Cough

What is Cough?

Coughing is a common health concern, and it frequently leads to about 30 million medical visits each year. Nearly half of these visits require a referral to a lung specialist. Coughing is a natural bodily response that helps protect us from foreign substances. However, there are many different conditions that can cause a person to cough. Moreover, there’s no practical way to measure the severity or frequency of a cough, so doctors usually rely on the patient’s personal account, which can vary significantly.

The exact cause of a cough can be tricky to identify due to its vague nature, and it might also be a sign of a more serious hidden medical condition. Given the potential disruption to daily life and the absence of objective assessment tools, it’s important to treat coughing as a significant issue until a harmless cause is found.

What Causes Cough?

Coughs are broadly classified into three types based on how long they last. If a cough lasts less than three weeks, it is considered ‘acute’. If it continues for three to eight weeks, it’s known as ‘subacute’. And if the cough lasts more than eight weeks, it is classified as ‘chronic’.

Common causes of a short-term or acute cough in adults include common colds and acute bronchitis. Bronchitis is typically caused by a virus, but about 10% of cases are due to bacterial infections. Other causes of an acute cough are sinus infections (rhinosinusitis), whooping cough (pertussisin), worsening of chronic lung diseases, allergies, asthma, heart failure, pneumonia, and food or drink going down the wrong pipe (aspiration syndromes), and blockages in the lung vessels (pulmonary embolism).

Rhinosinusitis, inflammation of the sinuses, is often due to a viral infection if it lasts less than ten days but may be caused by bacteria if the illness is longer than ten days. The main reason for coughing in this case is increased mucus production and continuous dripping of mucus at the back of the throat.

Whooping cough is a respiratory infection that can cause intense coughing fits followed by a loud gasping for breath. This disease lasts up to six weeks and goes through three stages of symptoms. It’s a serious infection especially for infants as it’s one of the main causes of sickness and death.

Asthma is a chronic lung disease where the body’s defense system overreacts to things in the environment, causing inflammation and narrowing of the airways, which results in a cough.

Chronic Obstructive Pulmonary Disease (COPD) is a severe lung disorder that affects a significant number of people. Patients with COPD are likely to develop infections such as bronchitis and pneumonia because their lungs are compromised, which causes inflammation and triggers a cough.

Allergic rhinitis is an allergic reaction that causes inflammation in the nose, leading to increased mucus production and a tickling sensation at the back of your throat, which results in a cough.

In congestive heart failure, the heart isn’t able to pump blood efficiently, causing fluid buildup and edema (swelling) in the lungs, irritating them and causing a cough.

Pneumonia can have many causes and may be viral or bacterial. It leads to inflammation and irritation of the airways, sometimes with increased mucus and pus, irritating the airways and inducing a cough.

Coughs that last for longer than three weeks but less than eight weeks, classified as subacute, often occur after an infection. They’re usually due to prolonged irritation of the airways due to inflammation in the bronchial tubes or sinuses from a preceding viral upper respiratory infection.

Chronic coughs, which last more than eight weeks, can have various causes and usually need evaluation by a lung specialist. Some potential chronic cough causes include post-nasal drip syndrome, reflux disease, non-asthmatic eosinophilic bronchitis, chronic bronchitis, intolerance to certain blood pressure medications, cancer, interstitial lung diseases, sleep apnea, and chronic sinusitis.

In summary, coughing is a symptom that can arise from various health conditions, ranging from minor issues like common colds to severe diseases such as pneumonia and cancer. If a cough persists and doesn’t improve with time or with over-the-counter remedies, it is advisable to seek medical attention.

Risk Factors and Frequency for Cough

A cough is the most common reason why people go to see a doctor. Your lifestyle, including whether or not you smoke, can greatly affect how often you cough, with estimates ranging from 5% to 40% of people being affected. The cause of the cough can also influence who is more likely to be affected by it, including their race and gender.

