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  1. Cough is a protective reflex, its purpose being expulsion of respiratory secretions or foreign particles from air passage. Cough may be useful or useless.
  2. Useless (nonproductive) cough should be suppressed. Useful (productive) cough serves to drain the airway; its suppression is not desirable, even be harmful.

Pharyngeal Demulcents)

Linctuses containing syrup, glycerine, losenzes, liquorice


a) Mucokinetics: Pot.citrate/Iodide, Guaiphenesin, Yasaka, Balsum of tolu, Ammonium chloride
b) Mucolytics: Bromhexine, Ambroxol, Acetyl cysteine, Carbocisteine

Antitussives (Cough Centre Suppressants)

(a) Opioids: Codeine, Pholcodeine.
b) Nonopioids: Noscapine, Dextromethorphan, Chlophedianol.
(c) Antihistamines: Chlorpheniramine, Diphenhydramine, Promethazine.

Adjuvant antitussives

Bronchodilators: Salbutamol, Terbutaline.


Types and management:

Upper/lower Respiratory tract infection
Smoking/chronic bronchitis
Pulmonary tuberculosis
Asthmatic cough
Postnasal drip due to sinusitis
Postnasal drip due to allergic rhinitis
Gastro-esophageal reflux
ACE inhibitor associated cough

Appropriate antibiotics
Cessation of smoking/avoidance of pollutants
Antitubercular drugs
Inhaled B1 agonists/ipratropium/steroids
Antibiotic, nasal decongestant, H1-antihistaminics
Avoidance of precipitating factor(s), corticosteroid, nasal spray, H1 antihistaminic
Life style modification, H2 blockers, proton pump inhibitors,
Substitute ACE inhibitors by Losartan, calcium channel blockers, NSAID


Antiasthma drugs

  • Two types:
  1. Bronchodilators
  2. Anti-inflammatory
  1. Bronchodilator
    1. Anticholinergics
      1. Ipratropium
      2. Tiotropium
    2. Methylxanthines
      1. Theophylline
      2. Aminophyline
    3. Beta-agonists
      1. Selective
        1. Salbutamol              
        2. Terbutaline          
        3. Salmeterol
        4. Formeterol              
        5. Bambuterol
      2. Non selective
        1. Adrenaline              
        2. Ephedreine          
        3. ​Isoproteranol  
  2. Anti-inflammatory
    1. Antileukotrienes
      1. Leukotriene antagonists
        1. Zafirleucast              
        2. Monteleukast              
        3. Pranleukast
      2. 5-lipooxigenase inhibitors
        1. Zileuton
    2. Corticosterioids
      1. Inhalational
        1. Budesonide              
        2. Ciclosenide                          
        3. Betamethasone.
      2. Systemic  
        1. Fluticasone                      
        2. Beclomethasone  
        3. ​Fluocinonide
    3. Mast cell stabilizers
      1. Chromoglycate                
      2. Nedochromil                    
      3. ​Ketotifen
    4. Anti-lgE antibody:  Omalizumab
  1. Beta-Agonists
    1. Adrenaline
      1. Used rarely as a SC or IV injection as a life supporting measure
    2. Isoproteranol
      1. Stimulate both beta- & beta-2
      2. Isoproteranol is shortest & fastest acting
      3. Cardiac side effects are major problems
      4. Safe in pregnancy
    3. Ephedrine
      1. Slow acting
      2. Used in mild chronic asthma
  • Nasal decongestant also


Selective Beta-2 agonists

  1. Salbutamol      
  2. Terbutaline  
  3. Salmeterol    
  4. Formeterol  
  5. Bambuterol

Beta-2 agonists


  • Adrenergic drugs cause bronchodilatation through B2 receptor stimulation leading to increased cAMP formation in bronchial muscle cell causing relaxation
  • In addition, increased cAMP in mast cells and other inflammatory cells decreases mediator release Since,B-2 receptors on inflammatory cells are more prone to desensitization the contribution of this action to the beneficial effect of B2 agonists in asthma is uncertain


  1. Well absorbed orally but have high first pass metabolism
  2. Could be given inhalationally
    1. Salbutamol/terbutaline-act for 6 hours
    2. Salmetrol/formeterol-act for 12 hours
    3. Bambuterol-acts for 24 hours
    4. Salmetrol –slowest acting-therefore contraindicated in acute asthma

Use of beta-2 agonists

  • DOC- Acute asthma

Side effects

  1. Tremors-MC                            
  2. Hypotension        
  3. Hypokalemia
  4. Hyperglycemia (beta-2 agonistic action in liver)                                
  5. Cardiac side effects
  1. Methylxyanthines
    1. Increase cAMP by inhibiting phosphodiaesterases Produces bronchodilation
    2. Improve cillary momements
    3. Stimulate diaphragmatic contractility
    4. Stimulate respiratory centre


  1. Well absorbed          
  2. High first pass              
  3. Half life=8 hours
  4. Zero order kinetics           
  5. Narrow therapeutic index
  6. *Monitoring of blood levels may be needed  


  1. Poorly controlled asthma (oral theophylline)
  2. Aminophylline-IV (acute asthma)-6mg/kg is loading dose

Dose modification

  1. Dose should be increased:
    1. Smokers
    2. Alcoholics
  2. Dose should be reduced:
    1. Neonates      
    2. Elderly  
    3. Cardiopulmonary disorders    
    4. Pneumonia        
    5. COPD 

