8.1 General advice

Patients in all groups should be advised to rest and drink plenty of fluids.

Paracetamol or aspirin should be advised as an antipyretic and analgesic.

Patients should also be advised to contact their general practice in the event of deterioration. An advice leaflet (see section 10) can assist in this.

8.2 Cough mixtures

Cough is a useful defence mechanism for clearing sputum in lower respiratory tract infection therefore its suppression in this circumstance may not be appropriate. Cough suppression in LRTI may be justified for a non-productive irritating cough.

There are a number of experimental studies where the severity of pharmacologically induced cough is reduced by dextromethorphan and codeine (but these tend to be small studies of around 20 patients) and there is conflicting evidence for the therapeutic effect of dextromethorphan and codeine and pholcodine in patients with chronic cough.^{100,101,102,103} Evidence level 1-

Two studies have addressed the efficacy of codeine in the treatment of cough associated with acute lower respiratory tract infection.^104,105 Neither of these placebo controlled studies have shown a benefit for codeine. The place of cough suppressants in non-productive cough due to LRTI remains unclear with the larger RCTs suggesting they are not of benefit. A recent meta-analysis concurs with this opinion.¹⁰⁶ Evidence level 1++,1-

A Cochrane review did not identify any evidence of a beneficial effect of b 2-agonists on cough in LRTI.¹⁰⁷Evidence level 1++,1-

It is also generally accepted that expectorants and demulcent cough preparations are ineffective.¹⁰⁸ Evidence level 4

8.3 Smoking cessation

The presentation of smokers with LRTI is an ideal opportunity to introduce smoking cessation measures. There are published UK guidelines on smoking cessation which have been endorsed by most of the key professional groups in this area.¹⁰⁹

A US public health service report lists the principal steps for developing smoking cessation:¹¹⁰

• Recognition that effective treatments for smoking cessation exist.
• The principle that all health care workers should promote smoking cessation at every contact the smoker makes with the health service.
• Tobacco dependence counselling is effective and the degree of effectiveness relates to the
  intensity of counselling.
• Nicotine replacement therapy will reliably increase long term smoking abstinence rates. (This is currently the subject of a Cochrane review).¹¹¹

Limited evidence suggests that prescription of bupropion leads to an increased rate of smoking cessation in patients who are involved in structured cessation programmes.^112,113 The effect of bupropion is independent of past history of depression or alcoholism.¹¹⁴