

5. Patients with cough accompanied by one or more symptoms of typical acid reflux, such as acid reflux, belching, burning sensation behind the breastbone, and epigastric fullness.

This cough is due to gastroesophageal reflux. Patients are generally treated for the cause and do not require antitussive therapy.

6. Cough caused by cough variant asthma, eosinophilic bronchitis, allergic cough, pharyngitis, drug-induced cough, and psychogenic cough.

Antitussive therapy is generally not required for these patients. Treatment should be directed at the cause of the patient's cough.

Read More

How to tell the difference between the common cold and the flu.💫💫💫

Winter is flu season. During this season, many patients with cold symptoms think they have the flu. Patients diagnosed with the common cold after examination may even worry that the examination was not careful enough. They will question the doctor's examination. So what is the difference between the common cold and the flu?

Etiological differences.

Common cold:

The common cold can be caused by different pathogens. They include
coronavirus, respiratory syncytial virus, ECHO virus, adenovirus, rhinovirus, influenza virus, and parainfluenza virus, among others. Common colds in children are caused by respiratory syncytial virus and parainfluenza. Adult colds are mainly caused by rhinoviruses.

Flu: 

Influenza is caused by the influenza virus. It is a single-stranded, negative-stranded, segmented RNA virus. It belongs to the Orthomyxoviridae family. Influenza viruses are classified into four types: A, B, C, and D according to their matrix proteins and nucleoproteins. The main causes of influenza in humans are types A and B. There are many glycoprotein protrusions such as hemagglutinin (H) and neuraminidase (N) on the outer membrane of the virus. Influenza A viruses are named according to the difference between these two glycoproteins, such as H1N1, H2N2, H5N1, etc. Influenza B is divided into two strains, Victoria and Yamagata. 

Epidemiology of the common cold and flu.

Common cold:

The common cold is less contagious and not classified as an infectious disease. It is mainly infected by inhaling infected droplets or touching infected secretions and then touching the nose. The population is generally susceptible. Severely ill patients are rare. It can happen all year round and has no apparent seasonality.

Flu:

Influenza is highly contagious and spreads quickly. Influenza viruses are mainly spread by droplets from sick and latently infected persons. It is also spread by aerosols in crowded and poorly ventilated spaces. The population is generally susceptible. The following groups of people are more likely to develop severe disease after infection:

1. Children under 5 years old. In addition, children younger than 2 years are more likely to develop serious complications.
2. Seniors 65 and older.
3. Patients with cardiovascular disease (except hypertension), chronic respiratory disease, liver disease, kidney disease, blood system disease, endocrine system disease, nervous system disease, immunosuppressed, cancer, etc.
4. Obesity: BMI>30.
5. Pregnancy and perinatal women.

Influenza mostly occurs in summer and winter. It is generally seasonal.

Clinical manifestations.

Common cold:

The common cold has a shorter incubation period and a more acute onset. Common symptoms are nasal congestion, sneezing, coughing, sore throat and chest discomfort. Fever, headache and other complications are rare. Symptoms of generalized pain and fatigue are mild. In the absence of complications, it usually takes 5 to 7 days to heal.

Flu:

The incubation period of influenza is generally 1 to 7 days, and most is 2 to 4 days. The patient's body temperature can reach 39 to 40 degrees. It can be accompanied by chills, marked headache, and generalized pain is common and severe. The flu is sometimes accompanied by nasal congestion, sneezing, sore throat, mild to moderate chest discomfort and coughing. The most common complication of influenza is pneumonia. Others include heart and nervous system damage, myositis, rhabdomyolysis, shock, etc. Laryngitis, otitis media, and bronchitis are more common in children with influenza than in adults. In uncomplicated patients, systemic symptoms generally improve 3 to 5 days after onset, but physical recovery and cough usually take longer. 

Treatment.

Common cold:

There are no effective antiviral drugs for the common cold. Generally, decongestants, antihistamines, expectorants, antitussives, antipyretic analgesics, etc. are used for symptomatic treatment. Isolation and hospitalization are generally not required.

Flu:

Common anti-influenza virus drugs for influenza include M2 ion channel blockers (such as Amantadine), neuraminidase inhibitors (such as Zanamivir, Oseltamivir), and hemagglutinin inhibitors (such as Arbidol). Fever patients can undergo physical cooling and take antipyretics. Sputum expectorants and antitussives may be prescribed for patients with severe sputum and cough. Symptomatic treatment according to the patient's condition. If the patient's symptoms are severe or the underlying disease is significantly aggravated, the patient needs to be hospitalized. Both clinically diagnosed and confirmed patients should be treated in isolation.

Prevention.

Good personal hygiene is an important measure to prevent all respiratory infections such as frequent hand washing, keeping the environment clean and well ventilated, wearing a mask, etc.

