Patient profile and prevailing trends of cough manage-ment in India: Results of the COFPRO Survey

Abstract

Objective: To find the profile and management pattern of cough in out patients visiting family physicians (general practitioners) in India. Material and methods: The survey was done in two phases (monsoon and winter). Parameters captured included occupational exposure of infection or irritant, duration of cough, history of similar episodes, nature, intensity and frequency of cough, associated symptoms, co-morbid conditions, concomitant medications, self-medication and drugs used for treatment of cough. Result: Of the 5115 enrolled patients (male 69%; female 31%),2404 (47%)had exposure to infection or irritants at work place. Duration of cough was five days in 3069 (60%) patients while 5064 (99%) had similar episodes in last 12 months. Nature of cough in 2916 (57%) patients was dry with no or minimal sputum. A total of 1995 (39%) patients had two to six bouts of cough per day whereas six to ten cough bouts were reported by 1739 (34%) patients. Common associated symptoms were headache 1330 (26%), hoarseness of voice 1228(24%), sore throat/throat pain 1125 (22%), nasal stuffiness 972 (19%), runny nose 921(18%), sleep disturbances 818(16%), sneezing 665 (13%), fatigue/body ache 614 (12%) and fever 614 (12%). Allergic rhinitis and asthma was present in 2506 (49%) and 512 (10%) patients respectively. History of self-medication was present in only 614 (12%) patients which included OTC/herbal cough syrups. Adverse events related to self medication included sleep pattern disturbances (excess and reduced) reported by 51% patients. Antitussives, decon-gestants, antibiotics and antihistamines were prescribed in 4245 (83%), 4552 (89%), 2609 (51%) and 2456 (48%) patients respectively. Conclusion: Patients with recurrent cough may have exposure to infection or irritants at the place of job. Dry cough with up to 10 bouts per day and atleast one similar episode history is the most common type of cough presenting to family physicians (general practitioners). Majority of patients seek medical opinion within five days of starting of cough symptom and self medication rate was low. Allergic rhinitis is the most common (49%) comorbid condition with cough. Antitussives, decongestants, antibiotics and antihistamines are the common medicines used for management of cough.

Full text

Cough Management Study
The Indian Practitioner q Vol.70 No.10. October 2017
17
Patient prole and prevailing trends of cough manage-
ment in India: Results of the COFPRO Survey
Abstract:
Objective: To nd the prole and management pattern of cough in out patients visiting family physicians (general practitio-
ners) in India.
Material and methods: The survey was done in two phases (monsoon and winter). Parameters captured included occu-
pational exposure of infection or irritant, duration of cough, history of similar episodes, nature, intensity and frequency of
cough, associated symptoms, co-morbid conditions, concomitant medications, self-medication and drugs used for treatment
of cough.
Result: Of the 5115 enrolled patients (male 69%; female 31%),2404 (47%)had exposure to infection or irritants at work
place. Duration of cough was ve days in 3069 (60%) patients while 5064 (99%) had similar episodes in last 12 months.
Nature of cough in 2916 (57%) patients was dry with no or minimal sputum. A total of 1995 (39%) patients had two to six
bouts of cough per day whereas six to ten cough bouts were reported by 1739 (34%) patients. Common associated symp-
toms were headache 1330 (26%), hoarseness of voice 1228(24%), sore throat/throat pain 1125 (22%), nasal stufness
972 (19%), runny nose 921(18%), sleep disturbances 818(16%), sneezing 665 (13%), fatigue/body ache 614 (12%) and
fever 614 (12%). Allergic rhinitis and asthma was present in 2506 (49%) and 512 (10%) patients respectively. History of
self-medication was present in only 614 (12%) patients which included OTC/herbal cough syrups. Adverse events related
to self medication included sleep pattern disturbances (excess and reduced) reported by 51% patients. Antitussives, decon-
gestants, antibiotics and antihistamines were prescribed in 4245 (83%), 4552 (89%), 2609 (51%) and 2456 (48%) patients
respectively.
Conclusion: Patients with recurrent cough may have exposure to infection or irritants at the place of job. Dry cough with up
to 10 bouts per day and atleast one similar episode history is the most common type of cough presenting to family physicians
(general practitioners). Majority of patients seek medical opinion within ve days of starting of cough symptom and self medi-
cation rate was low. Allergic rhinitis is the most common (49%) comorbid condition with cough. Antitussives, decongestants,
antibiotics and antihistamines are the common medicines used for management of cough.
Key words: Cough, India, management
Narayanan V1, Pawar S2, Rege P3
1 Head, Medical Affairs, Wockhardt Ltd, Mumbai. (Corresponding author)
2 Consulting physician, Bharatiya Arogyanidhi Hospital, Mumbai.
3 General Physician, Dr Rege’s Clinic, Mumbai.

