Chronic cough is difficult to diagnose and even more difficult to treat. It often takes sufferers several years and just as many doctors’ visits before a correct diagnosis is made. In the mean time, it can significantly impact one’s daily life.
Common Myths Around Chronic Cough
In this blog, we will try to debunk 4 of the most common myths in chronic cough:
- Common Myth #1 – is chronic cough a minor ailment?
- Common Myth #2 – is chronic cough a symptomo or a disease?
- Common Myth #3 – nothing to be done
- Common Myth #4 – cough syrup for chronic cough
Common Myth #1 - is chronic cough a minor ailment?
The prevalent myth in the medical community is that chronic coughing is a minor issue which patients must learn to live with, as it does not really cause any significant problem in their lives. By the time patients are seen in a specialized chronic cough clinic, they have often seen three or four other physicians (and they have probably waited five to eight years already).
Chronic Cough is not a minor ailment.
However, patients who suffer from chronic cough will not describe it as a minor ailment. It has had a significant impact on people’s relationships, their jobs, and their income. People can have terrible physical symptoms such as chest pain, abdominal pain, and urinary incontinence particularly in women, which is a terrible consequence to have.
Common Myth #2 - is chronic cough a symptom or a disease?
The second myth related to this issue is that chronic cough is just a symptom of another disease. Chronic cough is not seen as a distinct disease entity in and of itself. It is seen as something which is secondary to other things. For example, things like reflux disease, asthma, upper airway reactivity, nasal symptoms and post nasal drip. These are the common things that people often attribute to chronic cough.
Here, we will challenge some of the conditions which are usually attributed as the cause of chronic cough.
Reflux disease
People who visit a reflux clinic with terrible heartburn or indigestion are not coughing hundreds or thousands of times a day. Pregnant women who suffer from terrible incapacitating heartburn in the first second and third trimesters don’t have chronic cough.
Asthma
In the waiting room of a moderate to severe asthma clinic, patients have other symptoms like wheezing and breathlessness. Some will have a chronic cough, but they do not cough the hundreds or thousands of times a day like patients with unexplained chronic cough would.
Is there something else going on?
There are other diseases (asthma, reflux, …) that are associated to chronic cough, but they are not the direct cause of the coughing. There’s another bridge between those diseases and the chronic cough. It’s a cough hypersensitivity syndrome. The nervous system, which is responsible for making people cough has become too sensitive and responsive. It could be in the periphery between the lungs, in the throat, and or the brain. Or it could be brain itself that has become more sensitive.
There is much more data and research out there now, clearly showing that chronic cough is a distinct condition.
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Common Myth #3 - nothing to be done
The third myth relating to chronic cough is that nothing can be done for these patients. Once you’ve tried inhalers and nasal sprays you are out of options. It’s another myth because now there are many medications that been trialed to control the coughing.
Medications and non-medicinal treatment options for Chronic Cough
Many patients require low doses of morphine sulfate, Pregabalin or Gabapentin. These medications are designed to reduce the cough hypersensitivity component. Non-medicinal options include speech therapy which in some patients has a significant improvement in their coughing.
Potential upcoming treatments for Chronic Cough
Another promising treatment is Gefapixant, a novel new medication which inhibits the P2X3 receptors (the nerves that regulate cough). It has a dramatic improvement in cough frequency. However, as of the date this blog is being written, this drug is not yet accepted by the FDA or by Health Canada. There are several other promising new treatments currently being trialed to treat chronic cough.
Common Myth #4 - Cough Syrup for Chronic Cough
Meta-analyses and Cochrane reviews have been done on this subject. They have found that over-the-counter cough syrups do not have any significant improvement on cough frequency over placebo.
Cough syrup combinations for chronic cough
Dextromethorphan is centrally acting medication commonly found in cough syrups. Codeine can be added in small amounts. Guaifenesin or even menthol can also be added. None of them have ever shown any benefit in clinical trials. One theory is that these medications have a coating effect on the throat. It might not be the actual medication that’s helpful but it’s the syrup that coats and soothes the throat. Caution is needed because some cough syrups contain low dose opioids and can become addictive.
Candies for chronic cough
Like cough syrups, candies can coat the throat and the constant swallowing inhibits coughing. It’s impossible to cough and swallow at the same time.
In summary
Cough is a nervous or neuronal reflex which is activated in the peripheral nervous system. The brain processes the signal from the peripheral nervous system and decides whether or not to cough. Cough is seen as a defensive mechanism to try and protect the lungs from things that don’t belong, such as chemical or mechanical things or a foreign body (like a peanut). In people with chronic cough, that system has become too sensitive. Cough hypersensitivity and chronic cough – PubMed (nih.gov)
Conditions like asthma, reflux disease, nasal disease and laryngeal sensitivity are things which can trigger cough. A cough in someone with asthma can get better by treating the asthma. That is why it is important to investigate the potential underlying triggers and associations. A little detective work (in conjunction with a diagnostic algorithm) is needed to look for underlying factors that might be triggering and sensitizing that cough reflex.
Chronic cough is not a minor ailment that patients need to learn to live with. It should be seen as a distinct disease entity. It can be treated and there are promising new treatments on the horizon.
To learn more about chronic cough please go and read our latest report.
About the author
Katrina Metz is currently working as a consultant for RESPIPLUS, striving to improve education in the respiratory domain for healthcare professionals and patients alike. She has over 16 years experience working as a respiratory therapist and clinical research coordinator for the Research Institute of the McGill University Health Center.
