Pediatric Cough CME
Transcript of Pediatric Cough CME
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Role of cough syrups and anti-pyretics in treatment of pediatric
cough: Children are not miniature
adults
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Cough is a very elaborate act with the explicitintention of expelling irritants in the
respiratory tract
The irritants may be intrinsic eg. Mucus & phlegm
or extrinsic eg. Foreign particle or body
Cough is reflex-evoked modification of breathing pattern in
response to airway irritation
Cough can also be produced voluntarily
Why do we cough?
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How do we cough?
The event of cough is deep inspiration followed by forceful expulsion
Diaphragm and external intercostal muscles contract, creating a negative
pressure around the lung.Air rushes into the lungs
The glottis closes and the vocal cords contract to shut the larynx.
The abdominal muscles contract to accentuate the action of the relaxing
diaphragm; simultaneously, the other expiratory muscles contractincrease the pressure of air within the lungs upto 300mmHg.
The vocal cords relax &the glottis opensreleasing air at over 100mph.
The bronchi and non-cartilaginous portions of the trachea collapse to
form slits through which the air is forced, which clears out any irritantsattached to the respiratory lining.
However mechanical laryngeal stimulation as in aspiration results in
immediate expiratory stimulation without the preceding inspiratory
phase to protect the airway from aspiration by expiratory reflex.
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How do we cough?
Each cough occurs through the stimulation of acomplex reflex arc constituted by:
Afferent pathway: Sensory nerve fibers located in theciliated epithelium of the upper airways, branchesfrom the diaphragm. The afferent impulses go to themedulla diffusely.
Central Pathway : a central coordinating region forcoughing is located in the upper brain stem and pons.
Efferent pathway: Impulses from the cough centertravel via the vagus, phrenic, and spinal motor nervesto diaphragm, abdominal wall and intercostal muscles.
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How do we cough?
This is initiated by the stimulation of
cough receptors which are found in the
trachea, main carina, branching points of
large airways, and more distal smaller
airways, the pharynx, external auditory
canals, eardrums, paranasal sinuses,
pharynx, diaphragm, pleura, pericardium,
and stomach.
The receptors are mechano-recptors
stimulated by irritation by mucus plug,
foreign body, particulate matter etc or
chemorecptors stimulated by irritants,
fumes, aspirates,The afferent neural pathway is through the
internal Laryngeal branch of the Superior
Laryngeal branch of the Vagus.
The efferent neural pathway is mediated
through the Vagus, Phrenic nerve & theIntercostal nerves
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NOT SMALL ADULTS(CAUTION WITH EXTRAPOLATING ADULT LITERATURE)
Viruses responsible for common cold in adults may cause seriousrespiratory illness in kids.
Maturational differences in airway anatomy, respiratory
musculature, chest wall structure. Differences in medication response.
Medical history in young kids is limited by parental perception andavailability.
Children should be managed according to the studies and guidelines forchildren (when available), because etiologic factors and treatments inchildren are sometimes different from those in adults.
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DIAGNOSTIC APPROACHES
Children with chronic cough require careful and systematicevaluation for the presence of specific diagnostic indicators.
In children with chronic cough, the etiology should be defined andtreatment should be etiologically based.
Children with chronic productive purulent cough should always beinvestigated to document the presence or absence of bronchiectasisand to identify underlying and treatable causes such as cystic fibrosisand immune deficiency.
History and physical exam first:
Specific pointerssuggestive of specific cough.
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DIAGNOSTIC APPROACHES
Pointers to the Presence of Specific Cough
Auscultatory findings, wheeze, crepitations
Cardiac abnormalities
Chest pain
Chest wall deformity
Digital clubbing, FTT (CF)
Neurodevelopmental (potential for aspiration)
In children with nonspecific cough, cough may spontaneously
resolve, but children should be reevaluated for the emergence
of specific etiologic pointers.
