Exploring the Complexities and Solutions for Persistent Coughing Issues

Can’t seem to stop coughing? In this episode, the NJENT team explores the causes of chronic coughing, including ear, nose, and throat factors, as well as the diagnostic journey and effective treatments. This episode provides valuable insights for those grappling with long-standing cough issues. Discover the multifaceted approach these experts take to help patients find relief and regain control of their lives.

What you’ll learn

  • What can cause chronic cough from lungs, stomach, medications, to neurogenic triggers.
  • Why keeping a log can help to identify triggers and the seasonality effects on chronic coughs.
  • How the diagnostic process works, as well as the array of treatments, from inhalers and reflux medications.

 

Listen now for all your ear, nose, or throat matters and get insights from the experts. For professional ENT support, schedule a consultation today at our Marlton, New Jersey location by visiting NJENT.com or call 609-710-NOES (6673).

Listen to the audio version below.

Audio Transcript:

Dr Undavia:
Hey guys, I’m Dr. Undavia, this is Dr. Reddy, Dr. Smith, we’re from NJENT in facial plastic surgery. We wanted to talk to you about a topic called chronic cough and these are patients that we deal with quite often. I just wanted to set the history for these patients. These patients are people who have seen many doctors before seeing us. They’ve typically seen their primary care physicians, possibly in urgent care or an ER. They might’ve also seen a pulmonologist, a GI doctor, and they’re at their wits end where they’ve had this cough now for months or years and they just, it keeps them up at night, it disturbs them from social situations, it makes them feel awkward at restaurants, and it can be alienating. And so these are patients that we deal with quite frequently and we have a nice algorithm for what we should try for these patients. And every patient will have a slightly different response to our algorithm, so it makes it a little bit of a challenge to find out what to do next for these patients. So what I want to find out first, I’ll ask you Dr. Reddy, are there any things that you want to know from their history, or are there any musts that these patients should have in their workup that may not have happened by the time that they see you, that you wanna make sure that they’ve had?

Dr. Reddy:
Sure, so when I think of chronic cough, there’s a whole laundry list of potential causes of what may be causing the symptom of the cough. And so a lot of those symptoms of the cough may be related to an ear, nose, and throat cause, or may be related to another cause. You know, your cough, when you just think about what a cough is, a cough is essentially your vocal cords opening and closing really quickly against a quick burst of expiration of air, right? And so the cough is generally produced by your vocal cords and your larynx and your voice box. The energy from the cough is generated from your lungs and your vocal cords and voice box are, can be affected by many different things. And so the cough can either originate from this area, or it can be from anything that affects that area, or anything from your lungs. And so, you know, when I think of it from that perspective, we have to make sure that, you know, your primary care doctor, for example, has, or your pulmonologist has checked your lungs to make sure there isn’t a… a lung cause to the cough. Maybe getting a chest x-ray is key. Sometimes a cat scan of the chest. Looking for a very common cause of cough, which is something called cough variant asthma, which is a form of asthma where you don’t necessarily get the wheezing always, but you can get just a chronic cough. That’s usually diagnosed by pulmonary function testing. So that’s just part of part of the workup, but there’s many other causes. For example, gastroenterology plays a major role with chronic cough. Maybe Dr. Smith wants to touch base on that.

Dr. Smith:
Yeah, so I mean, I always start with telling patients that cough is there for a physiologic reason, like we have a cough and it’s there for a purpose. And the purpose is to keep the airway clear. And so if you have an upper respiratory infection, those patients are getting cough for two to three weeks because of the inflammation trying to expel secretions out of their lungs. So those are normal cough causes. So what we’re dealing with now is as Dr. Undavia put, yeah, these are patients that have had it for more than six weeks or two months or more. So if cough when it’s there for a reason, maybe go to drink something, it goes down the wrong pipe or into the airway. You cough to expel that out. If you go to eat and something hits the vocal cords, you’ll cough to keep that out.