Cough Management Study
The Indian Practitioner q Vol.70 No.10. October 2017
Introduction
Cough is one of the most common causes for
medical consultation in both adults and chil-
dren.1,2 Protective reex in the form of cough
may be a trivial symptom or could be a signal of un-
1. Patient code:________________
Age_________________ Male/
Female
(Patient code is initials of patient, ini-
tials of doctor and rst 3 leers of city)
2. Date of presentation____________
Season: Summer/Winter/Monsoon
3. Occupational exposure- Does job pro-
le or profession of patient suggests
exposure to infection or irritants: Yes/
No
4. What is the duration of
presenting symptom
(cough):____________________(days)
5. How many similar episodes of cough
suered in the preceding 12 months
________
6. Nature of current cough:
a. Dry cough with no or minimal spu-
tum
b. Productive Cough with NO diculty
in expectoration
c. Productive cough with thick/ viscous
mucus with diculty in expectoration
d. Broncho-spastic cough
7. What is the intensity paern of cough
currently?
a. Low in intensity (comfortably carries
out routine)
b. Fairly intense (Tiresome but is able to
continue routine)
c. High in intensity (Routine is inter-
rupted )
d. Extremely intense (Rest is preferred
over routine –work day loss)
8. How frequent are the cough bouts in a
day?
a. Nil or 1 b. 2-6 c. 6-10 d. 10-20
e. >20
9. Associated symptoms with current
cough episode: (tick as many as appli-
cable)
a. Sore throat or throat pain;
b. Hoarseness of voice
c. Nasal stuness
d. Runny nose
e. Sneezing
f. Nasal irritation or itching
g. Ear pain
h. Fever
i. Fatigue or body ache
j. Headache
k. Sleep disturbances
l. Breathlessness
m.Post-nasal drip
n. Lack of appetite
o. Other___________________
10. What are the co-morbid conditions
known to be associated at presenta-
tion of current episode? (tick as many
as applicable)
a. Asthma
b. Allergic Rhinitis
c. Chronic Bronchitis
d. Tuberculosis (current/past history)
e. Smoking or Tobacco chewing
f. Diabetes mellitus
g. Obesity
h. Hyperlipidemia
i. Hypertension
j. Cardiac Pathology
k. Other _______________
11. Concomitant medications:
a. No
b. Yes (Mention_____________________)
12. Is there history of self-medication for
present or past cough episode?
a. No
b. Yes (if brand/ ingredients/class
of medicines are known, men-
tion________________)
13. Any history of adverse eects experi-
enced due to self medications:
a. Sleepiness
b. Lack of sleep
c. Trembling hands
d. Palpitation
e. Dry mouth
f. Constipation
g. Gastro intestinal upset
h. Any other______________
14.Which class or classes of drugs is being
prescribed to the patient for the cur-
rent cough episode and for how many
days: (Even if it is a combination for-
mulation, please tick individual com-
ponents )
Appendix 1: Cough Feedback and Proling Questionnaire
a. Antitussives (Dextromethorphan-
DXM/Codeine)__________________
days (mention preference DXM or
CODIENE )
b. First generation sedative antihista-
mines (syrup/tab)_____________days
c. Second generation non sedative anti-
histamines (syrup/tab) _________days
d. Decongestants (syrup/tab/na-
sal)___________days
e. Mucolytics (syrup/tab) _________days
f. Expectorants (syrup/tab)
_____________days
g. Antipyretics/NSAIDs (syrup/tab)
_____________days
h. Antibiotics (syrup/tab) _____________
days
i. Bronchodilators (Oral/Inhaler –
specify Terbutaline/Salbutamol/
Levosalbutamol)) ________days
j. Corticosteroids (oral/inhaler/nasal
spray) _____________days
k. Nutritional supplements (syrup/tab)
_____________days
l. Any other_____________________days
15. Patient has expressed his/ her prefer-
ence for any type of treatment-:
a. With-sedation
b. Without-sedation
c. Sugar free medication
d. Syrup preferred to tablet
e. Tablet preferred to syrup
f. Addition of tonics/long term health
supplements
g. Avoidance of antibiotics
h. Any other______________________
I have explained to the patient in the lan-
guage he/she understands that during the
usage of the information above the pa-
tient’s identity or any details whatsoever
will be kept strictly condential and not
shared or revealed at any stage.
Date:
Place: Doctor’s signature
derlying signicant respiratory or non-respiratory dis-
ease.3 Causes of cough include acute respiratory tract
infection, asthma, nonasthmaticeosinophilic bronchitis
exposure to environmental irritants, occupational ex-
posure, smoking, gastroesophageal reux, rhinitis, si-
nusitis, post-nasal drip, laryngopharyngeal reux, ob-
18