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DIAGNOSTIC APPROACHES
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DIAGNOSTIC APPROACHES
12yo male with remote history of URI has been coughing since
Thanksgiving.
Children with chronic cough should undergo, as a minimum, CXR and
spirometry, if age appropriate.
CXR quick, readily attainable.
Spirometry reliably performed in kids > 6 yrs (often >3 yrs, with
appropriate personnel).
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DIAGNOSTIC APPROACHES
Also considered: Chest or sinus CT
a.) HRCT as current gold standard for eval of small airwayanatomy.
b.) Lifetime cancer risk is age and dose dependent.c.) Single Chest CT scan ~ 5.8 mSv (CXR ~ 0.02 mSv, so =300 CXRs).
Flexible bronchoscopy
1.) suspicion of airway abnormality.2.) localized radiology changes.3.) suspicion of inhaled foreign body.4.) eval of aspiration lung disease.
5.) micro studies and lavage (BAL).
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ETIOLOGY
In children with specific cough, further investigations may be
warranted, except when asthma is the etiologic factor.
Cough is the most common presenting symptom in patients
presenting to doctors in US and Australia.
Viral URIs, which also cause cough, are said to account for 80
percentof childhood asthma exacerbations.
7yo female with known RAD presents withcough and wheezing.
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ETIOLOGY
Upper Airway Disorders and Cough
Upper airway cough syndrome (aka post-nasal drip) well
documented in adults.
In children, relationship between nasal secretions and cough ismore likely linked by common etiology (infection or
inflammation).
Abnormal sinus radiographs found in 18-82% of
asymptomatic children.
No RCTs on therapies for upper airway disorders in kids with
improvement of nonspecific cough as outcome measurement.
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ETIOLOGY
GERD and Cough
PROOF that GERD causes chronic cough in kids is rare.
Infants often regurgitate, but few well infants cough with these
episodes. Available prospective studies of chronic cough in kids suggest
that GERD is infrequently the SOLE cause.
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ETIOLOGY
Airway Lesions and Cough
Prevalence of airway lesions found in asymptomatic children
is unknown.
Relationship of cough to airway lesion can only be postulated: Airway malacia impedes clearance of secretions; potential for
pneumonic process distal to lesion
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ETIOLOGY
Environmental Pulmonary Toxicants
Increases susceptibility to respiratory infections
Increases coughing illnesses
Close association to tobacco smoke exposure, especially inassociation with asthma.
15yo female with cough for past month, noticed by parents
that only occurs after home from school.
In all children with cough, exacerbating factors such as ETS exposure
should be determined and interventional options for the cessation of
exposure advised and initiated.
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ETIOLOGY
Chronic Nocturnal Cough
Unreliability and inconsistency of reporting.
Often used as a direct indicator of asthma.
Community based study revealed only a third of children withisolated nocturnal cough had asthma.
No studies that objectively document that nocturnal cough is
worse than daytime cough in uncontrolled asthmatics.
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ETIOLOGY
Respiratory Infections and Postinfectious Cough
Postviral cough refers to presence of cough after acute viral
URI. Unstudied natural history beyond 25 days.
Re-infection (when not completely recovered) may result inappearance of prolonged coughing.
Total respiratory illnesses per person year ranges 5-8/yr
(
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ETIOLOGY
Psychogenic Cough
AKA habit cough, tic cough, psychogenic cough.
Behaviorial association.
Inhalation of Foreign Body
Presentations usually acute, but chronic cough may be
presenting symptom of missedFB inhalation.
Normal CXR does not exclude. Specific history should be sought.
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ETIOLOGY
Parental Expectations
Parental expectations as well as the doctors perceptions (of said
expectations) influences consulting rates and prescription use.
Use of OTC meds and frequency of doctors visits were less
likely with more highly educated mothers.
Parental concerns can be extreme and include fear of child
choking and dying, SIDS, asthma attack, permanent chest
damage.
