cough – Symptom of serious morbidity
By Usha Perera
The current hot topic reported and debated over
print and electronic media is on the raging Dengue
epidemic in the country that has claimed the lives
of about 160 patients islandwide. until the month of
July. This infectious disease is in the spotlight
mainly because of its high mortality. But, when
Health statistics are perused, it is seen that the
highest number of morbidity (sickness) in the
country is caused by chronic Respiratory diseases.
Chronic respiratory diseases include disorders that
affect any part of the respiratory system, not only
the lungs, but also the upper airway such as the
nose, mouth, pharynx, larynx and trachea, the chest
wall and diaphragm, and the neuromuscular system
that provides the power for breathing. Prolonged
diseases and disorders of the respiratory system in
adults are those conditions that are present for
months to years, and are treatable, but generally
The chronic diseases of the Respiratory system
collectively result in profound human suffering,
mortality and economic loss. Most often, respiratory
diseases are preventable, but due to negligence, the
situation sometimes becomes chronic, which then
The Nation met Chest Physician Dr. Amitha Fernando,
to discuss an important symptom of the respiratory
system – persistent cough that indicates a range of
respiratory problems, and acts as a warning sign.
“Cough is meant primarily to protect our lungs and
breathing apparatus from intrusion of harmful
substances and infectious agents. However,
persistent cough assumes great importance, due to
associated Medical, Psychological and Social
problems”, says Dr. Fernando
In Medical terminology, a cough is termed
“prolonged” when it lasts for more than three weeks.
“A cough of shorter duration is termed an ‘acute
The commonest cause of an acute cough is the common
cold. This follows a viral infection of the upper
and/or lower air passages. This usually resolves on
its own. Paracetamol for fever and body aches, steam
inhalation and “home remedies” such as liquid
coriander may be all that is required.
“For those who experience more troublesome
symptoms of a blocked nose, headaches, persistent
cough or breathing difficulty, medical advice is
“At the same time, it must be remembered that, an
acute cough can also be due to serious underlying
illness”, further explains Dr. Fernando.
According to Dr. Fernando, the following facts have
to be remembered regarding a cough.
• Coughing at night in an asthmatic patient is an
indication of poorly controlled asthma.
• If a patient with heart disease coughs at night,
and finds it difficult to sleep without using two or
three pillows to prop him/herself up, this may
indicate the onset of heart failure.
• Fever, chills, chest pain on coughing, cough with
‘phlegm’, bloodstained ‘phlegm’ and breathing
difficulties may indicate pneumonia.
• A blood clot blocking a blood vessel in the lung
(pulmonary embolism) can manifest as an acute cough
with chest pain and breathing difficulties. Those
who have travelled long hours in a sedentary
position, those who are bedridden due to prolonged
illness or fractures of bones, smokers, females on
contraceptive pills are at risk of this condition
• Children often inhale foreign substances into
their air passages, which can go unnoticed, and
present as an undeserving cough. Prompt medical
advice should be sought in theses instances.
Medical consequences of Prolonged Cough
• More than 50% of females with prolonged cough,
experience passing of urine with a bout of coughing
(urinary incontinence) This results in serious
psychological and social embarrassment
• Most experience muscle aches, pain in lower
ribcage, cramps in muscles, chest pains
• If cough is persistent, it can give rise to hernia
• It can give rise to ‘gastritis’ (‘heartburn’)
• Sleep disturbance occurs
• Some patients with prolonged cough, experience
‘blackouts’ (cough syncope). Some experience
palpitations, severe headaches, sudden onset of
breathing difficulties due to collapse of a lung (Pneumothorax).
