How should patients take Ambroxol?😷😷😷

Ambroxol is a very commonly used expectorant in clinical practice. Recently, more and more people pay attention to other pharmacological effects of ambroxol. The following relevant knowledge can help us use ambroxol rationally.

1. Chemical structure of Ambroxol.

Ambroxol is the active product produced by the metabolism of bromhexine. Due to its local anesthetic properties, it is given as a lozenge to soothe sore throats. Ambroxol is broken down by light, so it needs to be stored away from light. Its granule form needs to be dissolved in room temperature water. The injection form of ambroxol will produce free base precipitation of ambroxol due to the increase of the pH value of the solution, so it should not be mixed with an alkaline solution with a pH>6.3.

2. The expectorant effect of ambroxol.

The main components of sputum secreted by humans are a small amount of acidic glycoprotein and a large amount of water. When inflammation occurs in the respiratory tract, there will also be a small amount of residual DNA from damaged inflammatory cells in the sputum. There are disulfide bonds (-S-S-) in the acid glycoprotein molecular structure, so the sputum has a certain viscosity. It is also the main component in white sputum. Ambroxol can reduce the production of acidic mucopolysaccharides in the trachea, bronchial glands and goblet cells to reduce the viscosity of sputum. In addition, it can also promote the movement of cilia on the trachea and increase the expectoration of sputum. Ambroxol is suitable for patients with white and sticky sputum that is not easy to cough up.

3. Common dosage forms and dosages of ambroxol.

Ambroxol is generally administered 2 to 3 times a day. Its half-life is about 10 hours. If ambroxol is in the form of injection, its dosage is about half that of oral administration. Inhaled dosage forms will have smaller doses. 

1. Ambroxol Hydrochloride Tablets: Adults take orally three times a day, 30 to 60 mg each time, after meals.
2. Ambroxol hydrochloride oral solution: 1 to 2 years old, twice a day, 15mg each time. From 2 to 6 years old, three times a day, 15mg each time. 6 to 12 years old, two to three times a day, 30mg each time. Over 12 years old and adults, twice a day, 60mg each time.
3. Ambroxol Hydrochloride Injection: Children under 2 years old twice a day, 7.5mg each time. From 2 to 6 years old, three times a day, 7.5mg each time. 6 to 12 years old, two to three times a day, 15mg each time. Over 12 years old and adults, two to three times a day, 15 to 30mg each time.
4. Ambroxol hydrochloride solution for inhalation: children from 6 months to 2 years old inhale once or twice a day, 7.5mg each time. From 2 to 12 years old, inhale once or twice a day, 15mg each time. Over 12 years old and adults inhale once or twice a day, 15 to 22.5mg each time.

4. What is Neonatal Respiratory Distress Syndrome?

The site of gas exchange in the lungs is the alveoli. Oxygen in the alveoli will diffuse into the blood through the liquid membrane on the inner surface of the alveoli, the epithelial cells of the alveoli, the interstitium between the epithelium of the alveoli and the endothelium of the pulmonary capillaries, the endothelial cells of the capillaries, and then enter the blood. Alveolar epithelial cells are classified into type I and type II. Type II alveolar epithelial cells are inlaid between type I alveolar epithelial cells. It can synthesize and secrete alveolar surfactant. The main component of this surface active substance is phospholipid protein. It reduces the surface tension of the alveoli, preventing the alveoli from collapsing or overinflating. Neonatal respiratory distress syndrome refers to symptoms such as progressive dyspnea and respiratory failure in newborns. Its main cause is a series of symptoms caused by alveolar atrophy due to the lack of alveolar surfactant. Because ambroxol can increase the synthesis and secretion of alveolar surfactant, it has been approved for the treatment of respiratory distress syndrome in premature infants and neonatal infants. The dosage is 30mg/kg as the total daily dosage, divided into 4 doses. It should be administered with a syringe pump and administered intravenously over at least 5 minutes. In addition, when amoxicillin, cefuroxime, erythromycin, doxycycline and other antibiotics are taken together with ambroxol, the concentration of antibiotics in lung tissue can be increased.

