Chronic cough

What cough is and when it is called chronic

Cough is a protective reflex that clears the airways of secretions and irritants. It is triggered by receptors in the throat, trachea and bronchi and directed by the cough center in the brainstem. Classification by duration helps point to the cause: acute cough lasts up to three weeks and is almost always the result of a viral upper respiratory infection; subacute cough lasts 3 to 8 weeks, often after an infection; chronic cough lasts more than 8 weeks and requires structured assessment.

Chronic cough is one of the most frequent reasons for seeing a pulmonologist. It is not a disease in itself but a symptom of one or more conditions, and the doctor’s task is to find and treat the causes.

What the possible causes are

In practice, most chronic coughs in adult non-smokers with a normal chest X-ray come from three causes, often coexisting:

• asthma or eosinophilic airway inflammation, including the form in which cough is the only symptom;
• upper airway cough syndrome: rhinitis and sinusitis, with secretions dripping behind the throat;
• gastroesophageal reflux, especially when there are typical symptoms (heartburn, regurgitation), but sometimes also without them (see gastroesophageal reflux).

Other causes: smoking, irritant exposures and COPD; some medicines, especially angiotensin-converting enzyme (ACE) inhibitors, used in hypertension and heart failure: they cause a dry cough, for which the cardiology doctor usually finds an alternative; prolonged infections, bronchiectasis (widening of the bronchi with recurrent secretions), tuberculosis, interstitial lung diseases, heart failure and tumors. After some infections, including pertussis, cough can persist for weeks.

There may be several factors at once. It is not correct to assume that every cough is due to allergy or reflux: this leads to wrong treatments and delays diagnosis of serious causes.

When to see a pulmonologist and which signs are alarming

Seek a visit if the cough lasts over three weeks, recurs or worsens. Some signs require assessment without delay: blood in sputum (hemoptysis), unexplained weight loss, persistent fever, night sweats, new shortness of breath, hoarseness that lasts, difficulty swallowing, repeated pneumonia, age over 45 with smoking, and any abnormal finding on examination or imaging. Tell your doctor about smoking, workplace exposures, travel, contact with sick people and all the medicines you take.

How the assessment is done

The doctor reviews the duration, whether the cough is dry or productive, what triggers it (food, lying down, cold air, activity) and accompanying symptoms. As indicated, spirometry is performed at the clinic, while a chest X-ray may be recommended at another center; it is the first imaging test for any chronic cough. As appropriate, blood tests, sputum examination or other tests are needed. CT is not automatically required for every chronic cough; it is recommended when there are clinical grounds or when the X-ray is abnormal.

How it is treated

Treatment targets the cause and the factors that sustain the cough: inhaled anti-inflammatory treatment for asthma, treatment of rhinitis, measures for reflux, stopping smoking, changing a medicine that causes cough. Antibiotics and acid-reducing drugs should not be used routinely without an indication; assessing the response after a few weeks of targeted treatment is part of the diagnosis.

In some cases, increased sensitivity of the cough reflex (cough hypersensitivity syndrome) contributes to persisting symptoms even after the causes have been treated. If the cough remains after the causes have been assessed and treated, specialized care may be needed: speech therapy for cough control and, in selected cases, medicines that reduce the sensitivity of the reflex.

What you can do

Avoid tobacco and irritants. Note when the cough appears, its triggers and accompanying symptoms; this helps the doctor to find the cause. Do not stop a prescribed medicine just because you suspect it causes cough; talk with the doctor, who may replace it. Drink enough fluids and avoid cough syrups without advice, because they do not treat the cause. Regular check-ups, every 6 months to a year or sooner when the doctor considers it reasonable, assess the course when the cause is chronic.

Care at Tirana Polyclinic: we offer pulmonology consultation, spirometry as indicated and interpretation of tests and imaging performed at other clinics. When needed, the assessment is coordinated with gastro-hepatology or other specialties.