Cough Management Study
The Indian Practitioner q Vol.70 No.10. October 2017
structive sleep apnea, or drug induced cough.2,4,5 Acute
cough is usually self-limiting or subsides after short
term treatment; however, chronic cough can cause
severe morbidity and impaired quality of life.3Severe
cough may cause serious complications including frac-
ture of ribs or pneumothorax.4,6 Management of cough
is based on the cause, type of cough, duration and se-
verity. The symptomatic treatment options for cough
include antitussives, mucolytic agents, expectorants
and bronchodilators5 whereas denitive treatment de-
pends on the underlying cause. Practice paern for
the management of only dry cough has been reported
in an Indian study.7 Another study has reported re-
sponse to cough formulations containing bronchodila-
tors in outpatient seings.5 However, epidemiological
data and nationwide prescription paern for the treat-
ment of cough in dierent weathers in Indian patients
is largely unknown.
Objective
The objective of this study was to examine prole
of patients and management paern of cough in out
patients visiting family physicians (general practitio-
ners) in India.
Material and methods
This cross sectional questionnaire based survey
was conducted among patients visiting family physi-
cians (general practitioners) from 12 cities across India
with cough as chief complaint. The survey was con-
ducted in two phases. Six cities were covered in mon-
soon (June to August) whereas other six were covered
in winter (December 2016 to February 2017). The sur-
vey questionnaire (Appendix 1) covered demographic
details, season of presentation, occupational exposure,
duration of cough, history of similar episodes in past
12 months, nature, intensity and frequency of cough,
associated symptoms, co-morbid conditions, concom-
itant medications, history of self-medication, adverse
eects due to self medications, class/classes of drugs
prescribed for the current cough and duration and
patient preference for treatment. Intensity of cough
was categorized into four types; low (comfortably car-
ries out routine), high (routine is interrupted), fairly
intense (tiresome, but is able to continue routine)
and extremely intense (rest is preferred over routine
work). It was decided to enroll 10 patients per fam-
ily physicians (general practitioners) in both phases.
The interviewers were trained to collect the data from
family physicians (general practitioners). Adequate
quality checks were carried out to ensure quality and
reliability of data.
Statistical analysis
Because of non-interventional nature of the study,
no formal sample size calculation was performed.
Only standard descriptive statistics is reported in
the results. No comparative analysis is performed.
Categorical data are presented as number and per-
centages.
Result
A total of 5115 patients from 12 cities of India
(Bangalore 553, Bhubaneshwar 416, Chennai 384,
Cochin 356, Coimbatore 396, Delhi 486, Hyderabad
351, Lucknow 502, Mangalore 373, Mumbai 507, Pune
394, Vizag 397) were enrolled in this study. Of the en-
rolled patients, 3529 (69%) were male and 1586 (31%)
were female patients. A total of 2660 (52%) patients
were enrolled in phase I (monsoon) whereas 2455
(48%) were enrolled in phase II (winter).
Figure 2: Duration of cough in days at the time of pre-
sentation
Figure 1: Age group of patients
19

