When a cough just won’t go away

Monique Tello, MD, MPH
Monique Tello, MD, MPH, Contributing Editor

Who has never had a cough? I bet no one can raise their hand. We see this in clinic all the time. But chronic cough— one that lasts at least eight weeks — can be hard for patients to deal with and difficult for doctors to figure out.

In the October 20, 2016 issue of the New England Journal of Medicine, lung experts describe a step-by-step approach doctors can use to help treat patients with chronic cough. Most often a prolonged cough is due to one of the “usual suspects.” But when it’s not, we have a long list of increasingly rarer conditions that we should run through and rule out. If it isn’t due to any of those, experts now recognize that the culprit may be overactive nerves that cause an exaggerated cough response to certain triggers.

The “usual suspects” that may be behind a chronic cough

The authors describe a typical patient with chronic cough, and she is very similar to many of my patients. She’s a middle-aged lady with a cough lasting many months. Of course, first we want to ask a whole lot of questions.

  • Has she had chronic allergy symptoms such as itchy, watery eyes and nose, stuffy nose, and postnasal drip? If so, it’s worth trying antihistamines and nasal steroids. Undertreated allergies can lead to chronic sinus infection, which causes cough by postnasal drip, so we may want to treat for this as well.
  • Could she have “cough variant” asthma that causes a cough but no wheezing? Many of my patients would rather not wait for an appointment with a lung specialist and undergo fancy tests. So, if we suspect cough-variant asthma, we simply begin inhalers. A few weeks of inhaled albuterol to help open the airways and a steroid inhaler to quell inflammation may both make the diagnosis and treat the problem.
  • Is she suffering from heartburn symptoms? Acid reflux can also trigger cough, and if someone describes heartburn symptoms, or even if we are not sure what is causing the cough, we often prescribe eight weeks of an acid-lowering medication.
  • Is she taking a medication for which coughing is a side effect? Lisinopril or another blood pressure medication from the class called ACE inhibitors can cause cough in 20% of patients. A trial period off this medication may be warranted.
  • Is she among the 17% of Americans who smoke cigarettes? If so, her cough may be due to chronic bronchitis, where cumulative lung damage prevents the body’s normal ability to clear particles, the airways swell and make excessive mucus, and eventually areas die off and leave “dead space.” In a smoker, other symptoms with the cough may raise concern about a lung infection or even cancer.
  • Does she have other health risks or conditions? If she has been incarcerated or in a shelter, or perhaps is from a resource-poor country, we consider tuberculosis (TB). If she has a weakened immune system as well, due to HIV or long-term use of corticosteroids, TB and a host of other unusual organisms are on the list.
  • Are we stumped? Rare conditions to consider include pulmonary fibrosis, sarcoidosis, autoimmune diseases, and anatomical abnormalities. Additional workup should include pulmonary and ENT evaluations.

Beyond the usual — and even the “unusual” — suspects

But what do we do for patients who either do not respond to treatments for their common conditions, or for whom extensive evaluation rules out the less common causes of a chronic cough? Well, researchers are now describing a new family of breathing and cough conditions caused by nerve dysfunction.

New evidence suggests that postnasal drip, acid reflux, or even forceful coughing in and of itself can aggravate nerve endings in the “cough centers” of the airways. These aggravated nerve endings then overreact to many other triggers, such as smoke, perfume, or temperature changes, causing an overwhelming urge to cough. They label this condition “neuronal hyper-responsiveness syndrome” and outline several approaches to treatment.

But wait, there’s more. Other researchers describe a similar concept at the level of the larynx, a family of disorders under “laryngeal dysfunction syndrome” that can include “laryngeal hyper-responsiveness.” Many of the treatments they describe are similar to the treatments for “neuronal hyper-responsiveness,” and the most promising include the anticonvulsants gabapentin and pregabalin, the antidepressant amitriptyline, speech therapy, or a combination of these.

Basically, medical experts are describing a new cause of chronic cough based on aggravated nerves and airway dysfunction, and more research will result in better treatments.

Comments:

  1. Lucy

    I’ve had a dry cough for 5 weeks and meds aren’t working. Could my Parkinson’s be causing the cough?

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  3. Sayeeda Hashmi

    I have exactly the same symptoms like Cathy for about a year. A course of inhalers didn’t help, but a course of steroids stopped the cough for about a month and then the same symptoms returned and am still enduring them. Nothing seems to help. Help!

  4. Janice Clarkson

    “When a cough just won’t go away”….I automatically think of lung cancer! That is exactly what happened to my sister and former spouse. A simple chest x-ray can tell if there is a mass in the lungs.

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      Yes, and this certainly needs to be considered and ruled out in everyone with chronic cough.

    • Karen Betman

      Cancer in the lung must be a quarter of an inch in diameter in order to be seen on a chest film.
      By this time, MILLIONS of cancer cells have been released. A cat scan scan can detect cancer of the lung more accurately.
      Karen Betman
      Former supervisor of pulmonary lab at NY Hospital-Weill Cornell Medical Center
      Smoking cessation instructor for over 32 years

  5. Maureen nzilani

    I have been coughing for 8months now ,have seen many doc’s but no help .mine is from throat and it’s a bit wet, am just worried what next to do.advise pls.