5. Off-label use of ambroxol.

Taking large doses of ambroxol has the effects of anti-inflammation, anti-oxidation and scavenging free radicals in the body. It also increases alveolar surfactant. This has a protective and therapeutic effect on lung damage. It is used off-label to prevent postoperative atelectasis in patients with chronic obstructive airway disease. It is used continuously for six days from the third day before the patient's lung surgery to the second day after the operation, with a daily dose of 1000mg. Ambroxol can cause adverse reactions such as nausea, stomach discomfort, and loss of appetite, so it is recommended to take ambroxol oral preparations after meals. Ambroxol may also cause severe skin reactions such as toxic epidermal necrolysis. If patient develops symptoms of progressive rash, discontinue use ambroxol and seek medical attention immediately.

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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.

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How to use nebulized medicine?💫💫💫

One of the important ways of treating respiratory diseases is aerosol inhalation therapy. One of the important means of treating respiratory diseases is aerosol inhalation therapy. Therefore, it is very important to understand the correct usage of nebulized drugs.

The process of inhaling a drug in the body.

Compared with administration methods such as injection or oral administration, the biggest advantage of aerosol inhalation administration is that the drug can be directly sent to the airway or lungs for local treatment. This advantage can make the drug less systemic adverse effects. The particle size of the aerosol inhalation drug is preferably 1 to 5 μm. If the particle size is larger than 5 μm, most of the drug will stay in the oropharynx and be swallowed into the body. If the particle size is less than 0.5 μm, although the drug can enter the alveoli and bronchioles, most of the drug will be excreted by exhalation.

Medication treatment of nebulized drugs.

Commonly used nebulized inhaled drugs are short-acting β-agonists (such as albuterol), short-acting anticholinergic drugs (such as ipratropium bromide), inhaled glucocorticoids (such as budesonide) and expectorants (such as ambroxol). 

Disease	Short-acting β-agonists	Short-acting anticholinergic drugs	Inhaled glucocorticoids	Expectorants
Acute exacerbation of bronchial asthma.	✔	Use when necessary.	✔	✖
Long-term control of bronchial asthma.	Use when necessary.	✖	✔	✖
Cough variant asthma.	✖	✖	✔	✖
Variant cough.	✖	✖	✔	✖
Eosinophilic bronchitis.	✖	✖	✔	Use when necessary.
Asthmatic bronchitis.	✔	Use when necessary.	✔	✖
Acute laryngotracheobronchitis.	✖	✖	✔	✖
Bronchiolitis obliterans.	Use when necessary.	Use when necessary.	✔	✔
Bronchiolitis.	✔	Use when necessary.	✔	✖
Pneumonia.	Use when necessary.	Use when necessary.	✖	✔
Acute epiglottitis.	✖	✖	✔	✖
Pertussis or pertussis-like syndrome.	Use when necessary.	Use when necessary.	✔	✖
Bronchopulmonary dysplasia.	✖	✔	✔	✖
Bronchiectasis.	Use when necessary.	Use when necessary.	✔	✔
Endotracheal intubation or throat surgery.	✖	✖	✔	✖
Cough after infection.	Use when necessary.	✖	✔	✖

 Commonly used nebulized drugs and their adverse reactions.

The nebulized drugs stay on the surface of the airway mucosa for a short time and have a short half-life in the blood, but have a long residence time in the local tissue.

1. Short-acting β-agonists: Commonly used drugs are salbutamol and terbutaline. Their common adverse reactions were headache, tremor and tachycardia.
2. Short-acting anticholinergic drugs: Commonly used drugs are ipratropium. Its common adverse reactions are headache, dizziness, dry mouth and vomiting.
3. Inhaled glucocorticoids: Commonly used drugs are beclomethasone dipropionate, fluticasone propionate and budesonide. Their common adverse reactions are pharyngitis, hoarseness and oropharyngeal candidiasis.
4. Expectorants: Commonly used drugs are acetylcysteine and ambroxol. Their common adverse reactions are stomatitis, oral numbness (ambroxol), disturbance of taste, nausea and vomiting.