Cough Management Study
The Indian Practitioner q Vol.70 No.10. October 2017
The study included 1790 (35%) patients between 21
to 30 years of age and 1739 (34%) patients between 31
to 40 years of age. The detail distribution of patients
according to age group is shown in
gure 1. 2404 (47%) patients per-
ceived exposure at workplace as
being the reason for their cough,
with multifactorial eitiology relat-
ed to infection or irritants, where
in other 2711 (53%) patients did not
perceive workplace exposure to in-
fection or irritant.
Acute cough was found to be
the most common presentation.
Duration of cough was ve days
in 3069 (60%) patients whereas in
1176 (23%) and 870 (17%) patients it
was ve to ten days and more than
10 days respectively (gure 2).
A total of 5064 (99%) patients
Figure 3: Similar episodes of cough suered in the preceding 12 months
Figure 4: Nature of cough
had similar episodes of cough in
last 12 months. A total of 2967 (58%)
patients had one to three similar
episodes of cough in last one year.
The percentage of patients with
4-6, 7-9 and 10-15 similar episodes
in preceding 12 months were 1637
(32%), 307 (6%) and 153 (3%) re-
spectively (gure 3).
A total of 2916 (57%) patients had
dry cough with no or minimal spu-
tum whereas 1228 (24%) patients
had productive cough with thick
or viscous mucus with diculty.
A total of 818 (16%) patients had
productive cough with no dicul-
ty in expectoration. Only 153 (3%)
patients had bronchospastic cough
(gure 4).
The percentage of patients with
low, high, fairly intense and ex-
tremely intense cough were 2404
(47%), 1535 (30%), 921 (18%) and
205 (4%) respectively (gure 5).
A total of 1995 (39%) patients
had two to six bouts of cough per
day whereas six to ten cough bouts
were reported by 1739 (34%) pa-
tients. Number of patients with
10-20 and more than 20 cough bouts per day was
870 (17%) and 256 (5%) respectively. Only 256 (5%)
patients reported one bout per day (gure 6).
Figure 5: Current intensity of cough
High inten-
sity, 30% Low inten-
sity, 47%
20

Cough Management Study
The Indian Practitioner q Vol.70 No.10. October 2017
Figure 6: Frequency of cough bouts in a day
Figure 7: Associated symptoms with current cough
episode
Table 1: Adverse eects with self medication
Adverse eect N (%)
Sleepiness 1381 (27%)
Loss of sleep 1228 (24%)
Dry mouth 870 (17%)
Constipation 563 (11%)
Gastrointestinal upset 512 (10%)
Trembling hands 358 (7%)
Palpitation 205 (4%)
Figure 8: Co-morbid conditions associated at presentation
21
Common associated symptoms seen in more than
10% patients included headache 1330 (26%), hoarse-
ness of voice 1228 (24%), sore throat/throat pain 1125
(22%), nasal stuness 972 (19%), runny nose 921 (18%),
sleep disturbances 818 (16%), sneezing 665 (13%), fa-
tique/body ache 614 (12%) and fever 614 (12%). Other
associated symptoms are shown in gure 7.
The most common comorbid condition at the
time of presentation was allergic rhinitis seen in
2506 (49%) patients whereas chronic bronchitis
was present in 921 (18%) patients. History of to-
bacco chewing or smoking was present in 1074
(21%) patients. Weather was associated with cough
in 15% patients. Asthma was present in 512 (10%)
patients. Other comorbid conditions at the time of
presentation are shown in gure 8. History of self-
medication for present or past cough was absent
in 4501 (88%) patients whereas only 614 (12%) pa-
tients reported history of self-medication.
Adverse eects with self medication are shown
in table 1. Sleepiness was reported by 27% patients
whereas loss of sleep was present in 24%. Dry
mouth, constipation, gastrointestinal upset, trem-
bling hands and palpitation was observed in 17%,
11%, 10%, 7% and 4% patients respectively (table
1). A total of 82% patients were not receiving any con-
comitant medications for other conditions. Only 18%
patients were taking some concomitant medication.
Antitussives and decongestants were prescribed
in 4245 (83%) and 4552 (89%) patients respectively.
Antibiotics were prescribed to 2609 (51%) patients.
Terbutaline was prescribed to 1995 (39%) patients
whereas rst generation antihistamines were
prescribed to 1586 (31%) patients. The prescrip-
tions of mucolytic and expectorants were given to
1279 (25%) and 1228 (24%) patients respectively.
Percentage of patients who were prescribed other
medicines is shown in tables 2a and 2b.
Syrup was preferred over tablet by 2506 (49%)
patients whereas 1739 (34%) patients preferred
tablet over syrup. Medications without sedation
were preferred by 1023 (20%) patients whereas
13% patients preferred medications with seda-
tion; 512 (10%) and 563 (11%)patients preered
avoidance of antibiotics and sugar free medica-

