Cough and coughing up blood in palliative care

Coughing is the body’s natural reflex stimulated by substances causing irritation to the airways, such as mucus, saliva, or stomach contents moving up into the esophagus. In the case of an advanced illness, mucus secretion may increase, or the mucus may become thicker. In addition, it may take longer for the mucus to leave the airways, or the patient may not have the strength to swallow the mucus or saliva, allowing it to remain in the airways and cause irritation. In addition, having dry indoor air often provokes coughing.

Coughing may also be caused by increased irritation to the airways during an infection. In addition to respiratory tract infections, a patient with a progressive illness may have other illnesses or conditions that cause a cough, such as asthma, chronic obstructive pulmonary disease, heart failure with fluid around the lungs, or disorders of the diaphragm, pleura, or sac around the heart (pericardium).

The airways may also be obstructed by a tumour that not only causes shortness of breath but also provokes coughing as a result of irritation to the airways. If the tumour damages the mucous membrane in the bronchi, there may be blood in the cough.

As many as every other patient with metastatic cancer develops pleural effusion, or fluid in the space between the layers around the lungs, the pleura. While the most common symptom of pleural effusion is shortness of breath, the build-up of fluid may also cause a cough. Sometimes coughing is caused by the patient’s medication, including certain blood pressure medicines (so-called ACE inhibitors).

Cough

A cough is best treated by treating the cause. Medicines specifically aimed at treating a cough have been found unhelpful in palliative care or hospice care. Morphine-like pain medications can be used to control the cough response.

Mucus

Thick mucus can be made thinner in consistency by inhaling a saline solution. Once the mucus is thinner, it’s easier to cough up. There are even medications that can be used to try and control mucus secretion. Medications used to dry up mucus often cause dry mouth as a side effect.

Coughing up blood (haemoptysis)

If coughing up blood is caused by cancer, it can sometimes be treated with radiation therapy. Mild cases can also be controlled with medication.

Death rattle

During the last days of life, a dying patient’s breathing may be accompanied by what is known as a “death rattle”. This symptom is caused by the accumulation of saliva and mucus in the airways. Whether the patient finds the mucus interfering at this point is unknown. Medication can be used to try and control the secretion of mucus, if necessary. Airway suctioning using a catheter is unpleasant and is only performed as an exception.

In palliative care, coughing is a symptom that negatively impacts the quality of life of both the patient and their loved ones. Over-the-counter medicines aimed at treating a cough have been found unhelpful, especially in the case of a patient receiving hospice care.

For loosening mucus, there are various methods that don’t require medication, such as bottle PEP therapy (blowing into a water bottle through a plastic tube) and different breathing and coughing techniques. In addition, steam inhalation helps make the mucus looser. Some patients find artificial respiratory gas humidification helpful, or may find it easier to breathe while in the shower as air humidity rises inside the shower stall.

Quitting smoking reduces coughing, as the smoke no longer irritates the airways and the passage of mucus from the airways is improved.

Sleeping or resting on one side helps keep the upper respiratory tract open. If there is pleural fluid on one side only, keep that side down while lying down, so that the better lung has more room to breathe. It’s easier to cough properly with the upper body raised or while standing and leaning slightly forward.