If you have an infection and something’s draining down from the sinuses or coming out from the lungs, you’ll cough to expel that out. So cough is typically there for a reason when it’s there in the absence of an unknown reason. That’s when we get patients. And so Dr. Reddy talked about asthma, which is a very common cause of that inflammation or irritation that triggers cough. The one thing I ask in their medical history always is medications because sometimes they are missed. There are medications that can actually cause cough. And so one common medication that can cause cough are ACE inhibitors. Those are blood pressure medications that actually change some of the neurochemicals within the body. And one of those is bradykinin, which causes these C-ceptors and strep, stretch receptor sensitivity within the throat and airway which lead to some inflammatory mediators like substance P and norokin and A and all of that kind of pathway stuff is in response to inflammation. And so a lot of cough is due to inflammation and trying to figure out what the cause of that inflammation can be kind of tricky. And so Dr. Reddy was talking about reflux and that is certainly one cause of inflammation that can trigger cough as well. And so that’s probably one of the most common causes of chronic cough that we see or at least the underlying original etiology or cause may have been reflux. And so a lot of times those patients, and we’ve talked about this in one of our other older podcasts, they come in with like a drip in the back or their throat or a globus or stuck sensation in their throat. They may have vocal fatigue, so their voice may fatigue easier, or they may have some hoarseness or raspy throat clearing. But cough is a very, very common symptom of reflux as well. And so a lot of those patients present with cough. Another common.

Dr. Undavia:
I was gonna, I’ll stop you there for a second, because I think in general, there are a couple of different categories that the cough can come from. And we’ve touched base on two. One is from the lungs, and others from the stomach, so acid reflux. There’s the ear, nose, and throat sources that we could talk about in a moment and then there’s the medications with Dr. Smith talked about. So those are the four general categories which have the highest hits for maybe the cause for the cough. And then there’s a fifth category which is called like a neurogenic cough or kind of a cough that we don’t really have a method to prove the reason for. So, and I wanted to get back to just the chest x-ray part. I think that’s a big part that gets missed a lot just because patients might have this cough, they don’t have any weight loss or anything else, and we just wanna make sure that the lungs are clear, there’s no masses or infection or anything else, and chest x-ray is a great way to just kind of have that checkbox tipped. From an acid reflux perspective, is there anything that you would want to have in the background for those patients that have that checkbox that’s been done so that you don’t need to worry about anything else?

Dr. Smith:
Yeah, so if it’s been going on for a long time and they’ve been treated for a reflux and sometimes I’ll ask that they see the GI doctor and make sure they’ve had an endoscopy, make sure that there’s nothing else that might be contributing to the acid production. We talked about this, I think, in our LPR talk, but the H. pylori and other things within the stomach ulcers can also trigger this as well. So yeah, if it’s been going on for more than a couple months, we normally wanna make sure our GI or gastroenterology colleagues have been… you know, in the loop as well in the patient care of the chronic cough patient.

Dr. Undavia:
And so at this point, most of the patients come to us after they’ve seen the pulmonologists or the GI and their primary doctors. So can you talk, Dr. Reddy, about what you might do as a part of your exam when you see those patients?

Dr. Reddy:
So first you start off with a full ear, nose, and throat exam. Looking in, even looking in the ears is important because there’s these rare causes of cough for example like a foreign body in the ear or a little piece of hair in the ear. That is what I wanted to get. Yeah there’s and that can trigger a nerve called the Arnold’s nerve which is a branch of the vagus nerve which actually goes to your throat and that’s been shown actually a simple maneuver of just cleaning out the ear can sometimes make your cough better. Nose and sinus problems making sure there isn’t a drip like Dr. Smith said.

And then really the mainstay of the most important part of the exam is really looking at the vocal cords, making sure there isn’t any structural issues with your vocal cords, things like vocal cord paralysis that might cause you to have some aspiration of thin liquids that might be causing the cough or a vocal cord nodule or a polyp or any type of another growth in your voice box, either a benign or malignant growth.

