What do we do if a cough doesn’t want to quit? Pulmonologist and cough expert Dr. Kathryn Robinett walks us through a real-world approach and how doctors use chronic cough treatment as a diagnostic tool.
Chronic Cough Treatment As Diagnostic Tool
Chronic Cough Definition and Causes
By definition, a cough is chronic if it lasts more than eight weeks. Less than eight weeks, but more than three is a subacute cough, and anything less is acute.
The three most common causes are:
- Gastroesophageal reflux disease (GERD)
- Post-nasal drip (now known as upper airway cough syndrome)
We should try and manage patients’ expectations relating to viral infections. There are so many varieties of viruses that some may only cause an acute cough where others may last upwards of ten weeks.
Asthma and cough variant asthma could also cause a chronic cough. And, especially with smokers or ex-smokers, chronic obstructive pulmonary disease (COPD) is quite common.
There are potentially life-threatening causes, but these are much rarer. Some diseases we look out for include:
- Lung cancer
- Interstitial lung disease
- Eosinophilic bronchitis
Lastly, occupational factors may be behind a chronic cough. For example, if a cough improves while on holiday or once you start a new job, it’s possibly something at work.
Diagnosing Chronic Cough
The problem with chronic cough is there’s not much research. As a result, there are few guidelines, and diagnosis varies by provider.
Most physicians use empiric treatment and educated guesses when they don’t have complete information. There’s a lot of trial and error when diagnosing chronic cough. We often use a treatment approach in addition to diagnostic testing.
Chronic Cough Treatment Approach (Empirical therapy)
Some physicians systematically prescribe treatment for each cause. For instance, your doctor may treat GERD for a week, and if there’s no improvement, trying an inhaler.
Another approach is to prescribe multiple treatments at the same time to give chronic cough treatment the best chance to succeed.
Coughing begets coughing. That is to say, the mechanical act of coughing causes irritation and swelling, which results in more coughing. In many cases, stopping a cough allows the swelling to go down and the throat to heal. So, inhibiting a cough is a priority.
The empiric treatment lasts a month to six weeks.
Usually, when a cough turns chronic, we do a chest x-ray and CBC (complete blood count). We’re looking for anything a patient may have inhaled or anything concerning in the blood test.
If there’s no improvement after four weeks of empiric treatment, the next steps are PFTs and CT scans. We’re looking for much rarer conditions, and the PFTs and CT scans will give us those answers.
Pulmonary function tests (PFTs) measure lung volume, capacity, rates of flow, and gas exchange.
A CT scan will give a much clearer image than an x-ray. Today’s CT scans are so good we only need a standard scan.
After three months, it’s time to consult a pulmonary specialist if a chronic cough doesn’t respond to treatment, and your regular physician can’t pinpoint the underlying cause.
RELATED: How To Describe A Cough?
Chronic Cough Treatment Options
Prednisone taper of two to three weeks is an option, since inflammation may play a role in chronic cough. It will treat a post-nasal drip, and it may also improve cough variant asthma.
Your doctor may also treat GERD with a Proton Pump Inhibitor (PPI). Esophageal pH testing isn’t always helpful in cough because your PH may be normal despite your GERD-related cough. Many people have an acid reflux-related cough or respond to GERD treatment that doesn’t have abnormal PH probes.
Short-acting beta-agonist, benzonatate, or codeine may help suppress a cough.
An inhaled corticosteroid may help treat the cough’s cause, especially at the start of an upper respiratory infection (URI). But if you’re already on oral steroids, an inhaled corticosteroid won’t be specifically helpful.
If a cough improves, your doctor will stop one treatment at a time, starting with the cough suppressants. And then the remaining treatment based on the level of suspicion for the underlying cause. In other words, we stop treatment for the least likely underlying condition first.
What If It Doesn’t Work?
One possible cause is chronic cough hypersensitivity syndrome. In both post-URI coughs and coughs that aren’t responding to treatment, the nerves and lungs may become overly sensitive.
Alternatively, it may be vocal cord dysfunction, in which case your family doctor will refer you to an ENT.
Lastly, a chronic cough may be a tic or habit. Treatment includes behavioral therapy or speech therapy.
Do you have a chronic cough? What was your experience with diagnosis and treatment? Tell us in the comment section!
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Chronic Cough – hippoed.com