These are the most serious consequence of a
prolonged cough, which require urgent medical
• Most patients are troubled and embarrassed by
uncontrollable bouts of coughing in public. They
fear that people may think that they are harbouring
infectious agents such as tuberculosis
• They tend to avoid public gatherings, leading to
social isolation and serious disruption of
• Patients continue to try various cough syrups,
exposing themselves to undesirable side effects of
• They are distressed by the inability of Medical
Practitioners to help them
• All these can lead to severe depression
“If you are troubled by prolonged and persistent
cough, do not feel distressed, there is light at the
end of the tunnel. Over recent years, much
information has become available to medical science
of the causes of persistent cough and how to treat
it”, reassures Dr. Fernando.
Medical Practitioners who are knowledgeable about
this condition are able to come to a diagnosis in
the vast majority of cases. This has led to higher
treatment success rates, and is a rewarding
experience to the treating doctor.
According to Dr. Fernando, the following facts have
also got to be remembered regarding a cough.
• A persistent cough can result from infectious
conditions such as tuberculosis. Such patients will
also have other symptoms such as loss of appetite,
loss of weight and fever
• Also, persistent cough or a change in the
character of the cough in a smoker can mean a
serious underlying condition such as tumours of the
• Prolonged exposure to harmful gases or chemicals
at workplace or home can also give rise to a
• Permanently damaged lung tissue (pulmonary
fibrosis) or breathing tubes (Bronchiectasis) can
also give rise to persistent cough
However, these conditions also have symptoms other
than cough, other physical manifestations and
changes in X–rays of the chest.
Causes of prolonged cough in patients who have a
normal X-ray of the chest, can include post-nasal
drip syndrome, asthma and asthma-like syndromes,
reflux cough- Conditions that result from
regurgitation of acidic and non-acidic contents of
stomach (Gastro-esophageal reflux disease),
post-infectious cough, drug induced cough and
chronic bronchitis/smokers cough.
According to Dr. Fernando, Post-Nasal Drip
Syndrome results from secretions (phlegm) built up
in sinuses and/or the upper air passages, trickling
down to the throat. This build-up of secretions
(phlegm) can result from many allergic and
non-allergic conditions and infections of the
sinuses and upper air passages.
Symptoms of this, according to Dr. Fernando,
• Patients experience and complain of a sensation of
“something dripping down into their throat”
• A feeling of a lump of ‘phlegm’ in the throat
• A cough that is worse at night or while lying in
• A frequent need to clear the throat
• Nasal discharge or block
• Symptoms of a recent viral infection (flu) or
Allergic rhinitis (catarrh or hay fever) can give
rise to symptoms of a post-nasal drip.
These patients commonly experience;
• A watery nasal discharge (runny nose)
• Itching/irritation of ears and/or nose
• Tearing, itching of eyes
• Nosebleeds may also be experienced
Patients often complain of onset of symptoms on
cleaning, dusting, breaking cobwebs, exposure to
cold environments, on close contact with household
pets such as cats, dogs, partaking in cold drinks,
cigarette smoke, fumes of mosquito coils, mats,
vaporisers, hairsprays, dyes etc.
Many find these symptoms extremely troublesome
and they interfere with daily activities and studies
One-third of patients with allergic rhinitis
(catarrh or hay fever) have wheezing and symptoms of
asthma, explains Dr. Fernando
Very effective oral medications and nasal sprays are
available to treat this condition.
• Certain oral tablets causes drowsiness and may
interfere with studies and certain occupations,
which should be brought to the notice of one’s
• If you are a pregnant mother or breast feeding,
this should be brought to your doctor’s notice
• If you are on medications for other medical
conditions such as heart disease, the doctor should
• Decongestion nasal spray should not be taken on a
long-term basis, as these can lead to worsening of
symptoms (rebound symptoms)
• Desensitising injections are also a method of
treatment, but are not available for treatment in
Dr. Fernando says that, all attempts should be made
to avoid known triggers (some of which were
mentioned above) of symptoms.
• Particular attention should be given to bedroom
and living areas in the house
• Do not take domestic pets such as cats, dogs
indoors. Cat fur is a very potent allergen and is
extremely difficult to get rid of
• Regularly clean/wet mop bedroom, furniture,
ceiling fans, pedestal fans, curtains, bed linen.