Signs and Symptoms of Cough

When diagnosing a medical condition like a cough, collecting a detailed health history and conducting a thorough physical exam are crucial steps. A cough isn’t a disease by itself but a symptom of an underlying condition. Therefore, many people seek medical help for problems caused by the cough instead of the cough itself. Important elements to be discussed during the medical history include:

How long the cough has been present
Whether the person smokes
Use of certain medications, like angiotensin-converting enzyme inhibitors
Any loss of weight
Occupation
Changes in the cough based on time of day
What makes the cough better or worse
If the cough brings up mucus, and if so, what color it is
Presence of blood when coughing
Associated fever
Associated shortness of breath

In addition, the onset of the cough in relation to an upper respiratory tract infection should also be talked about. A systematic approach is needed to identify any other illnesses that may be contributing to the cough. The timing, character, and presence or absence of mucus during a cough can help narrow down the potential causes. Other common symptoms accompanying a cough can include feeling tired, having trouble sleeping, lifestyle changes, chest pain, voice changes, excessive sweating, urinary incontinence, fainting, heart rhythm problems, headaches, redness in the eyes, hernia, or acid reflux. These specific complaints should guide the focus of the physical exam and further tests to determine the exact cause of the cough.

Testing for Cough

When you experience a sudden cough that lasts a short while (acute and subacute cough), typically you don’t need any tests. The doctor will usually treat your symptoms unless they suspect a more serious illness. If your cough is severe or you seem extremely unwell, they might recommend a chest x-ray to examine your lungs.

On the other hand, if your cough persists for a long time (a chronic cough), different tests might be necessary. These could include a chest x-ray and comprehensive lung functionality tests. If these tests don’t provide any specific clues and you appear healthy otherwise, you may be referred to a lung specialist for a more thorough examination.

Investigating a chronic cough can be tricky because it’s often caused by several diseases collectively. Procedures like a bronchoscopy might be required. This is where a camera is lowered down into your lungs to check for any abnormal growth or blockages in your vocal chords, windpipe, or airways. Sometimes, small samples may be needed for further examination in the lab. This process is known as biopsy or bronchoalveolar lavage.

You might also need an echocardiogram to examine your heart function, a CT scan of the chest for a detailed look at the structure of your lungs, or tests to understand your swallowing and stomach health. If your cough occurs mainly at night and you show signs of obstructive sleep apnea, a sleep study could be suggested to diagnose and treat this sleep disorder.

As for a cough caused by a neurological issue (neurogenic cough), it can be diagnosed if the following symptoms are present: you cough almost all the time during the day; your cough is dry; there is weakness in one or both vocal folds observed during a larynx exam; this weakness is confirmed through a special test called laryngeal electromyography; and finally, your symptoms completely disappear once the appropriate treatment is applied.

Treatment Options for Cough

When someone has an acute cough, the treatment is generally focused on relieving symptoms, and this often involves over-the-counter cough and cold medicines. Interestingly, many antihistamine-decongestants that are commonly used don’t seem to be more effective than a placebo. Cough suppressants, like dextromethorphan, can reduce the intensity of the cough, and expectorants (guaifenesin is a common one) can be used when there is a lot of mucus.

However, it’s important to note that coughing is a natural defense mechanism, crucial to our immune system, so attempts to suppress the cough reflex potentially can slow down recovery time. This is why the American College of Chest Physicians doesn’t recommend using over-the-counter combinations for treating acute cough caused by a common cold.

If an infection is suspected, doctors may culture the sputum (mucus that is brought up from the lungs by coughing), and tailor the antibiotic therapy to the germ causing the infection. When dealing with persistent respiratory infections, antibiotics may be needed for 3 to 6 weeks. The first choice is often amoxicillin/clavulanate, but there are alternatives like clindamycin, cefuroxime, and others.

