Elizabeth Landry had a cough that wouldn’t stop. She made an appointment to see her doctor.
“I have been coughing day and night for 11 days. It just won’t stop. I can’t even sleep,” explained the obviously distressed mother. “It started about the time we evacuated to Baton Rouge for Hurricane Ivan. My husband had come home a few days before from a trip with a cold, and I caught it from him. He was coughing too, but not as much as me,” continued Landry.
Her husband, Robert B. Landry III, a lawyer who travels frequently, attributed his respiratory infection to catching something on an airplane.
The doctor listened to her story and performed what doctors call a focused physical examination. She had no fever. Her throat was clear, and there were no abnormal-looking deposits, postnasal drips or signs of allergy problems. On auscultation of her chest, all sounds were normal.
Landry went home with a prescription for a codeine-containing cough suppressant that also causes mild sedation – the perfect ticket to help deal with the nocturnal phase of her cough.
“After two nights, I already feel better. I’m able to sleep at night, and I am coughing less during the day,” said Landry during a telephone follow-up. Her symptoms are classic for an acute postinfectious cough.
“Anything over three weeks constitutes a chronic cough,” says pulmonary disease specialist Dr. Ewing Cook, whose practice is mostly referral from other doctors. “About 30 to 40 percent of the new patients I see are coughing more and longer than they think they should. They don’t get to me unless they have been coughing for at least three weeks.”
Often the history and physical examination allow a doctor to make a good presumptive diagnosis, allowing some rational treatment recommendations. If a simple solution dissolves the cough, usually special testing is not needed.
“Many persons with chronic cough who end up in my office fear that they have cancer. Actually only about 1 percent of patients I see with lung cancer have a cough as the initial complaint, but I usually order at least a chest X-ray if they have made it to me,” adds Cook.
Cook listed several common causes of chronic cough. One of these is the classic postinfectious cough, which at least in Landry’s case was still acute rather than chronic. Other common problems uniting persons under a common banner of coughing are postnasal drips, asthma, gastric reflux and drug-induced coughs. Postinfectious coughs. “A postinfectious cough is common after influenza, but it can occur after any viral or bacterial infection. It can last up to eight weeks or even longer,” says Cook.
In Landry’s case, her September onset was a little too early for acute influenza, which also causes more of an acute febrile illness with body aches and pains. Her history of coughing after the return of her coughing husband suggests one of the more minor respiratory viruses at play.
“Explanation of the process is the best treatment. I advise staying away from irritating odors, including perfumes, cooking smells and sprays, which can stimulate overly sensitive airways. And drink lots of water. Water is one of the best ways to liquefy secretions and ease them out of the lung. Water is just as effective as any of the cough medications as a mucus liquefier,” says Cook.
“If cough suppression is needed for restful sleep, I prescribe a codeine-based cough syrup,” Cook adds.
If daytime cough suppression is needed, the prescription drug Tessalon might be worth a try. It does not have the sedating and gastrointestinal adverse effects often reported with codeine. Other options include short courses of steroids taken orally or by inhalation.
Tessalon is an oldie that is not promoted heavily these days, and consequently it is only infrequently prescribed. I learned about Tessalon firsthand when I was in medical school, before I learned the value of an annual influenza immunization.
Tulane pulmonologist Dr. Dean Ellithorpe heard me coughing one day at lunch in the Tulane Medical School cafeteria, and after hearing my story, recommended I try Tessalon. My cough gradually faded over the next week. I was never sure whether the Tessalon really worked or whether “tincture of time” simply came to my aid.
Another approach to a persistent postinfectious cough might be a brief trial of one of the inhalers usually reserved for persons with chronic allergy or pulmonary conditions. Atrovent is a non-steroidal inhaler usually prescribed for persons with asthma, chronic bronchitis and emphysema who have wheezing or shortness of breath. Several puffs from an Atrovent inhaler for a couple of days might stem postinfectious coughing episodes by relaxing overly sensitive airway passages. Postnasal drips. Postnasal drips aren’t unusual after common colds, so some transient postinfectious coughs are actually multifactorial in etiology. Effective treatment depends on the cause of the cough. For example, if bacterial sinusitis is the culprit, an antibiotic is needed.
Treatment options include prescription nasal sprays, antihistamines, and combinations of decongestants and antihistamines. The more sedating first-generation antihistamines are actually more potent than their more expensive non-sedating relatives. Both are usually efficacious, however, if the underlying diagnosis is simple allergic rhinitis.
The best option is prevention through avoidance of the precipitating trigger, which might be anything from a seasonal allergy to cooking fumes. Asthma. Coughing may be the only sign of asthma in some people, and cough-variant asthma is often a missed diagnosis. The typical patient reports a recurring cough, which is often worse at night and may be aggravated by exercise or breathing cold air.
The best test to see if asthma is the culprit is a short trial of an asthma medication to see if the cough goes away. Regular preventive asthma medication can help keep the cough away. Gastric reflux. “Gastroesophageal reflux disease [GERD] is another cause of chronic cough. The gastric acid does not have to come all the way out of the stomach and be aspirated into the lung. The acid can irritate the lower esophagus and cause a reflex-induced cough. This is becoming more common in an aging population,” says Cook.
A chronic cough can also be caused by gastric juices washing back into the esophagus, stimulating a reflex mechanism and causing a cough without any heartburn or gastrointestinal symptoms. This is called silent GERD – harder to diagnose but often easier to treat.
Traditional treatment for GERD calls for a low-fat diet and avoidance of acidic foods or beverages. Many patients with GERD also have sleep disorders. Proper diagnosis and treatment of sleep apnea can also reduce or stop the chronic cough associated with GERD.
Doctors like to recommend diagnostic tests that are also therapeutically beneficial. Persons with suspected GERD are usually treated empirically with one of the proton-pump inhibitors such as Prevacid, Nexium, Prilosec or Protonix. These drugs should be tried for several weeks or months before seeking a more aggressive approach to the diagnosis and treatment.