Chronic 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 not curable.

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 becomes irreversible.
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 cough’.
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 needed”.
“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 (pulmonary embolism).
• 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 attention.
Psychological Distress
• 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 day-to-day living
• Patients continue to try various cough syrups, exposing themselves to undesirable side effects of these treatments

• 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 lung

• Prolonged exposure to harmful gases or chemicals at workplace or home can also give rise to a prolonged cough
• 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 bed
• A frequent need to clear the throat
• Nasal discharge or block
• Symptoms of a recent viral infection (flu) or ‘sore throat’
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)
• Sneezing
• 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 in students.
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 doctor
• 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 be informed
• 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 Sri Lanka
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 all means
• Certain foods with colouring, additives and preservatives, fizzy drinks, seafood can worsen symptoms
• 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 similar symptoms.
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 efficiently.
Nasal irrigation (washing of nasal passages) with saline preparations also helps clear ‘blocked’ passages.

Asthmatic Cough
All asthma patients cough. In most, cough is accompanied by;
• Wheeze (whistling noises in chest)
• Chest tightness
• Difficulty in breathing and limitation of physical activity

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 asthma
• 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 symptoms.
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.

Reflux Cough
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, belching).
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 breathing.
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 suggestive
• 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 meal)
• Abdominal puffiness of a bloated feeling
• Regurgitation of acidic contents in to mouth (bitter taste in mouth, gaseous feeling, belching)
Special tests
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 benefit
• In a small group of patients, anti reflux surgery may help
General Advice
• Avoid very hot, spicy, oily foods, coffee, chocolates
• 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) induced Cough
This group of drugs is used in the treatment of high blood pressure.
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.

Post-infectious Cough
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 be sought.
Chronic Bronchitis
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 the condition.
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.