Treatment for a sustained cough includes trying to address the underlying cause rather than suppressing the cough. For example, some medications could be causing the cough. In these cases, it’s best to switch to an alternative medication. For coughs associated with airway sensitivity, inhaled steroids or anticholinergic medications might be used. If the cough is due to heart problems, the heart function should be optimized. Acid reflux should be managed by avoiding certain foods and medications, propping the head up while sleeping, and not eating shortly before bedtime.

Treating a chronic cough that originates from a nerve condition is a bit different. Medications like tramadol or amitriptyline are often used to start treatment, with further medication adjustments as needed. If there are accompanying symptoms such as laryngopharyngeal reflux, gabapentin is normally the preferred treatment. Other medications can also be considered in certain situations.

When trying to determine the cause of a cough, a few different categories could be taken into account, including acute, subacute, and chronic. There are also some very rare possibilities to consider when the diagnosis isn’t clear.

In acute instances, which are sudden and often severe, the cause could be:

acute bronchitis (inflammation in the bronchial tubes)
sudden worsening of chronic obstructive pulmonary disorder (a type of lung disease)
acute rhinosinusitis (sinus inflammation)
acute viral upper respiratory infection (a common cold)
allergic rhinitis (hay fever)
asthma
aspiration syndromes (foreign matter has entered into the bronchial tubes)
congestive heart failure
pertussis (whooping cough)
pneumonia
pulmonary embolism (a blood clot in the lungs)

If the cough is subacute, meaning, it’s not as severe as acute but lasts longer, the cause could simply be:

post-infectious cough due to irritation from a recent upper respiratory infection

In chronic cases, a cough that lasts a long time, the cause might be:

chronic bronchitis (again, inflammation in the bronchial tubes but over a longer period)
chronic sinusitis (long-term sinus inflammation)
gastroesophageal reflux disease (stomach acid irritates the esophagus)
various lung diseases
intolerance to medication (angiotensin-converting enzyme inhibitors)
cancer
non-asthmatic eosinophilic bronchitis (allergic inflammation in the bronchial tubes)
obstructive sleep apnea (pauses in breathing while sleeping)
a post-infectious or psychosomatic cough (caused by psychological factors)
upper airway cough syndrome

Lastly, there are very rare causes, such as:

earwax buildup (cerumen impaction), which can stimulate a nerve in the ear leading to a cough
troubles with esophageal movement (esophageal achalasia)
abnormal communication between the esophagus and windpipe (tracheoesophageal fistula)
reflex from the esophagus
Ortner syndrome: calling of the vocal fold causing cough
an autoimmune disorder affecting children (PANDAS) which can lead to a tick-induced cough
certain side effects of peritoneal dialysis (a treatment for kidney failure)
certain types of pneumonitis (inflammation of lung tissue)
infections from certain types of parasites
tracheobronchial collapse
vitamin B12 deficiency
pouches developing in the esophagus (Zenker or distal esophageal diverticulum)

What to expect with Cough

Coughing, by itself, is generally harmless. However, the exact outlook for a patient greatly depends on what is causing the cough in the first place.

Possible Complications When Diagnosed with Cough

A continuous cough or intense coughing spells can lead to several problems, such as:

Interrupted sleep
Headaches
Throwing up
Fainting or brief loss of consciousness
Increased sweating
Broken ribs from the force of coughing
Loss of bladder control

Frequently asked questions

Coughing is a natural bodily response that helps protect us from foreign substances.

Estimates range from 5% to 40% of people being affected by cough.

Signs and symptoms of a cough can vary depending on the underlying cause. Some common signs and symptoms associated with a cough include: - Duration: How long the cough has been present. - Smoking: Whether the person smokes or has a history of smoking. - Medications: Use of certain medications, such as angiotensin-converting enzyme inhibitors. - Weight loss: Any significant loss of weight. - Occupation: The person's occupation, as certain jobs may expose them to respiratory irritants. - Time of day: Changes in the cough based on the time of day. - Triggers: What makes the cough better or worse. - Mucus production: If the cough brings up mucus, the color of the mucus can provide important information. - Blood: Presence of blood when coughing. - Fever: Associated fever. - Shortness of breath: Associated shortness of breath. In addition to these specific signs and symptoms, there are other common symptoms that may accompany a cough, including feeling tired, having trouble sleeping, lifestyle changes, chest pain, voice changes, excessive sweating, urinary incontinence, fainting, heart rhythm problems, headaches, redness in the eyes, hernia, or acid reflux. These additional complaints should guide the focus of the physical exam and further tests to determine the exact cause of the cough.

