How Doctors Crack the Code for Your Chronic Cough

Treating the most likely cause usually brings relief

Are you constantly coughing? Chronic cough — lasting eight or more weeks — is one of the most common reasons for a doctor visit.

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“This kind of cough is quite troublesome for patients and can be challenging for doctors to treat, too,” says pulmonologist Rachel Taliercio, DO. “Many people have dealt with chronic cough for years, and sometimes decades.”

3 common reasons for chronic cough

Chronic cough is most commonly caused by one of three conditions:

  1. Upper airway cough syndrome (UACS): Post-nasal drip accompanied by frequent nasal drainage and throat-clearing can have several causes, including allergic rhinitis and chronic sinusitis. Allergic rhinitis may be due to airborne allergies (like pollen), irritants (like tobacco smoke), infections (like the common cold) or swelling and congestion caused by blood vessel dilation (vasomotor rhinitis). Chronic sinusitis involves sinus inflammation and drainage.
  2. Asthma: Cough is sometimes the only sign of asthma. Called “cough-variant asthma,” this condition stems from airway inflammation.
  3. Gastroesophageal reflux disease (GERD): If you have heartburn or a sour taste in your mouth, your cough may be caused by acid back-up into the esophagus. “Some patients do not have classic symptoms of GERD, but their cough can be related to reflux,” notes Dr. Taliercio.

Less common causes of chronic cough include non-infectious bronchitis unrelated to asthma and laryngeal reflux (acid back-up into the throat and voice box).

And to complicate things a bit, “it’s not uncommon to have more than one reason for your chronic cough,” says Dr. Taliercio.

How doctors diagnose chronic cough

The doctor may order a chest X-ray or breathing tests (spirometry and nitric oxide). Some patients may need their throat, voice box and vocal cords examined with a tube called a laryngoscope.

“Because the reasons for chronic cough can overlap, we start by treating the most likely cause of your cough,” says Dr. Taliercio.

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  • If your history and spirometry show hyper-reactive airways, and if steroids have helped you in the past, you likely have cough-variant asthma.
  • If your exhaled nitric oxide levels are high, you likely have bronchitis caused by chronic airway inflammation.
  • If your history, a barium x-ray of the esophagus and acid (pH) levels confirm it, GERD is likely responsible for your chronic cough.

If you have UACS or asthma, you should experience a 50% reduction in your cough within a few weeks of treatment. If you have GERD, it may take several months for anti-reflux therapy to work.

Using this approach works for the majority of patients Dr. Taliercio and Paul Bryson, MD (an ear, nose and throat specialist), see in their Chronic Cough Clinic.

For the minority who do not respond, further evaluation may begin with a CT scan to check for less common, more serious causes for lingering cough. These include chronic infection, pneumonia, cancer and chronic airway damage (bronchiectasis).

When standard treatments don’t work

“If patients don’t respond to treatment for the more common causes of chronic cough, and we exhaust all other possibilities, then we consider treating them for a condition called cough hypersensitivity syndrome,” says Dr. Taliercio.

Neuromodulator therapy, with drugs such as gabapentin, or tricyclic antidepressants such as amitriptyline or nortriptyline, is prescribed for cough hypersensitivity syndrome. Dosages must be carefully increased to safely reach effective levels.

“Studies find that gabapentin can improve the quality of life in patients with chronic cough,” says Dr. Taliercio.

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She and Dr. Bryson are now studying gabapentin, amitriptyline and nortriptyline in patients with unexplained chronic cough, scoring their coughs before and after treatment to document each drug’s effects.

“Most patients with cough hypersensitivity syndrome have at least some improvement with treatment,” she says. The study is continuing to collect longer-term data.

Other options to consider

When medications don’t provided relief from coughing, botox injections are another option they consider.  Finally, behavioral cough suppression therapy from a speech pathologist can help reduce the impact of coughing on your life.

The bottom line: With so many treatments available, you don’t have to suffer with coughing indefinitely. Seek expert help, and chances are good that you’ll find relief.

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