Common cold:

There is no need for drug prophylaxis and no specific vaccine for the common cold. The best way to prevent it is to practice good personal hygiene.

Flu:

The best way to prevent the flu is to get the flu shot. Key groups such as healthcare workers, patients with chronic diseases, pregnant women, the elderly over 60 years old, children 6 months to 5 years old, and those who need to take care of children less than 6 months old should be vaccinated annually. Post-exposure drug prophylaxis is available for close contacts who have not been vaccinated or have not yet acquired immunity after vaccination and who are at high risk for severe influenza. It recommends taking oseltamivir or zanamivir once daily for 7 days within 48 hours of exposure.

Read More

How to choose acetaminophen or other NSAIDs when patient has a cold and fever?😷😷😷

Common cold symptoms are mainly nasal congestion, runny nose, sneezing, coughing and so on. It may also have a sore throat, muscle pain or fever. Clinical treatment is generally aimed at the symptoms and to relieve its symptoms. The following will introduce the dosage and precautions of commonly used antipyretic analgesics.

1. Acetaminophen.

It is an aniline compound. It inhibits prostaglandin synthesis and release in the central nervous system. It is a selective cyclooxygenase-2 (COX-2) inhibitor, which has antipyretic and analgesic effects. Because it selectively inhibits COX-2, it has no significant gastrointestinal irritation. Its oral absorption is rapid and complete. Its metabolic pathway occurs mainly in the liver. It is combined with glucuronic acid in the liver and excreted in the urine.

Dosage and contraindications:

When having pain or fever, children over 12 years and adults take 500mg each time. If the pain or fever does not go away, take another tablet 4-6 hours later. Do not take more than 4 times a day. 

Patients allergic to acetaminophen are contraindicated. To prevent overdose, it should not be taken with other medicines that also contain acetaminophen.

Adverse effects:

When acetaminophen is taken correctly, side effects such as liver and kidney toxicity are less likely to occur. It is also a very safe antipyretic and analgesic drug for pregnant women. The FDA's pregnancy drug classification is Class B.

2. Diclofenac.

Diclofenac is a fenamic acid compound. It is a strong NSAID. It changes the release and uptake of fatty acids. It causes the concentration of free arachidonic acid in leukocytes reducing. 

Dosage and contraindications:

Its recommended dose is 25 mg 1 to 2 times a day after meals.

It is not suitable for children under the age of 16 or breastfeeding women. Pregnant women are forbidden to use it. It should not be used in patients with a history of allergy to aspirin, diclofenac or other NSAIDs, peptic ulcers, urticaria, asthma or other allergies.

Adverse effects:

Gastrointestinal reactions such as epigastric discomfort, gastric bleeding, gastric perforation, etc. are common adverse reactions of diclofenac. It should be used with caution in the elderly or patients with liver and kidney dysfunction. Diclofenac can penetrate the placenta, so it is forbidden for pregnant women.

3. Aspirin.

Aspirin is a salicylic acid compound. Under its action, the hypothalamus thermoregulatory center causes peripheral blood vessels to dilate, increase blood flow to the skin, and sweat. This will increase the body's heat dissipation to achieve antipyretic effect. It also inhibits the synthesis of prostaglandins and other substances that make pain sensitive to external stimuli. It is a peripheral analgesic drug.

Dosage and contraindications:

The recommended dose of aspirin is 50 to 150 mg daily in 1 to 2 divided doses.

Aspirin is contraindicated in patients with aspirin allergy, asthma, hemophilia, thrombocytopenia, peptic ulcer with bleeding symptoms, or other active bleeding. Aspirin is not recommended for use in children, pregnant and breastfeeding women unless directed by a doctor.

Adverse effects:

Since aspirin also inhibits COX-1 and reduces prostaglandin synthesis, it can induce or exacerbate the risk of gastrointestinal ulcers and bleeding. Allergic reactions such as angioedema, asthma, and urticaria also occur in patients with  idiosyncrasy. Use aspirin for flu or chickenpox in children. It may cause Reye's syndrome. It can cause severe encephalopathy and liver damage. Therefore, it is not used to treat colds in children.

4. Indomethacin.

Indomethacin is an indole derivative. It has a strong inhibitory ability on COX, but it is not selective and it inhibits COX-1 and COX-2.

Dosage and contraindications:

Indomethacin is 6.25 to 12.5 mg each time for antipyretic. It should not be taken more than 3 times a day.

Indomethacin is contraindicated in patients allergic to indomethacin, urticaria after taking other NSAIDs or aspirin, asthma or other allergies, undergoing coronary artery bypass grafting, pregnant and lactating women. It is also not suitable for children under the age of 14.