Coughs can be caused by various health conditions, ranging from minor issues like common colds to severe diseases such as pneumonia and cancer. The specific cause of a cough depends on the underlying condition, such as viral or bacterial infections, allergies, asthma, heart failure, lung diseases, sinus infections, and blockages in the lung vessels.

The doctor needs to rule out the following conditions when diagnosing a cough: - Acute bronchitis - Sudden worsening of chronic obstructive pulmonary disorder - Acute rhinosinusitis - Acute viral upper respiratory infection - Allergic rhinitis - Asthma - Aspiration syndromes - Congestive heart failure - Pertussis - Pneumonia - Pulmonary embolism - Post-infectious cough due to irritation from a recent upper respiratory infection - Chronic bronchitis - Chronic sinusitis - Gastroesophageal reflux disease - Various lung diseases - Intolerance to medication (angiotensin-converting enzyme inhibitors) - Cancer - Non-asthmatic eosinophilic bronchitis - Obstructive sleep apnea - Post-infectious or psychosomatic cough - Upper airway cough syndrome - Earwax buildup (cerumen impaction) - Troubles with esophageal movement (esophageal achalasia) - Abnormal communication between the esophagus and windpipe (tracheoesophageal fistula) - Reflex from the esophagus - Ortner syndrome - Autoimmune disorder affecting children (PANDAS) - Side effects of peritoneal dialysis - Certain types of pneumonitis - Infections from certain types of parasites - Tracheobronchial collapse - Vitamin B12 deficiency - Pouches developing in the esophagus (Zenker or distal esophageal diverticulum)

The types of tests that may be needed to diagnose a cough include: - Chest x-ray to examine the lungs - Comprehensive lung functionality tests - Bronchoscopy to check for abnormal growth or blockages in the airways - Biopsy or bronchoalveolar lavage to collect samples for further examination - Echocardiogram to examine heart function - CT scan of the chest for a detailed look at lung structure - Tests to assess swallowing and stomach health - Sleep study to diagnose obstructive sleep apnea - Laryngeal electromyography to diagnose neurogenic cough These tests may be ordered depending on the duration and severity of the cough, as well as other symptoms and suspected underlying causes.

When treating a cough, the focus is generally on relieving symptoms. Over-the-counter cough and cold medicines are commonly used, including cough suppressants like dextromethorphan to reduce the intensity of the cough and expectorants like guaifenesin when there is a lot of mucus. However, it's important to note that coughing is a natural defense mechanism, so attempts to suppress the cough reflex can potentially slow down recovery time. The American College of Chest Physicians does not recommend using over-the-counter combinations for treating acute cough caused by a common cold. If an infection is suspected, doctors may culture the sputum and tailor antibiotic therapy to the specific germ causing the infection. Treatment for a sustained cough involves addressing the underlying cause, such as switching medications if they are causing the cough or managing conditions like airway sensitivity, heart problems, or acid reflux. Chronic coughs originating from a nerve condition may be treated with medications like tramadol or amitriptyline, with further adjustments as needed.

The side effects when treating a cough can include interrupted sleep, headaches, throwing up, fainting or brief loss of consciousness, increased sweating, broken ribs from the force of coughing, and loss of bladder control.

The prognosis for a cough greatly depends on the underlying cause. Coughing, by itself, is generally harmless, but if it is a symptom of a more serious medical condition, the prognosis will depend on that condition.

A lung specialist or pulmonologist.