Mosquito nets, if used, should be washed at least
once-a-week. Avoid carpets in bedrooms. If
air-conditioners are used, these should be serviced
regularly, and filters changed, as mould tends to
grow in humid water systems of air-conditioners.
• Perfume sprays, hair dyes, hair gels and shampoos
can bring on symptoms
• Exposure to cigarette smoke should be avoided by
• Certain foods with colouring, additives and
preservatives, fizzy drinks, seafood can worsen
• Cold water baths may trigger symptom but this can
be minimised by avoiding late evening baths and
drying your hair and body well after a bath
• Drugs such as Aspirin may give rise to a
particular form of rhinitis.
Another form of Rhinitis (Vasomotor Rhinitis)
results from irritation of nerves in the lining of
the nose. This causes outpouring of large amounts of
thin watery fluid from the nose. Also hormonal
changes that occur during menstruation, pregnancy,
certain blood pressure medication gives rise to
Infections of the nose, sinuses and upper air
passages (Rhinosinusitis) can also give rise to the
syndrome of post-nasal drip.
Symptoms of infective Rhinosinusitis
• Unlike in patients with allergies who experience
sneezing, itching and a ‘runny nose’, these patients
experience symptoms of a ‘blocked nose’
• Nasal passages are blocked, thick yellowish
‘phlegm’ may be coughed up
• Patients loose their sense of smell and taste
• Patients experience headaches that is worse when
looking down, pain over forehead, pain over front of
face and teeth
• If symptoms are confined to one nasal passage,
this is of particular concern and urgent medical
attention must be sought
This group of patients may require X-rays of
sinuses, CT-scans or endoscope of nasal passages, if
thought necessary by the treating specialist.
These patients require prolonged courses (over
two-three weeks) of antibiotics, and should strictly
follow advice of the treating Specialist.
Steam inhalation is useful in clearing up blocked
nasal passages, and helps nasal drops to work more
Nasal irrigation (washing of nasal passages) with
saline preparations also helps clear ‘blocked’
All asthma patients cough. In most, cough is
• Wheeze (whistling noises in chest)
• Chest tightness
• Difficulty in breathing and limitation of physical
In the majority of asthmatic patients, these
symptoms have a pattern. Symptoms come in episodes-
Patients enjoy symptom free periods, symptoms are
worse on waking up or in the early hours of the
morning. Most patients are able to identify factors
that make symptoms worse.
Some patients may already be on asthma medication.
Dr. Fernando says that, if, while on asthma
medication, cough persists, it may be that;
• You are not compliant with the prescribed dose and
prescribed frequency of use of asthma medication
• The prescribed dose may not be sufficient enough
to control your asthma
• You may be continuously exposed to triggers of
• Your technique of inhaler use may be wrong
• The cough may be due to some other cause such as
allergic rhinitis (catarrh), ‘gastritis’ which
frequently accompanies asthma
In a minority of asthmatics, cough may be the only
symptom of asthma (cough variant asthma). In these
patients, the pattern of cough is similar to that of
an asthmatic, and can be brought on by physical
activity or various triggers that bring on asthma
These patients respond well to asthma medication
such as inhalers. An adequate course of treatment
should be given and patients must be informed that
complete resolution of symptoms may take 2-4 weeks.
If symptoms do not resolve by this time, alternative
diagnosis should be considered by the doctor.
This is another common cause of a persistent cough,
and a cause that is often undiagnosed.
Doctor’s are often reluctant to diagnose this
condition, in the absence of classical symptoms such
as ‘heartburn’, burning sensation in abdomen and
chest, sometime after meals, abdominal puffiness of
a bloated feeling regurgitation of acidic contents
into mouth (bitter taste in mouth, gaseous feeling,
In a significant number of patients, reflux is
non-acidic in nature. When we swallow our food, our
food passes from our gullet (oesophagus) to the
stomach, the ring of muscle that connects the two,
relaxes, allowing passage food into the stomach.