In children with nonspecific cough, parental expectations should be
determined, and the specific concerns of the parents should be sought and
addressed.
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Types of coughs
Dry or non productive cough
Phlegmy or productive cough
Croupy or barking cough Cough with wheezing
Pertussis or cough with a whoop
GERD or cough with choking
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Dry or nonproductive coughShort bursts of incessant cough
Occurs daytime as well as nighttime
Associated with hoarseness of voice, pain while swallowing and
on external pressure
Nocturnal dry cough is aggravated in supine position due to post
nasal dripAcute dry cough is caused by upper respiratory infections due to
virus including Flu virus, bacterial infections including
Streptococcus, H Influenzae and Chlamydia
Chronic dry cough could be due to enlarged tonsils, adenoidswith post nasal drip or intraluminal or extraluminal obstruction in
upper airway eg. Endobronchial/ paratracheal LNs
Pharyngeal irritation directly is unlikely to induce cough because the innervation is
Glossophayngeal & not vagus.
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Phlegmy or Productive cough
Productive cough is due to catarrh due excessive
production or non clearance of mucus from upper/ lowerairway
It could be infective or noninfective
Infective productive cough could be due to infection in
upper airway as in paranasal sinusitis or lower airway as in
pneumonia or bronchiectasis
Non infective productive cough could be due to allergic
catarrh or due to thick tenacious phlegm as in cysticfibrosis
Cough is seen daytime as well as night time
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Croup or barking cough
Sudden onset spasmodic non productive cough with a barkingquality
Mostly occurs in early half of night
Mostly occurs in children below 3 years of age
Generally preceded by mild corryza with/ without fever of shortduration
Although dramatic in onset & presentation, child doesnt appear
toxic or in pain or distress. No dysphagia.
Very few children have recurrences till age of 3 years.X-ray neck AP view shows subglottic narrowing of airway:
Steeple sign
Toxic child with dysphagia, dysphonia should have X-ray neck
Lateral view to r/o epiglottitis which is a medical emergency.
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Pertussis or cough with a whoop
Prolonged cough with short outbursts of cough ending
with asound of whoop
Lasts from a few weeks to months even after specific
treatment with appropriate antibiotics.
Severity of cough esp in small infants can lead toconjunctival , oral mucosal bleed, intracranial bleed
can lead to convulsions or loss of cosciousness.
A bout of cough may lead to severe vomiting as wellas poor intake of food, leading to malnutrition
GERD h ith h ki
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GERD or cough with choking
Coughing associated with feeding events
More common in supine feeding- more in bottle-fed than breast fed
infants.Occurs in neonates and may continue till late infancy when child starts
to feed in sitting position esp semisolid & solid feeds
Typically starts within few minutes of feeding with mild clearing throat
sounds leading to head bobbing followed by bout of vomiting or coughas mouth fills with milk rising from the esophagus. Head bobbing may
even lead to retraction of neck .
Severity of GERD is classified in terms of frequency as well as degree of
reflux.It occurs due to physiological laxity of lower esophageal sphincter with
acidic stomach contents coming into esophagus
The cough is due to stimulation of chemoreceptors in the distal airway & Vagal
innervated receptors in the esophagus
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Why should we treat cough?
It is obvious that the process of cough is beneficial andhelps to clear mechanical or chemical irritants in the
respiratory tract.
However the large pressures & velocities generated in the
airways are also responsible for many of the complicationsof cough, including hoarseness, excessive perspiration,
urinary incontinence, rib fractures, musculoskeletal pain,
exhaustion, headache, dizziness & self-consciousness.
The nocturnal cough with/ without post nasal drip leaves the
child insomnic with daytime somnolescence & hyperkinetic
behavior.
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Choice of cough medications
The purpose of cough medications is alleviation of
symptoms.They are always add-ons to specific medications such as
Antibiotics, Bronchodilators, antiallergics eg
antihistaminic & interleukin receptors inhibitors egMontleukast or anti-inflammatory eg steroids
Cough medications are given as cough suppressants,
decongestants, expectorants & mucolytics.