Dr. Undavia:
Are there any, like, let’s say the exam didn’t help and the history didn’t help, are there any other studies you might want to have on board?

Dr. Reddy:
Yeah, so sometimes, you know, one cause of cough, for example, is something called the Zenkirz diverticulum, which is a little outpouching in your upper part of your esophagus that can lead to trouble swallowing, cough and other symptoms. And… The way you diagnose that oftentimes is with a study called a swallow study, specifically a barium swallow study. So basically you’re drinking some type of radiolabel dye and we have you get pictures of your neck as you’re swallowing food. So that might be one study, is the swallow study.

Dr. Undavia:
I typically stop after that in terms of other diagnostic imaging. Do you have any others that usually do that?

Dr. Smith:
As long as they’ve had PFTs or pulmonary function studies just to make sure there’s not a reactive component, like an asthmatic component or a chronic bronchitis, the picture that might be triggering it. Sometimes I will order a CAT scan of the sinuses if it’s been something that’s been going on for a long time and my exam gives me some detail or sign that there might be some inflammation. A lot of these patients may have chronic allergy as well, and so they often may have coinciding chronic sinus disease, which may be a trigger as well. I mean, sometimes you’ll scope in the back of the nose and see a trail of pyrrolein drainage coming from a sinus and the patient doesn’t have any symptoms of it, whether it be chronic in nature from sinus issues or a silent or some problem with the sinuses. And you see just this drainage going down the back and you go, all right, well, obviously there’s a cause there. So that’s when I’ll do a CAT scan of the sinuses. If I get a little history or at least some physical exam, finding that might be consistent with, because more often than not, there is some underlying sinus pathology as well.

Dr. Undavia:
So when the patient who has this chronic cough comes to our office, they really are at wit’s end. They’ve tried antibiotics, they might have already tried acid reflux, they might have already tried inhalers and I’m gonna get to the ear, nose, and throat part in a second, but what that has translated to is that we have become experts on going to that extra level of medication. So what I wanted to talk about first, we’ll do it from a pulmonary perspective, we tend to prescribe at higher doses or combinations of medications just to get this cough to go away because we know the conventional stuff has already been tried. So from a lung perspective, if you want to talk about maybe like the cocktail that you might try.

Dr. Reddy:
Um, referring to neurogenic cough?

Dr. Reddy:
No, I’m going to talk about that in a second. Okay. Or maybe I can answer the pulmonary part and then you go over the asterisks. So from a pulmonary perspective, there are all sorts of inhalers that you can use that are topical steroids, anticholinergics, you can use oral you can go above the max dose that’s recommended for short periods of time. And I’ve found that most of these chronic coughs, not all, but most of these chronic coughs are somewhat steroid responsive. So just giving a big burst of an oral steroid at the same time that you try these other inhaled steroids can be a big win for patients. Often just doing the inhaled steroids, which is a smaller dose, just isn’t enough to cross the threshold to get an improvement so that oral steroids can be a big, and really just helping them get over that curve and then they can get better with the inhaled steroids. How about acid reflux? What’s your max that you’ve ever gone to for acid reflux?