What is the difference between inhaled glucocorticoids?

Commonly used drugs are beclomethasone dipropionate, fluticasone propionate and budesonide. Inhaled glucocorticoids have two mechanisms of action. The first is the genetic pathway. Their lipid solubility allows them to enter cells, where they bind to cytoplasmic receptors and then enter the nucleus. Once in the nucleus, they initiate gene transcription. It promotes anti-inflammatory protein synthesis and inhibits pro-inflammatory protein synthesis. They develop an anti-inflammatory effect after about a few hours. The second is the non-genetic pathway. They bind to hormone receptors on cell membranes. Cell energy metabolism and lysosomes are affected by it. They act as anti-inflammatory within minutes.

1. Beclomethasone dipropionate: It is the only prodrug of the three glucocorticoids. Its elimination half-life is approximately 0.5 hours. It has the highest rates of oropharyngeal candida infections and pharyngitis of the three.
2. Fluticasone propionate: It has better receptor affinity. Its stagnation time in the lungs is the shortest of the three. Its elimination half-life is approximately 8 hours. In addition, its inhibitory effect on the adrenal cortex is the strongest of the three.
3. Budesonide: It has the best hydrophilicity. Its stagnation time in the lungs is the longest of the three. Its elimination half-life is approximately 3 hours.

What is the combined use of nebulized drugs?

Short-acting β-agonist and inhaled glucocorticoid act synergistically, so they are the most commonly used combination. Short-acting β-agonist and short-acting anticholinergic drug are also more commonly used in combination.

1. Dual therapy: Short-acting β-agonist + short-acting anticholinergic drug, inhaled glucocorticoid + short-acting anticholinergic drug, acetylcysteine + short-acting β-agonist/short-acting anticholinergic drug/inhaled glucocorticoid.
2. Triple therapy: Short-acting β-agonist + short-acting anticholinergic drug + inhaled glucocorticoid, short-acting β-agonist/short-acting anticholinergic drug + inhaled glucocorticoid + acetylcysteine.
3. Quadruple Therapy: Short-acting β-agonist + short-acting anticholinergic drug + inhaled glucocorticoid + acetylcysteine.

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Several medicines that can cause coughing.😷😷😷

Cough is a very common symptom of respiratory disease. There are many
reasons for a cough. In addition to illness, drugs can also cause coughing. It's called a drug-induced cough. The following medicines can easily cause coughing.

Angiotensin-converting enzyme inhibitors.

Angiotensin-converting enzyme inhibitors such as captopril and enalapril increase prostaglandins. The increase in prostaglandins can make coughing easier. In addition, they increase the amount of bradykinin and cell fiber stimulators such as substance P in the lungs. These substances induce bronchoconstriction leading to a severe dry cough. Such dry coughs are generally irritating and persistent in character. No secretions are excreted when coughing. Sometimes it appears paroxysmal. Symptoms can be worsened by lying down and at night. This can affect the patient's sleep. Symptoms of dry cough usually appear within 3 to 7 days of taking an angiotensin-converting enzyme inhibitor. It will get worse over time. This cough cannot be cured with cough suppressants or antibiotics. It usually resolves gradually with discontinuation of the drug.

Antiarrhythmic drugs.

Among the antiarrhythmic drugs that most commonly cause dry cough is amiodarone. It is mainly used to prevent or treat ventricular arrhythmia, atrial fibrillation, etc. Its most common side effect is pulmonary toxicity-related symptoms, occurring in approximately 1 to 17%. Generally, hypersensitivity pneumonitis or interstitial pneumonitis will occur after continuous use for 3 to 12 months. In patients with lung disease, excessive doses or prolonged courses of amiodarone are more likely to develop pulmonary toxicity. Its most common clinical manifestation is dry cough. Therefore, monitoring of lung function is recommended within 3 to 6 months of taking amiodarone. In addition, it is necessary to pay attention to the adjustment of the drug dosage when using it.