They are available as tablets, syrups or lozenges
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Cough suppressants
Cough suppressants prevent or stop coughing
Cough suppressants cross the blood brain barrier &
act on the center in the medulla that controls the
cough reflex i.e. they act centrally
They are narcotic derived e.g. Codein, pholcodein,Noscapine and non addictive narcotic like
Dextromethorphan or non narcotic like Benzonatate
They are useful to suppress dry cough, nocturnalcough and pertussis.
They are prone to be abused
They are not safe below 6 years of age.
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Cough suppressants Dextromethorphan is the commonest cough suppressant
available either alone or in combination with antihistamines ordecongestants
Derived from morphine, it is a narcotic antitussive but has noanalgesic or addictive property
Although it is as effective as Codein as an antitussive inadults, its efficacy is no better than placebo
Although it is non addictive in therapeutic dose , in very highdose it is used for recreation and is prone to be abused.
Dosage: 0.5 mg/kg/dose 3-4 times a day Codein: Centrally acting narcotic antitussive available either
alone or in combination with antihistmines.
Dosage: 0.3mg/kg/dose 2-3 times/day
Noscapine: Non addictive narcotic antitussive.
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Mucokinetic agentsThese are various agents which help to keep the mucus
thin and helps the mucociliary mechanism to expelthe thick mucus.Act on the afferent wing of cough reflex, either as:
Expectorants : stimulate body to hydrate & thin the
mucus eg. Guiphenesine
Mucolytic agent: Helps to make mucus thin e.g. oralCarbocystein, Ambroxol, Bromhexine or inhaled
acetylcysteine. Adhesives / surfactants: Reduces affinity between
secretions & biological surfaces eg. Ammoniumchloride, potassium iodide
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Combination cough medicationsCommon available combinations:
Antitussive + Antihistamine
Decongestant + Antihistamine
Decongestant + Mucolytic
Expectorant + Mucolytic Expectorant + Antiadhesive
Expectorants + Brochodilator
Combinations that should be banned
Montlukast + Expectorants
Expectorants + Zinc / Calcium
Mucolytic + Amoxycillin
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Herbal medicines & Home
remedies
Mostly cough suppressants act as demulsifying
agents soothing for throat
Contain various combinations of honey, tulsi,
ginger, methi.
Recent preparations with dry ivy leaf extract
Give temporary relief
Do not treat underlying cause
Generally safe & non addictive
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Fever
Elevation of body temperature above normal range of 36.5
37.5 C (98100 F) due to elevated temperature regulatory
set point is fever.
Elevation of body temperature greater than or equal to 41.5
C (106.7 F) due to elevated temperature regulatory centreis hyperpyrexia which is fever.
Elevation of body temperature without elevated temperature
regulatory set point as in elevated environmental
temperature or heat stroke is hyperthermia
In hyperthermia the body temperature rises above its set point &hence is notfever!
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Thermoregulatory mechanism
The brain orchestrates heat effector mechanisms
via the Autonomous Nervous system:
Increased heat production:
by increased muscle tone, shivering
hormones like epinephrine
Prevention of heat loss
vasoconstriction.
This temperature regulation is controlled in the hypothalamus
Thermoreg lator centre & afferent & efferent arms
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Thermoregulatory centre & afferent & efferent arms
The preoptic region, in & near
the rostral hypothalamus,acts as a coordinating center.
The preoptic area contains
neurons that are sensitive to
subtle changes in hypothalamicor core temperature & also
receive somatosensory
input from spinal & skin
thermoreceptors & integrate
central and peripheral thermal
information
M h i f f
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Mechanism of fever
Fever & Hyperpyrexia result from elevation of
thermoregulatory set point in response to chemicalmediators called pyrogens.