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      Unfortunately, I am unable to provide medical advice specific to your case in this venue; it is always best to see your own doctors. If the ones you have seen have been unhelpful, the best next step is to ask for another opinion. I wish you the best.

  6. Mayur Chavan

    Hello Team,

    Good to read blog’s on Cough my self facing Chronic cough problem specially in Diwali and Cold season i think it is due to dry whether but it is so high that i cannot say what i am facing in diwali and cold season so you have some tips to cure this

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      Generally, we advise people to wash their hands often and especially after they have been out in public. This helps to curb upper respiratory infections.

  7. mimi Filer

    Why has no one mentioned fungus in the airway ?
    Sounds like it could be a cause many times.

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      Atypical bacteria and fungi can certainly cause chronic cough, but these are not that common in otherwise healthy people. These would be among the rarer things to be considered in the last step above.

  8. Anthony Huang

    “Low body temperature” is one of the common causes of cough. Of course “low body temperature” triggers sputum secretion and cough varies individually.
    After excluding all other causes, keep body warm plus cough suppressants will gradually cure chronic cough.
    This method works for me and my patients.

  9. ilana zinguer

    It took more than 3 months to disappear. My medecin was clear, it will go by itself, I was dubitative because my voice was changing, feeble and unrecognisable besides the cough. Since I had no other symptoms, I could eat, I could swallow, speak, no pain but an unbearable dryness…It desappeared by itself. I suspected a psychological situation very tense. I paid attention to that . This special attention (my own care as I could understand).
    I can say now that I worried and my doctor was so sure of himself. But he had no explanation for the phenomenon.

  10. Tom Morgan

    I’m not surprised to find the aim of this article is “simply” treating the symptoms. As our trained elite, especially here in a first world country, you follow the expected path of: you exhibit this therefore you need (or dare I say) “we’ll try that” (big pharma can fill in the blank).
    I’m curious if our elite system of doctoring will ever delve into the toxic soup (to varying degrees, of course) in which we live and might be the cause of the symptom? So many of these symptoms could be (likely are) environmental.
    When you’re stumped you go for more expensive procedures but still may not get at the cause.
    Surely, I’m an inexperienced person who has only managed 50 years breathing air. But, this article scared me.
    It seems the investigative “doctoring” practices seemed to be lost in the equation. At least in this short article.
    Replaced with searching for a code of “diagnosis” and then “treatment” and then payday. Rinse repeat.

    • David Coonrod

      Tom Morgan, you’re stupid.
      David Coonrod

      • Richard

        Is that what you call a “reply” ? Are there moderators here ?

      • Erik Craig

        Dear David, Why not consider many truths, many possibilities. Our environment is no small thing and most scientists, including biologists, zoologists, neuroscientists, physicists, not to mention social scientists including philosophers embrace what is broadly called an “ecological perspective” (not to be confused with so called “environmentalism”) recognizing the unified, interdependent field of organism AND context. Why not be more generative, open, welcoming of multiple perspectives in understanding the complexities of nature, including human nature? Respectfully, Erik

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      I respect your opinion! I agree with you that the commenter below used inappropriate language and will ask the moderators to remove that. .

  11. John G. langdon, M.D., FACP

    A syndrome noted widely recently is the”100 day cough”. A lot of us docs have had it and it is a light cough that produces modest amounts of clear to white mucous. No sore throat, no fever , no nothing and then one day it just goes away. Possibly an intracellular virus that eventually is handled by the immune system? Beats me. I am an internist in Florida and my brother is an internist in Omaha. Just as you are thinking you need a workup it’s gone. what do you think. JL

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      You know, it may be chronic cough due to this new hypothesis, the “aggravated nerves and airway dysfunction” brought on by whatever the original irritant was. This is still an area of investigation though.

  12. Russell W. Currier DVM

    I read in JAMA decades ago in a series of ‘Ask the Expert’ columns that excessive ethanol beverage consumption can result in chronic cough even after controlling for cigarette smoking that is obvious. Determining how much someone drinks is sometimes very problematic. Russell Currier DVM

    • Chico

      Especially if they’re a dog or cat, right Dr. DVM?

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      Yes, many people aren’t ready or willing to divulge how much they really drink, this is true. I can see where excessive alcohol could contribute to cough through several mechanisms, including acid reflux and aspiration.

  13. Pedro Ernesto Vargas, MD

    Interesting short review of causes of persistent coughing. In my experience down here in a tropical country as Panama, persistent coughing is associated more often than suspected to Mycoplasma pneumonia respiratory infection.

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      Yes, this is definitely a common cause of cough, though active mycoplasma infection is less likely to be the cause a cough lasting over 8 weeks. Perhaps it triggers reactive airways or aggravates nerve endings.

  14. Cathy

    My cough is chronic and productive . It’s post nasal drip and cough with clear sticky coughed up . Cough stops for a while then starts again . Sometime I take mint hot tea which calms the cough for a while .,it’s also started with smoke , perfume and other scents and cold air