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Lung Disorders

2004 Edition

When A Cough Turns Chronic
If coughing persists for more than two months, it can be a sign of a serious condition requiring a doctor’s care.

Coughing up phlegm, infectious agents, and foreign matter is one of the ways that the lungs protect themselves. Occasional coughing is normal, as is coughing associated with a cold. Any cough that lasts more than two months, however, is defined as chronic and requires medical attention. A chronic cough needs to be evaluated even if it occurs only in the morning, at night, or during certain times of the year.

Severe coughing may signal a respiratory disease. Obstructive diseases of the lungs (asthma and chronic bronchitis) and lung cancer often cause a person to cough up phlegm. Yellow or green phlegm may signal a lung infection. Coughing up blood (hemoptysis) may suggest a benign problem such as bronchitis or a potentially life-threatening disease like lung cancer or pulmonary embolism. Hemoptysis is a serious sign, especially in current or former smokers. Other symptoms that may occur as a result of chronic cough include fatigue, irritability, headaches, sleeping problems, urinary incontinence, and sore throat.

Chronic cough is not a disease; rather, it is considered a symptom of another condition, and your doctor will need to diagnose the underlying cause. The doctor will most likely ask when the cough started, if you are coughing up any phlegm or blood, whether the cough has changed pattern recently, and whether it is worse at certain times of the day. He or she may examine your ears, nose, throat, and chest, as well as perform some diagnostic tests such as a lung function test or a chest x-ray. Treating the underlying cause will usually resolve a chronic cough.

Causes of and Treatment for Chronic Cough

Chronic cough associated with a normal chest x-ray most often results from postnasal drip, asthma, or gastroesophageal reflux (GERD, the flow of stomach acid into the esophagus), or a combination of these conditions. Other common causes include smoking, chronic bronchitis, and certain medications.

Interstitial lung disease, bronchiectasis (persistent dilatation of the bronchi or bronchioles), and pneumonia—all of which produce inflammation or scarring of the lungs—are less common causes of coughing. Lung cancer is usually suspected only when a person with a history of smoking has an abnormal chest x-ray.

Postnasal drip. Postnasal drip—characterized by a runny nose, a feeling that fluid is draining down the back of your throat, and a frequent need to clear your throat—is the most common cause of chronic cough. In turn, postnasal drip is most commonly caused by sinusitis (an infection of the sinuses) or allergies. When postnasal drip is caused by allergies, treatment usually involves taking a decongestant such as dexbrompheniramine with pseudoephedrine (Drixoral). Treatment also may involve a first-generation antihistamine such as chlorpheniramine with pseudoephedrine (Deconamine); this medication can cause drowsiness, so you will need to be carefully monitored by your doctor. Postnasal drip caused by sinusitis is treated with antibiotics. Inhaled nasal corticosteroids also may be helpful. Once treatment has begun, chronic cough should clear up in a few weeks to two months.

Asthma. Asthma, the second most common cause of chronic cough, usually is associated with shortness of breath. However, some people with asthma have chronic cough as their only symptom. This type of asthma (called cough-variant asthma) can be difficult to diagnose because the physical exam and pulmonary function tests usually are normal; however, it is often triggered by cold air, strong fumes, or exercise. A cough that begins after starting therapy with a beta-blocker (a medication typically used for high blood pressure and heart disease) may also be due to asthma, as beta-blockers can trigger asthma symptoms in some people. Treating the asthma (and switching to another blood pressure medication, if necessary) should help relieve chronic cough.

GERD. GERD is the third most common condition responsible for chronic cough. About 40% of people with GERD do not have the traditional symptoms of heartburn and indigestion—instead, a cough is their only symptom. If GERD is suspected, treatment of the disorder may be used to determine whether it is the cause of your chronic cough; if the cough is relieved, GERD was the culprit. Treatment for GERD usually includes lifestyle changes such as avoiding large meals, acidic or fatty foods, caffeine, alcohol, and smoking, as well as sleeping with the head of your bed elevated. Medications for GERD may include antacids, histamine-receptor antagonists (also known as H2-blockers), mucosal protectants, proton pump inhibitors, and prokinetic agents. Reduction in cough may occur only after several months of treatment.

Smoking and chronic bronchitis. Chronic bronchitis is suspected as the cause of a chronic cough if you have a history of smoking and have had a productive cough (one that produces phlegm) on most days of the week for at least three months in the past two years. If you still smoke and have chronic bronchitis, quitting can help relieve your cough. Medications called bronchodilators (which promptly open airways by relaxing bronchial smooth muscles) also may be necessary to help reduce coughing.

Medication. Some medications, particularly ACE inhibitors (commonly used to treat high blood pressure), can cause a chronic cough. In fact, approximately 25% of people who take ACE inhibitors develop a dry, hacking cough. Discontinuing the ACE inhibitor for several weeks (under your doctor’s supervision) can help determine whether it is causing your cough. (The cough usually takes one to four days to resolve after discontinuing the medication, but it can persist for up to four weeks). Switching to another type of blood pressure medication may be helpful.


 


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2005
WHITE PAPERS
Lung Disorders

The Lung Disorders White Paper from the Johns Hopkins White Papers series is an annual, in-depth report written by Johns Hopkins physicians.

 

 

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