Improving Outcomes, Mythbusting, Pulmonary, Twelve Trials of Christmas!

Day six of Christmas – curing the bronchitis!

Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the sixth of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM. Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

Essentially, there are about 4 things to do for a cough.  Dextromethorphan (robitussin), anything with Benadryl/codeine/phenergan/hydrocodone, tessalon, and honey.  For pediatrics at least, honey seems to be the preferred method for parents and seems work better than Dextromethorphan and Benadryl in head to head trials.  I’ve yet to find data on Tessalon, Phenergan, or codeine suggesting it is useful for a cough when compared to placebo.  I’d like to add another medication to the toolkit for an intractable cough: nebulized lidocaine.

The studies are not of the best quality, but here is what I can find:

– 21 patients with obstructive, restrictive, or infective disease who received 10-20mg of nebulized lidocaine Q4-6hrs seemed to improve and/or resolve the cough when compared to standard of care (hycodan, Robitussin).

– A case series of 3 pts treated with a single dose 10mg lidocaine and 5mg bupivacaine (both nebulized) and had no recurrence of cough.

– A case series of 3 patients with a chronic cough secondary to lung cancer treated with higher doses of nebulized lidocaine  (up to 400mg!) along  with 2-5mg albuterol.  Resolution of cough persisted for >1week in all patients.

– A case report of a pediatric patient treated with 30mg nebulized lidocaine for a cough refractory to cough suppressants, beta agonists, steroids, and antibiotics.  The cough completely resolved.

 

There are multiple studies looking at nebulized lidocaine for endoscopy and laryngoscopy, but no reports of systemic toxicity from nebulized lidocaine as there appears to be less systemic uptake when administered via nebulizer.  So, it appears safe in that regard.   The asthma literature is a mixed bag, as some say it cause harm during asthma exacerbations as it may decrease FEV, but others show benefit.  However, for COPD flares, it appears beneficial.


For those hacking coughs that truly feel bad for, I’d love to see an ED trial of nebulized lidocaine as a one time dose – or even perhaps in an observation unit for your COPD’ers / pneumonia/bronchitis patients.  Easy trial to perform, and one that would significantly improve patient satisfaction – and perhaps then something other than a z-pack would get credit for improving the cough!  

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