Adverse effects:

Its most common adverse reactions are central nervous system reactions. In addition, gastrointestinal reactions, asthma, skin and mucous membrane allergies also occur. Its incidence of adverse reactions is high. If treatment with indomethacin is required, the lowest dose that can achieve efficacy should be used under the guidance of a doctor.

Medication guidelines for special populations.

Children: The WHO recommended antipyretics for children worldwide are acetaminophen and ibuprofen. In addition, it is not recommended to use the two in combination or alternately for antipyretic in children. Routine use of acetaminophen to prevent fever in children before and after vaccination is also not recommended.

Pregnant: On the basis of physical cooling, water supplementation and corresponding treatment, acetaminophen can be used to reduce fever. Other antipyretics should be avoided.

Patients with gastrointestinal ulcers or a history of gastrointestinal bleeding: For them, acetaminophen is relatively safe. Aspirin and NSAIDs are not recommended. They can irritate the gastrointestinal mucosa and have the risk of gastrointestinal bleeding.

Patients with cardiovascular and cerebrovascular disease: Most of them will need to take aspirin as a preventive medicine. Therefore, it is not recommended to use NSAIDs and is recommended to use acetaminophen.

Elderlies: Be aware of the medications they are taking to avoid interactions. In the absence of clear contraindications, normal doses may be considered.

During the antipyretic period, all patients should be adequately hydrated to avoid the risk of shock. Generally, the symptoms will disappear or improve after 1 week of treatment, otherwise you should seek medical attention in time.

Read More

Several causes and treatment options for coughing.😷😷😷

Cough is a very common symptom. Although coughing is generally not very harmful, chronic coughing can be very annoying and damage the respiratory tract. Many different diseases can cause cough symptoms. This article will introduce the diagnosis, pathogenesis of coughs, and guidelines for their treatment.

1. Cough caused by the common cold.

The most common cause of colds is a viral infection. In addition to coughing, its clinical manifestations are also accompanied by upper respiratory tract-related symptoms such as throat irritation or discomfort, runny nose, nasal congestion, sneezing, postnasal drip, and fever. There are usually few systemic symptoms. Postnasal drip is often associated with coughing of the common cold.

Treatment method: 

• Central antitussive drugs such as codeine are generally not recommended for routine use alone in coughs of the common cold. 
• Antitussives in combination with decongestants and first-generation antihistamines are recommended for adults with the common cold with cough.
• For the common cold with cough, first-generation antihistamines alone have no obvious therapeutic benefit. Combining first-generation antihistamines and decongestants can effectively improve symptoms such as sneezing, nasal congestion, and relieve cough.
• It is not recommended to use NSAIDs if a patient with the common cold has no symptoms of headache, muscle pain, and fever.

2. Cough caused by acute tracheitis and bronchitis.

Most of acute tracheitis and bronchitis are caused by viruses and a few are caused by bacteria. Its initial clinical manifestations are symptoms of upper respiratory tract infection. The cough then gradually intensifies and with or without expectoration. The expectoration caused by bacterial infection is yellow and purulent sputum. 

Treatment method: 

• Antitussives should be used in patients with severe cough without sputum. Mucolytic or expectorant is recommended for patients who have sputum but cannot expectorate it. 
• Symptoms of acute respiratory infection can be relieved with extended-release guaifenesin. It can irritate the gastric mucosa and reflexively cause an increase in airway secretions. Increased secretions reduce the viscosity of phlegm. It also has a bronchodilator effect, which can enhance the effect of expectoration.
• Routine antimicrobial therapy is generally not recommended unless the patient has yellow and purulent sputum. Antibiotics may also be considered in patients with elevated peripheral white blood cell counts.

3. Cough after a cold.

The cough persist for 3 to 8 weeks after the acute respiratory symptoms of the cold disappeared, and the chest X-ray examination was no significant abnormal. 

Treatment method: 

• In the short term, decongestants, antihistamines, and antitussives can be recommended to treat some patients with obvious cough symptoms.
• Inhaled montelukast and corticosteroids are not recommended.

4. Cough caused by postnasal drip syndrome.

The nose produces secretions due to disease and the secretions flow back to the back of the nose and throat. It stimulates the cough receptors and causes coughing. The main clinical manifestation of postnasal drip syndrome is chronic cough. Coughing more during the day or during postural changes and less after falling asleep.

