Using Behavioral Management to Control Chronic Refractory Cough
June 21, 2021 01:46pm
By Kristen Coppock, MA, Managing Editor
It is that time of year again, when health care providers see an increase in patient volume because no one has time to be sick.
It is that time of year again, when health care providers see an increase in patient volume because no one has time to be sick. Ah yes, the common
cold that can keep children out of school, athletes out of games, adults out of work, and elderly individuals out of commission and basically disrupt life as we know it. There are more than 100 strains of rhinoviruses that cause the majority of colds.
The common cold typically starts with a sore throat, turns into nasal congestion, a runny nose, and sneezing, and then finishes off with a nagging cough that can last up to 2 weeks. Who has time for this?
Education on Prevention
The first step in educating patients: Tell them to try not to catch the common cold in the first place. They should be aware that hands carry cold viruses and those viruses can stay on skin surfaces for up to 2 hours. People need to cough into the bend of their elbows and not their hands. And if they do touch their hands, they should not touch their eyes, noses, or mouths. In addition, they should wash their hands before they eat, as cold viruses can live on surfaces such as doorknobs, faucet handles, phones, armrests, and tray tables on planes. And those who happen to stand next to a person with a cold virus who coughs or sneezes a droplet into their eyes, nose, or mouth likely won’t be feeling well within the next 48 to 72 hours.
OTC Treatment Options
Treatment is all about controlling the symptoms, and an antibiotic isn’t going to help. Let’s look at this from the patient’s perspective. They head to the OTC cold-and-cough section, only to be met by all sorts of cards to take to the pharmacy for pseudoephedrine, multiple rows of phenylephrine, as well as nasal sprays, antipyretics, and cough medicine. They are asking themselves, “Do I need just guaifenesin or guaifenesin with dextromethorphan or just dextromethorphan? Is it combined with acetaminophen and/or phenylephrine? Do I need something for day and something for night?” Let’s not mention the rows of antihistamines. Health care providers can help patients sort through the multiple available OTC options to treat symptoms of the common cold. Let’s educate patients regarding
treatment options for the most common acute illness in the United States, which is responsible for about 37 million doctor’s office visits every year.2
Pseudoephedrine Versus Phenylephrine
Nasal decongestants, such as pseudoephedrine and phenylephrine, are used for short-term relief of nasal congestion and sinus pressure. What is the deal with pseudoephedrine, and why is it available only behind the counter at a pharmacy? Pseudoephedrine has been used illegally to produce methamphetamine, a highly addictive stimulant. The Combat Methamphetamine Epidemic Act of 2005, which was incorporated into the Patriot Act in 2006, mandated that retailers sell pseudoephedrine behind the counter only, require a photo ID, limit quantities purchased, and keep per- sonal information about the customers for at least 2 years.Different states have different limitations. State governments have issued additional regulations because of the misuse of methamphetamine. I recently visited Arkansas and had a cold, and I could not purchase pseudoephedrine without identification from that state and was told by the pharmacist that I would need a prescription. Furthermore, certain pharmacies have additional regulations requiring a prescription, no matter what state a person is from. When recommending pseudoephedrine for patients, be aware of the state and pharmacy regulations. Waiting in line at the pharmacy for an OTC medication that can’t be purchased can be frustrating for patients with the common cold. As for effectiveness, results from studies have shown pseudoephedrine to be more effective than phenylephrine in reducing nasal congestion.Keep in mind that alternative options may be preferred for patients with heart disease, hypertension, thyroid disease, diabetes, an enlarged prostate, or glaucoma.
Dextromethorphan and Guaifenesin
Dextromethorphan (DXM) is a cough suppressant that is one of the more commonly abused cough and cold medicines. Misused at high doses, it can cause hallucinations and euphoria, referred to by teenagers and young adults as robotripping or skittling.
Interestingly, many brands combine DXM with guaifenesin. However, guaifenesin at high doses
induces nausea; needless to say, the combination brand is avoided by those with the intent to misuse. Patients should not take DXM with antidepressants because of the risk of serotonergic syndrome, which can be life-threatening.Guaifenesin is an expectorant that works to thin mucous and clear congestion. Patients should know that if they drink a lot of water, this medication will be even more effective.
Saline nasal sprays are a safe and effective remedy to clear nasal congestion. Nasal sprays that contain a decongestant, such as phenylephrine, are also available. Tell the patient that decongestant nasal sprays should not be used for longer than 3 days, to avoid rebound nasal congestion. Very little research has been done on the effectiveness of nasal corticosteroids for the common cold. In my opinion, it may take several days for optimal symptom control, by which time the common cold will have resolved.
Antihistamines block histamine, which is responsible for allergic symptoms that are very similar to the symptoms of the common cold caused by a virus. This prompts the question, “Do antihistamines help relieve symptoms of the common cold?” Let’s review the evidence from 18 trials with 4342 participants reported in 17 different publications.In adults, there was a benefit on the first or second day of treatment, with 45% feeling better versus 38% on placebo. But there was no difference over the remaining days. The trials in children were smaller and of lower quality, lacking evidence of effectiveness.
We will get through this season together, one cough at a time. Prevention is key. But educating patients about the appropriate OTC treatment options for them specifically can help improve symptoms and reduce the disruptions caused by the common cold.
I am going to go wash my hands now.
Kristen Marjama, DNP, FNP-BC
, is a doctorally prepared family nurse practitioner with 9 years of experience in the retail health clinic industry.
She is the manager of clinic education and professional development at Walmart Care Clinic.
1. Sexton DJ, McClain MT. Patient education: the common cold in adults (beyond the basics). UpToDate website.uptodate.com/contents/the-common-cold-in-adults-beyond-the-basics. Updated March 1, 2016. Accessed November 1, 2017.
2. Common cold: epidemiology. BMJ Best Practice website.bestpractice.bmj.com/best-practice/monograph/252/basics/epidemiology.html. Accessed November 1, 2017.
3. Legal requirements for the sale and purchase of drug products containing pseudoephedrine, ephedrine, and phenylpropanolamine. US Food and Drug Administration website.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm072423.htm. Updated on September 13, 2016. Accessed November 1, 2017.
4. Horak F, Zieglmayer P, Zieglmayer R, et al. A placebo-controlled study of the nasal decongestant effect of phenylephrine and pseudoephedrine in the Vienna Challenge Chamber.Ann Allergy Asthma Immunol.2009;102(2):116-120. doi: 10.1016/S1081-1206(10)60240-2.
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6. Drug Enforcement Administration. Dextromethorphan.deadiversion.usdoj.gov/drug_chem_info/dextro_m.pdf. Published March 2014. Accessed November 1, 2017.
7. De Sutter AIM, Saraswat A, van Driel ML. Antihistamines for the common cold.cochrane.org/CD009345/ARI_antihistamines-common-cold. Published November 28, 2015. Accessed November 1, 2017.