Pyrogens are generally immune mediated cytokines
eg. IL 1, IL 6, TNF generally released frommacrophages engulfing various pathogens.
These cytokines then bind with endothelial receptors on
vessel walls activating the arachidonic acid
pathwayformation of PGE2mediator of fever(COX2)
by acting on the preoptic area of hypothalamusfever response
Body responses to temperature variations
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Body responses to temperature variationsEffector Response to low temperature Response to high temperature
Smooth
muscles in
arterioles in
the skin.
Muscles contractVasoconstriction.
Extremities can turn blue and feel cold and
can even be damaged (frostbite).
Muscles relaxvasodilation. More
heat is carried from the core to the
surfacelost by convection & Skinturns red.
Sweat glands No sweat produced. Glands secrete sweat onto surface
of skinevaporates, it takes heat
from the body
Erector pili
muscles in
skin
Muscles contract, raising skin hairs and
trapping an insulating layer of still, warm
air next to the skin.
Muscles relax, lowering the skin hairs
and allowing air to circulate over the
skin convection and evaporation.
Skeletal
muscles
Shivering: Muscles contract & relax
repeatedly, generating heat by friction &
metabolic reactions
No shivering.
Adrenal &
thyroid glands
Glands secrete adrenaline and thyroxine
respectivelyincreases the metabolic rate
in different tissues generating heat.
Glands stop secreting adrenaline &
thyroxine.
Behavior Curling up, huddling, finding
shelter, putting on more clothes.
Stretching out, finding shade,
removing clothes
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Why fever?
Fever is a very energy consuming process thatevolution has preferred to persistwhy?
It is presumed that fever improves host immune
response:Increased mobility of leukocytes
Enhanced leukocytes phagocytosis
Endotoxin effects decreasedIncreased proliferation of T cells
Those with bacterial infection are seen to have lower mortalitywhen associated with fever.
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Why treat fever?
Although fever seems to be beneficial to the host, thediscomfort associated with fever eg. Malaise, headache,
tachycardia, hypertension necessitates treating the fever.
Certain high risk patients eg. Congenital heart diseases esp
with LR shunt, certain metabolic disorders & those with
H/O febrile convulsions as well as epilepsy benefit from
controlling fevers.
Fever controlling medications do not alter the course of the disease causing the fever
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Treatment of fever
Physical methods:
Sponging natural sweating areas of the body i.e. head,
arms, legs, axilla & scrotum.
Sponge with plain water or with salt or cologne added.
Preferable to use warm water.temp body-water = 2OF
Avoid blocking sweat pores with oil, woolen clothes.
Keep the surroundings cool
Keep well hydrated
T f f
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Treatment of feverMedications:
Paracetamol: aniline analgesic which is not an NSAID. Weak inhibitor ofCOX.
Rapidly absorbed with/ without food
Onset of action 11minutes
Duration of action 4 hours.
Dose related liver toxicity.
Paracetamol in regular dosage safe in G6PD deficiency
Ibuprofen: Nonselective COX inhibitor NSAID
.Rapidly absorbed with/ without food
. Rapid onset of action
. Duration of action 8 hours
. Because of nonselective COX inhibition G I disturbance is common.