Treatment method: 

• Oral first-generation antihistamines and decongestants are the first recommended treatment for postnasal drip syndrome caused by the common cold and nonallergic rhinitis.
• Oral second-generation antihistamines and nasal inhaled corticosteroids are recommended first for the treatment of postnasal drip syndrome caused by the common cold and allergic rhinitis. For allergic rhinitis, leukotriene receptor antagonist therapy is also effective.
• To avoid unnecessary surgery, nasal inhaled corticosteroids are recommended for the treatment of chronic sinusitis with nasal polyps.
• Sequential treatment of oral corticosteroids and topical nasal inhaled corticosteroids is more effective than nasal inhaled corticosteroids alone in patients with chronic rhinosinusitis with nasal polyps.
• Nasal decongestants can relieve nasal congestion. It will reduce the congestion and edema of the nasal mucosa, thereby facilitating the drainage of secretions. However, patients should be alert to its adverse reactions when using it. It can cause drug-induced rhinitis and should not be used for a long time. Its course of treatment is generally less than 1 week. It recommends a combination of nasal decongestants and first-generation oral antihistamines. Their course of treatment is 2 to 3 weeks.
• For the treatment of patients with chronic sinusitis, mucolytics (such as carbocisteine, erdosteine) may be beneficial. It can also be used to flush the nasal cavity with saline.

5. Gastroesophageal reflux cough.

One of the common causes of chronic cough is the reflux of stomach acid and other stomach contents into the esophagus, which causes a cough. This cough occurs mostly during the day, with upright and postural changes. It generally has no phlegm or a small amount of white sticky phlegm. Greasy and acidic foods can trigger or aggravate a cough. 40 to 68% of patients also experience typical acid reflux symptoms such as acid reflux, belching and retrosternal burning.

Treatment method: 

• Acid-suppressing drugs, including potassium-competitive acid blockers (such as vonoprazan) and proton pump inhibitors (such as omeprazole), are the first choice of treatment.
• Gastroprokinetic agents (such as mosapride) can relieve symptoms associated with acid reflux. It can be used in combination with acid-suppressing drugs. The anti-reflux course of treatment is at least 8 weeks, and then the dose is gradually reduced.

6. Cough variant asthma.

It is a specific type of asthma. It is also one of the most common causes of chronic cough. Its main clinical manifestation is irritating dry cough. The cough is generally severe and occurs at night and in the early morning. It generally has no obvious symptoms such as shortness of breath or gasp for breath, but there will be airway hyperresponsiveness. 

Treatment method: 

• Treatment with inhaled corticosteroids alone or in combination with bronchodilators (such as long acting β2-agonist) is recommended.
• Classic asthma may be prevented with long-term use of inhaled corticosteroids.
• Leukotriene receptor antagonists, such as montelukast, reduce symptoms of airway inflammation and cough. It improves quality of life and is effective in treating cough variant asthma.

7. Eosinophilic bronchitis.

About 13 to 22% of chronic coughs are caused by eosinophilic bronchitis. The necessary basis for diagnosis is elevated sputum eosinophils. Chronic irritating cough is usually the only clinical symptom. It is usually a dry cough or with a little white mucus sputum. Cough is more common during the day, and occasionally at night. Cough triggers are mostly cold air, dust, odors or smoke. The patient had no associated symptoms of airway restriction such as dyspnea and gasp for breath.

Treatment method: 

• Cough was significantly relieved or disappeared soon after glucocorticoid treatment. Inhaled corticosteroids such as fluticasone propionate aerosol are the recommended first-line therapy. It should be used continuously for more than 8 weeks.
• Oral prednisone (10 to 20 mg daily for 3 to 5 days) can be combined for initial treatment.
• More than half of patients still relapse after treatment. Patients with persistent eosinophilic inflammation and rhinitis are risk factors for recurrence.

8. Allergic cough.

Some patients with chronic cough have normal sputum eosinophils and no hyperresponsive airways, but the patients are atopic. Effective with antihistamines and glucocorticoid therapy. This type of cough is called allergic cough. Cough occurs during the day or night, mostly paroxysmal and irritating dry cough. Cold air, dust, smoke, and talking can all induce coughing and often an itchy throat. 

Patients with allergic cough have one of the following indications:

1. Antihistamines or glucocorticoids are effective.
2. Positive skin test for allergens.
3. Increased serum total IgE or specific IgE.
4. History of allergic disease or exposure to allergens.

Treatment method: 

• Initial treatment can be short-term low-dose oral glucocorticoids for 3 to 5 days. Oral antihistamines and/or inhaled corticosteroids for more than 4 weeks.

9. Refractory chronic cough.

Clinically, there are some patients with underlying chronic cough etiology, but the cough has no obvious relief after targeted treatment. This cough is called refractory chronic cough. 

Treatment method: 

• The neuromodulator drug gabapentin is effective in the treatment of refractory chronic cough. It can also choose other drugs such as baclofen, amitriptyline, pregabalin, and carbamazepine.
• Patients with refractory chronic cough can use aerosol inhalation of lidocaine to achieve a certain temporary relief effect.

Read More