Diuretic drugs.

Diuretics such as hydrochlorothiazide can increase urine output and lower blood pressure. One of its common side effects is a dry cough. Most coughs are induced within a few hours of taking the medicine. In severe cases, it can even lead to asthma. The cough usually gets better after the drug is stopped.

Nitroimidazole antibiotics.

Among the nitroimidazole antibiotics, nitrofurantoin is the most likely to induce cough. Its most common side effect is acute pneumonia injury. If the patient has pneumonia or is allergic, it will be more likely to induce pneumonia damage. Its clinical manifestations are mainly dry cough. Most acute pneumonia injuries occur within 1 month of taking nitrofurantoin. If a dry cough develops after more than 6 months of use, it should be considered as possible pulmonary toxicity. Symptoms usually get better when the drug is stopped. If the symptoms do not improve after stopping the drug, oral antihistamines and glucocorticoids can be used to relieve the symptoms.

Antituberculosis drugs.

Among the anti-tuberculosis drugs, para-aminosalicylic acid is the most likely to cause dry cough. Most of the irritating coughs it causes appear within 3 weeks of taking the drug and usually get better when the drug is stopped.

Anti-cancer drugs.

Among the anticancer drugs, bleomycin is one of the drugs that is more likely to cause lung damage. It produces reactive oxidative products that cause direct damage to lung tissue. This results in massive infiltration of leukocytes, increased release of proteases, proliferation of fibroblasts, and pulmonary fibrosis. The common clinical symptom is dry cough. It occurs in about 2 to 4 percent. Lung damage can still occur weeks, months, or even years after the drug is stopped. If lung injury occurs while taking the drug, the drug should be discontinued immediately. If symptoms do not improve after stopping the drug, intravenous glucocorticoids should be administered to inhibit fibroblast activity. Patients can also supplement with oxygen to improve the symptoms of dyspnea.

Antibiotics.

Antibacterial drugs such as penicillins, cephalosporins, macrolides, etc. can cause cough. Patients with allergies are more likely to induce cough. Symptoms generally improve when the drug is stopped.

Anticoagulant drugs.

The most common adverse effect of anticoagulant drugs is bleeding. If the bleeding is in the chest cavity or lung parenchyma, it can damage lung tissue and cause coughing. Therefore, it is recommended to observe whether there is bleeding during taking the medicine, and adjust the dose in time. It is recommended to start with a low dose and then gradually increase the dose.

Sodium cromoglycate

Sodium cromoglycate can be used to prevent asthma attacks and the prevention and treatment of allergic symptoms. However, inhaled sodium cromoglycate tends to irritate the mucous membranes of the airways and cause coughing when used. Coughing may occur a few minutes after taking the medicine. Symptoms can be improved with dose reduction or discontinuation.

Aspirin.

Aspirin can increase the production of leukotrienes. It irritates the mucous membranes of the airways causing coughing. Cough usually occurs within 30 minutes of taking the medicine. Symptoms will gradually relief after the drug is discontinued.

Drug-induced cough usually improves when the drug is discontinued. If it does not improve, it should be promptly treated according to the patient's condition.

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How should anticoagulants and thrombolytics be used in patients with pulmonary embolism❓❓❓

Coronary heart disease, stroke and pulmonary embolism are the top three
causes of death in patients with cardiovascular disease. Pulmonary embolism includes pulmonary thromboembolism, air embolism, fat embolism and tumor embolism. Among them, pulmonary thromboembolism is the most common type of pulmonary embolism. Deep vein thrombosis of the lower extremities is the main cause of pulmonary thromboembolism. Pulmonary thromboembolism has a high morbidity and mortality rate. Therefore, the correct and rational use of anticoagulant and thrombolytic drugs in the treatment of pulmonary thromboembolism is very important.

Treatment of acute pulmonary thromboembolism.

Risk classification for acute pulmonary embolism.