Cough Management Study
The Indian Practitioner q Vol.70 No.10. October 2017
Table 2a: Classes of drugs with duration prescribed to the patient for the current cough episode
Total
(n=5115)
N (%)
Syrup
(n=1586)
N (%)
Tablets
(n=1586)
N (%)
1-3 days
(n=5115)
N (%)
Up to 6
days
(n=5115)
N (%)
Up to 8
days
(n=5115)
N (%)
First generation antihistamines 1586 (31%) 1174 (74%) 412 (26%) 563 (11%) 3632 (71%) 921 (18%)
Second generation non seda-
tive antihistamines
870 (17%) 1047 (66%) 539 (34%) 2864 (56%) 1841 (36%) 409 (8%)
Mucolytics 1279 (25%) 1066 (68%) 502 (32%) 1023 (20%) 3581 (70%) 512 (10%)
Expectorants 1228 (24%) 888 (56%) 698 (44%) 2660 (52%) 2251 (44%) 205 (4%)
Antipyretics/NSAIDs 563 (11%) 555 (35%) 1031 (65%) 1535 (30%) 3376 (66%) 205 (4%)
Antibiotics 2609 (51%) 143 (9%) 1443 (91%) 1176 (23%) 3478 (68%) 460 (9%)
Nutritional supplements 512 (10%) 761 (48%) 825 (52%) 972 (19%) 1432 (28%) 2711
(53%)
Dextromethorphan/codeine
containing antitussives
(Preference for dextrometho-
rphan 81%; codeine 19%)
4245 (83%) NA NA 1995 (39%) 2762 (54%) 358 (7%)
Decongestants (preference for
syrup 42%; tablets 10% and
nasal 48%)
4552 (89%) NA NA 2916 (57%) 1688 (33%) 460 (9%)
Table 2b: Use of bronchodilators and corticosteroids
Bronchodilators Oral Usage
(n=5115)
N (%)
Inhaler Usage
(n=5115)
N (%)
1 to 3
days
N (%)
Up to 6
days
N (%)
Up to 8
days
N (%)
Terbutaline 1995
(39%)
Terbutaline 409 (8%) 74% 18% 8%
Salbutamol 614 (12%) Salbutamol 358 (7%) 75% 20% 5%
Levosalbutamol 767 (15%) Levosalbutamol 563
(11%)
78% 19% 3%
Oral
(N=5115)
N (%)
Inhalaer
(N=5115)
Nasal spray
(N=5115)
N (%)
1 to 3
days
(n=972)
N (%)
Up to 6
days
(n=972)
N (%)
Up to
8 days
(n=972)
N (%)
Corticosteroids 358 (7%) 358 (7%) 256 (5%) 602
(62%)
301 (31%) 68 (7%)
22
tions respectively (table 3).
Discussion
In this cross sectional nationwide questionnaire
based survey, we examined the patient presentation,
occupational risk factors and prescription paern for
cough by Indian physicians. We enrolled physicians
from 12 cities covering all four (South, North, East and
West) zones of India to get nationwide representation.
To avoid weather related bias, we enrolled almost half
(52%) of the population during monsoon and remain-
ing during winter.
A study from Jharkhand reported that cough is
more common in male patients than females.8 Our