Ibuprofen not safe in G6PD deficiency
Other NSAIDs
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Other NSAIDs
1) NONSELECTIVE COX INHIBITORS
- acetylsalicylic acid at high dosage
- diclofenac - ibuprofen
- ketoprofen
- flurbiprofen
- indomethacin
- piroxicam
- naproxen
2) COX-1 SELECTIVE INHIBITORS - acetylsalicylic acid at low dosage
3) MORE COX-2 SELECTIVE INHIBITORS
- nimesulid
- nabumeton
4) COX-2 SELECTIVE INHIBITORS
- celecoxib
- etorcoxib -
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Commonly used drugs in coughand cold preparations
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Chlorpheniramine maleate
Class - Antihistamines
Antihistaminic action :
Blocks the action of histamine (a substance causes
allergic symptoms)
Promptly relieves symptoms in Rhinitis (sneezing,
itching of eyes, nose & throat)
Anticholinergic action:
reduce secretion - Rhinorrhoea
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Chlorpheniramine maleate
Chlorpheniramine relieves
Red, itchy, watery eyes
Sneezing
Itchy nose or throat
Runny nose (Rhinorrhoea)
Chlorpheniramine helps control the symptoms of
Common Cold
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Phenylephrine Hydrochloride
Nasal Decongestant
Decongestants are the drugs of choice for a
stuffy, congested nose
Decongestants act by narrowing the blood
vessels in the nose, leading to decreasedblood flow in the nasal tissues and reduced
leakage of fluid from the nose
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Phenylephrine Hydrochloride
Nasal Decongestant
Direct Sympathomimetic
Selective alpha1 agonist action
Act on alpha adrenergic receptors in the mucosa of
the respiratory tract producing vasoconstriction
which results in shrinkage of swollen mucus
Relieves Stuffy Congested Nose
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Paracetamol
Paracetamolis one of the most popular andwidely used drugs for the treatment of pain and
fever
Central Analgesic Actionraises pain
threshold
Anti-pyretic action
Good safety profile
Relieves fever, sore throat and body ache
N h i f A ti f
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Newer mechanism of Action for
Paracetamol
Cananbinoids have a role in modulation of
pain (decrease the pain)
Active metabolite of PCM goes and bind to
cannabinoid receptor
Analgesic effect of paracetamolis due to the indirect activation ofcannabinoid CB(1) receptors
CNS Drug Rev.2006 Fall-Winter;12(3-4):250-75.
http://www.ncbi.nlm.nih.gov/pubmed/17227290http://www.ncbi.nlm.nih.gov/pubmed/17227290http://www.ncbi.nlm.nih.gov/pubmed/17227290 -
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Caffeine
Methyl xanthine alkaloid
Consumed as beverages
CNS Stimulant primarily affect the higher centers
Produces
Sense of well being,
Alertness,
Beats bordem,
Allays fatigue,
Improve performance
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Sales Training
Dextromethorphan Hydrobromide
(DMR)
Non - narcotic cough suppressant (anti tussive).
Acts centrally on cough centre, (Medulla) andelevates the threshold for coughing.
Equipotent to codeine in depressing cough reflex.
D t th h
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Sales Training
Dextromethorphan
Hydrobromide (DMR)
Average dose is 10 to 30 mg 3 to 6 timesdaily.
Has no expectoration action and does not
inhibit ciliary action. Rapidly absorbed from
G.I. Tract.
Exerts effect within 15-30 minutes after oral
administration.
Duration of action is 5-6 hours.
Metabolized in the liver.
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Sales Training
Cough suppressants with
equipotent doses
Dextromethorphan 10 mg
Codeine 15 mg Noscapine 15 mg
Pholcodeine 10 mg
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Favorable Features of
Dextromethorphan Hydrobromide
Equipotent antitussive to Codeine,
Pholcodiene which are narcotic.
No addictive properties.
Does not cause CNS depression nor it
affects respiratory rate.
Sales Training
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Sales Training
Favorable Features of
Dextromethorphan Hydrobromide
Does not cause drowsiness, constipation
unlike codeine.
Is safe & effective.
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Sales Training
Guaiphenesin
Most commonly used expectorant.
Often used singly or in combination.
Readily absorbed from GI tract
Increases the output of respiratory tract fluids, this
helps to liquefy the thick mucus.
Though not a cough suppressant reduces the intensityand frequency of dry or productive cough.
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Sales Training
Reference
Guaiphenesin
From a study in 239 patients it wasreported that Guaiphenesin reduced cough
intensity and frequency in patient with dry or
productive cough and helped to thin
sputum.
RE Robinson et al, Robins, Curr ther Research, 1977 : 22 ;
284
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Thank you