	Hypotension or shock	Right ventricular insufficiency	Elevated cardiac biomarkers
Low risk	-	-	-
Low to moderate risk	-	Either is positive.
Moderate to high risk	-	+	+
High risk	+	+	+/-
Cardiac biomarkers: Markers of heart failure (eg, B-type Natriuretic Peptide, N-terminal pro-brain natriuretic peptide) and markers of myocardial injury (eg, cardiac troponin T, cardiac troponin I)

The treatment regimen is administered according to the risk classification.

Low risk: Anticoagulant therapy is used in low-risk patients. It is recommended for clinical observation in patients with subsegmental pulmonary embolism without proximal deep vein thrombosis of the lower extremities and in patients with a low risk of recurrent venous thromboembolism.

Low to moderate risk: Low to moderate risk patients are treated with anticoagulants.

Moderate to high risk: Patients at moderate to high risk are initially treated with anticoagulants. When the clinical symptoms of the patients worsen after treatment and there are no contraindications for thrombolytic drugs, the patients can be treated with thrombolytic drugs.

High risk: Treat high-risk patients with thrombolytic drugs. If the patient has contraindications to thrombolytic drugs, the patient should be treated with surgery or interventional therapy.

Thrombolytic therapy.

Commonly used thrombolytic drugs are alteplase, streptokinase and urokinase. Their thrombolytic effects are similar, and they are selected according to the clinical situation of the patient.

• Alteplase 50 mg is given by continuous intravenous infusion for 2 hours.
• Recombinant streptokinase 1.5 million U is given by continuous intravenous infusion for 2 hours.
• Urokinase 20,000 U/kg is given by continuous intravenous infusion for 2 hours.

Thrombolytic drugs activate plasminogen, which is converted into plasmin. Fibrin is hydrolyzed by plasmin and leads to thrombolysis. Thrombolytics are most effective when started within 48 hours and they can dissolve some or all of the thrombus rapidly. The treatment period is generally within 14 days.

Anticoagulation therapy.

Anticoagulant drugs can promote the action of the fibrinolytic mechanism to dissolve the formed thrombus. They are also effective in preventing the recurrence of embolism and the re-formation of thrombus. There are three recommended anticoagulation regimens for the treatment of pulmonary thromboembolism. Anticoagulation therapy should take at least 3 months.

Monotherapy: The following regimens may be considered for most patients with low to moderate risk pulmonary embolism.

• The loading dose of rivaroxaban was 15 mg twice daily for 21 days, then changed to 20 mg once daily.

• Or a loading dose of 10 mg apixaban twice a day for 7 days, then changed to 5 mg twice a day.

Sequential therapy: Patients are initially treated with a parenteral anticoagulant such as heparin. Because warfarin has a slower onset of action, overlap warfarin within 24 hours of initial treatment to adjust INR values within 2.0 to 3.0. After reaching the INR target, heparin was discontinued.

Sequential therapy: Patients are initially treated with a parenteral anticoagulant such as heparin for 5 to 14 days, and then switched to edoxaban or dabigatran.

Commonly used parenteral anticoagulant drugs are low molecular weight heparin, unfractionated heparin and fondaparinux. Unfractionated heparin is recommended for severely obese patients and with severe renal impairment (creatinine clearance <30ml/min). Unfractionated heparin has the highest risk of inducing thrombocytopenia, followed by low molecular weight heparin. Fondaparinux has the lowest risk of induction. If the platelet count decreases by more than 50% of the baseline value, heparin anticoagulants should be discontinued and non-heparin anticoagulants such as bivalirudin and argatroban should be used instead. 

Warfarin: Its anticoagulant effect is mainly by inhibiting the synthesis of new coagulation factor Xa. Because it has no effect on the already synthesized clotting factors, its onset will be slower.

Edoxaban, Apixaban and Rivaroxaban: Its anticoagulant effect is mainly by inhibiting the activity of coagulation factor Xa thereby reducing the synthesis of thrombin.

Dabigatran: Its anticoagulant effect works by directly inhibiting the activity of thrombin.

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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.

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