This relaxation of the muscle occurs again to allow
air swallowed along with the food to be passed back
out to the gullet.
During this process, if the muscle relaxes for too
long, some of the contents of the stomach pass back
into the gullet, and as far back into the air
passages. These contents occur in very minute
amounts, and are called micro-aspirates. These
contents are non-acidic, as food has neutralised the
acidity of the stomach. However, these
micro-aspirates can give rise to bouts of spasmodic
coughing, a chocking sensation and difficulty in
Thus patients can have Reflux cough without
associated symptoms of ‘gastritis’.
Symptoms of reflux Cough
• Cough occurs during eating. Certain foods such as
citrus fruits, chocolate, alcohol are more likely to
bring on cough
• Cough occurs within 10 minutes of eating
• Cough occurs when talking, singing. Cough
occurring while talking on the telephone is highly
• Patients frequently cough severely on going to bed
• Patients do not cough on waking, as long as they
lie in bed. Once they get out of bed and stand up,
they start coughing
Symptoms due to reflux of acidic contents of stomach
• ‘Heartburn’, burning sensation in abdomen and
chest, sometime after meals, (about one hour after a
• Abdominal puffiness of a bloated feeling
• Regurgitation of acidic contents in to mouth
(bitter taste in mouth, gaseous feeling, belching)
No special tests are required at the outset of
treatment. If other common causes of cough mentioned
above have been excluded, a trial of treatment with
anti-reflux medication is often tried.
Your doctor may decide to perform an endoscopic
procedure, if symptoms are slow to resolve.
• Anti-reflux medication combinations
• The timing of these medications in relation to
food is of great importance, and your doctor’s
advice should be sought on this
• A reasonable period of treatment is 2-6 months. It
may take about two weeks for patients to experience
• In a small group of patients, anti reflux surgery
• Avoid very hot, spicy, oily foods, coffee,
• Cut down on alcohol intake
• Do not lie down in bed soon after a meal
• Avoid tight clothing, belts etc
• Use of pillows to prop yourself up when sleeping,
will help to reduce reflux
Angiotensin-converting-enzyme inhibitor (ACEI)
This group of drugs is used in the treatment of high
Patient can develop cough many years after being on
this medication, or following a viral infection
while on medication.
Only definitive treatment is to discontinue the drug
and replace it with a different group of drugs.
It may take about 4 weeks after stopping the drug
for cough to resolve completely.
This follows a viral infection of the air
passages. Cough lingers on even after initial flu
symptoms have completely resolved. Chest X-rays,
blood counts are completely normal, and cough is the
only unresolved symptom.
This is due to air passages becoming increasingly
sensitive to a variety of environmental factors,
after the initial viral infection.
Repeated courses of antibiotics should not be taken,
as there is no ongoing infection, and this practice
has harmful side effects.
This cough resolves in 4-6 weeks.
If symptoms are troublesome, medical advice should
Irritation of the air passages from harmful
fumes/gases is the cause of this persistent cough.
Cigarette smoke is the commonest cause of this.
Also domestic wood-fires, irritant gases in
workplace, dust in grinding mills, chemical/diesel
fumes and environmental pollutants can give rise to
this persistent cough.
Avoidance of these irritants, quitting smoking is
the best mode of treatment.
Dr. Fernando says that, in the vast majority of
patients, a diagnosis of the cause of cough can be
made by a physician experienced in treating these
patients, which will lead to successful treatment of
Most over-the-counter cough syrups do not help, and
unsupervised use of these should be avoided, as they
have harmful side effects, and do not treat the
underlying cause of the cough.
Unsupervised and unrestricted repeated courses of
antibiotics should be avoided.
Certain patients suffer from more than one cause or
from a combination of causes mentioned above. For
example, a patient with asthma may also suffer from
allergic rhinitis (catarrh). Patients with sinusitis
may have reflux symptoms too.