Side effects

  1. MC-GI upset            
  2. Tremors              
  3. Hypotension         
  4. Hypokalemia            
  5. Palpitations          
  6. Seizures in overdose             
  7. Aminophyline (IV injection)
    1. Headache              
    2. Hypotension      
    3. Palpitations
  1. Mast Cell Stabilizers
    1. Anti-inflammatory
    2. Not bronchodilators
      Nedochromil more potent than chromoglycate
    3. Not absorbed orally
    4. Preventive drugs
    5. DOC
      1. Exercise induced asthma              
      2. Food allergy
  2. Corticosteroids
    1. Not bronchodilators                          
    2. Anti-inflammatory
    3. Not used in acute asthma          
    4. Inhaled corticosteroids have no systemic effects           
    5. DOC Persistent asthma
  3. Anti-Leukotrienes
    1. Monteleukast / zafirleukast
      1. Cys-leu receptor blockers
      2. Short acting
      3. Monteleukastis more potent than zafirleukast
      4. Well absorbed; high first pass
      5. Used as monotherapy also
      6. Steroid sparing agents
      7. Safe in children
      8. Have no value in acute asthma as these are anti-inflammatory and not bronchodilators
    2. Zileuton
  • DOC
  1. Aspirin induced asthma
  2. Also used in exercise induced asthma  

Side effects

  1. Churg-Strauss syndrome
  2. Hepatitis occurs with zileuton
  1. Omalizumab
    1. Humanized IgE anti- body reduces circulating IgE
    2. Given S/C q 2-4 weeks
      Used in refractory patients, Reduces frequency of asthma exacerbations.
    3. Can cause hypersensitivity reactions so given with monitoring for initial 3 mnth of therapy.

Management Of Asthma


Mild episodic asthma

Short acting beta-2 agonist SOS

Seasonal asthma

Regular inhaled Cromoglycate/low-dose inhaled Steroid started 3-4weeks before anticipated season attacks and continue till 3-4weeks after the season is over.
Treat individual episodes with inhaled short-actin beta-2 agonist.


Mild chronic asthma with occasional exacerbations

Regular inhaled low-dose Steroid
Alternatively, inhaled Cromoglycate.
Episode treatment with inhaled Short acting beta-2 agonist.


Moderate asthma with frequent exacerbations

Increasing doses of inhaled Steroids + inhaled long-acting Beta-2 agonist
Leukotriene antagonists may be tried in patients not accepting inhaled steroids or those not well controlled.
Theophylline may be used as an alternative/additional drug.
Episode treatment with inhaled Short acting beta-2 agonist .


Severe asthma

Increasing doses of inhaled Steroids + inhaled long-acting Beta-2 agonist
AND any one/more of following:
Leukotrine antagonist/sustained release oral Theophylline/ oral Beta-2 agonist/ inhaled ipratropium bromide
Along with rescue treatment with Short acting beta-2 agonist SOS


Still uncontrolled

Oral Steroid Therapy


Status Asthmaticus

  • Acute severe asthma previously referred to Status asthmaticus is an acute exacerbation of asthma that does not respond to standard treatments of bronchodilators (inhalers) and steroids.
  • It is a life-threatening episode of airway obstruction and is considered a medical emergency. Upper respiratory tract infection is most common precipitant.


  1. Hydrocortisone hemisuccinate (100mg or equivalent dose of another steroid) i.v. stat followed by 100-200mg 4-8 hourly; may take up to 6 hours to act.
  2. Nebulized salbutamol (2.5-5mg) + ipratropium bromide (0.5 mg) intermittent inhalations driven by O2
  3. High flow humidified Oxygen inhalations.
  4. Salbutamol/terbutaline 0.4 mg i.m./s.c. may be added, since inhaled drug may not reach smaller bronchi due to severe narrowing/plugging.
  5. Intubation and mechanical ventilation, if needed.
  6. Treat chest infection with intensive antibiotic therapy.
  7. Correct dehydration and acidosis with Saline + Sod. Bicarbonate/ Lactate infusion.
  8. Arninophylline 250-500 mg diluted in 20-50 ml glucose (5%) solution injected i.v. over 20-30 min had been routinely used, but recent evidence shows that it does not afford additional benefit may even produce more adverse effects; use is restricted to resistant cases.

Golden Point

Respiratory Pharmacology

  1. Dry cough is suppressed (codeine, dextromethorphan), while wet cough is encouraged (with expectorant)
  2. Bromhexine is MC mucolytics-rhinorrohea\lacrymation is MC side effect
  3. DOC of initial choice in bronchial asthma is inhaled beta-2 agonist
  4. Corticosteriods are used for persistent asthma
  5. Theophylline is a methylxanthines (inhibits PDE); increases cAMP in smooth muscles-it is a bronchodilator used for poorly controlled asthma
  6. MC side effect of theophylline is tremor-more common with ciprofloxacin or erythromycin-seizures, hyperreflexia occur in high doses-DOC for apnea in newborn
  7. Chromyglycate sodium is a mast cell stabilizer (Not absorbed orally) and is DOC for prevention of exercise induced asthma
  8. Zileuton, zafirlekast, montelukast (not used in acute asthma) are used for aspirin induced asthma
  9. Ipratropium bromide is DOC for COPD; anticholinergic drug causes dry mouthfungal infections can occur-nystatin is used
  10. Ketotifen is serotonin antagonist used for asthma prevention; chromogoycate however is the drug of choice for exercise induced asthma.

Recent Advances = Newer Drugs

Arformoterol (beta-2 agonist)


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