Cough Management Study
The Indian Practitioner q Vol.70 No.10. October 2017
in terms of age group, occupational exposure and type
of cough. Bronchospastic cough was uncommon in
the study population, possible because such patients
present less to family physicians (general practitio-
ners) and more to specialists. Number of patients with
dry cough was more common than those with produc-
tive cough.
Request for antibiotics from patients and prescrip-
tions of antibiotic for acute cough are common.12 In our
study too, use of antibiotics was high. Eorts should
be done to reduce unnessesory use of antibiotics for
cough.
Chronic cough adversely impacts the quality of life
of patients1 contributed by dierent symptoms. In
our study,patients reported dierent symptoms in-
cluding headache, hoarsness of voice, pain in throat,
nasal symptoms and sleep disturbances.
High use of over the counter medications for cough
and cold is well known.2,13 Cough and cold prepara-
tions, cough syrups and decongestants are some of
the commonly used over the counter medications.2
Surprisingly, most of the patients in our study did not
report self-medication for present or past episode of
cough. Among the self medications, use of cough syr-
up and products containing antihistamines was com-
mon in our study. Sleepiness was the most common
adverse event associated with self medication fol-
lowed by loss of sleep. Allergic rhinitis was the most
common comorbidity in this study. Second generation
anthistamines are preferred in allergic rhinitis while
in cough and cold formulations majorly contains rst
generation antihistamines. Some medications (e.g.
OTC cough-cold syrups)contain rst generation anti-
histamines known to cause sedation due to penetration
of blood brain barrier.14 Dry mouth, another common
adverse event because of self medication could be be-
cause of the anticholinergic adverse events associated
with rst generation antihistamines.14 Prescription of
decongestants, codeine and dextromethorphancon-
taining products for short duration was very com-
mon in this study. However, dextromethorphan was
the preferred antitussive over codeine possibly due to
beer side eect prole. Other commonly prescribed
medications for the management of cough included
antihistamines, antibiotics, mucolytics and expecto-
rants.
Convenience of medication intake is one of the im-
portant factors for improving compliance.15Almost
half of the patients preferred syrup over tablet which
maybe aributed to swallowing ease and soothing ef-
Table 3: Patient preferences for any type of
treatment
Patients preference N (%)
Avoidance of antibiot-
ics
512 (10%)
Sugar free medication 563 (11%)
With-sedation 665 (13%)
Addition of tonics/long
term health supple-
ments
818 (16%)
Without sedation 1023 (20%)
23
study population was also dominated by males (male
to female ratio was 7:3). Adult age group is more com-
monly aected by cough.8 Similar ndings were ob-
served in our study too. In India, use of tobacco has
been reported to be more among middle aged adult
males.9 In our study close to one fth patients were
smokers or tobacco chewers. Smoking could be one of
the contributing factors for higher prevalence of cough
in male patients in our study. However, this needs to
be conrmed. A total of 83% patients had cough up to
ten days suggesting much more common occurance
of acute than chronic cough in the study population.
Females usually have higher risk of chronic cough
possibly due to more sensitivity to cough reex.10 Our
results are in accordance with this as seen by the male
predominance and mostly short duration of cough.
Acute upper respiratory tract infection is one of the
most common reasons of acute cough.1 Sore throat
plus hoarsness seen in up to 46% patient points to-
wards upper respiratory tract infection. Nasal symp-
toms including nasal stuness, watering and sneez-
ing were seen in more patients as compared to fever,
suggesting more common occurance of non-infective
cough. The most common comorbid condition in the
study was allergic rhinitis followed by chronic bron-
chitis.
Very high rate of recurrence was found in the pa-
tients. Exposure to irrititants at work place is one of
the reasons for chronic/recurrent cough.5 In our study,
job prole or profession of 47% patients suggested ex-
posure to infection or irritants. These ndings strongly
suggest that physicians should not ignore occupation
related history in patients with cough.
Patient population of cough is usually heterog-
enous with dierent risk factors and comorbid condi-
tions.11 Our study population was also heterogenous

Cough Management Study
The Indian Practitioner q Vol.70 No.10. October 2017
fect of syrups; however, almost one third preferred
tablet. More patients preferred medication without
sedation than those with sedation. Awareness about
rationale use of antibiotic and concern about sugar in
medication seems to be rising among patients. Some
patients in this study preferred avoidance of antibiot-
ics and sugar free medications.
Our study provides signicant insights into patient
prole of cough and its management. Large sample
size, enrollment of patients from all regions of the
country and enrollment in two dierent seasons are
the strengths of this study. However, the study is as-
sociated with some limitations. We did not evaluate
and compare the prole of patients in two dierent
seasons. Similarly, we did not compare gender or age
wise dierence of the patients and inclusion of pediat-
ric population was limited.
Conclusion
Recurrent cough is a common problem in people
in adult age group. Exposure to irritants at work place
could be kept in mind as one of the reasons for the re-
current cough. Dry cough is more common than pro-
ductive cough or bronchospatic cough. Allergic rhini-
tis is the most common comorbidity in patients with
recurrent cough. Decongestants and antitussives con-
taining dextromethorphan are commonly prescribed
by Indian physicians for the symptomatic manage-
ment of cough.
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