Dr. Smith:
Yeah, so I mean, a lot of patients already come in trying a medication like an antihistamine type of medication like a Pepsid or famotanine, or what’s called a proton pump inhibitor, which is another type of reflux medication like Anexium or Prevacid. So I often I’ll have patients on, if I have a strong suspicion and clinically that it refluxes the underlying problem, I’ll typically maximize them on a proton pump inhibitor. And that’s that sometimes is twice a day for the proton pump inhibitor plus the antihistamine as well on top of that. And even then sometimes we’re doing some more like coating agents on the stomach and esophagus as well, even on top of that, to get everything down. But most importantly, when it comes to the reflux or asthma is removing the inciting agent. And so there might be an allergic cause that’s triggering it. And there may be a dietary cause that might be triggering it. And so a lot of times it’s a little bit of trial and error to try to figure out what, so if you remove the inciting agent, a lot of these coughs will slowly start to get better once you keep the reflux at bay or the asthma at bay, and it’ll start to kind of reset itself. Sometimes though the cough, this, you know, the cough inflammation, irritation, triggers this overactive or overexcited nerve problem. And so despite being on maximal allergy or asthma medication, despite being on maximal reflux therapy, sometimes the cough will just continue and continue and continue. And that’s almost like a nerve response. The nerve is overly sensitive to the point where sometimes patients will just take it, inhale a nice cool breath of air and that’ll trigger this cough. And that’s kind of when those over-excited nerve type receptors that I was mentioning earlier get involved, the cough can just continue and continue and continue and that’s where then we start to think about neurogenic cough as a possible diagnosis.

Dr. Undavia:
So yeah, you want to talk about what you do for neurogenic cough?

Dr. Reddy:
So with neurogenic cough, it’s a bit like a diagnosis of exclusion after you’ve tried everything else and make sure there’s nothing else going on. The theory is that the nerve in your throat is excited, overexcited, and that whatever medication you try to use, you’re essentially trying to reset the nerve.

So some of the most commonly used medications that we use for that are gabapentin and amitriptyline. And sometimes we use them in combination. And we usually start off with like a smaller dose, like a baby dose of the medication, and we slowly kind of titrate the dose up until we hopefully get some type of response. So that’s the main medication. There was another medication actually that was undergoing clinical trial that I was actually quite excited about by Merck and it’s actually approved for use in Europe, but recently as of like a couple of months ago, it failed clinical trials for FDA approval in the United States. And so we technically can’t use that on label, but that is an option to potentially use off label in the US as well.

Dr. Smith:
How long do you typically, do you start with gabapentin first, usually? I, yeah, that’s normally my first go-to. Again, a lot of it has to do with patient, um, health age. There’s a lot of different factors that, that weigh into what medication I’ll start, but I’ll normally start with gabapentin and kind of slowly increased until the, and titrate them up until they get to an effective before trying to switch if it doesn’t work or, um, but most people do get, uh, as long as you have kind of dampened down the agent that got them there, whether it was the reflux or the asthma or the science disease, that medication usually is very effective at diminishing the cough to a tolerable or almost absent level.

Dr. Undavia:
We didn’t mention this, but it’s super important in a chronic cough patient is to keep a log because you’re gonna have ebbs and flows. Certain foods like Dr. Smith said might trigger this. And so if you keep a log, it’s sometimes helpful to see on paper what things you were doing before the cough got worse. And those can be helpful in reducing that activity or that food or that exposure to whatever it is.

Dr. Smith:
There are even cough tracker apps and things that you can download that’ll actually listen and record and count how many coughs. So sometimes, especially for patients that have had this ongoing for years, that app can actually be kind of helpful so that you can see a response because people think, oh, no, I’m still coughing. It’s not just a yes or no, it’s how much to, like you may get some response and say, oh, I’m on the right track, my cough is diminishing, or sometimes there’s seasonality effects to it as well. So it really can help with a little bit more history and data finding.

Dr. Undavia:
I think we covered most of the topics, the things that we find in the ear, nose, and throat like Dr. Smith spoke about are easy to fix, whether it’s antibiotics, nasal sprays, oral steroids, antihistamines, those are all easy things. But what we really wanted to convey today is that it is getting rid of the chronic cough. I actually don’t think we have a patient that we haven’t been able to treat, but it sometimes can be frustrating because it is a process and there’s an algorithm. First the patient comes in, we see what they’ve tried, what they haven’t and we go down that route. And it sometimes can be weeks to months of trying that route until you get to a full-court press before you say, okay, that’s not working, let’s try something new. And so it can be a process to go through all of the different options that you have. But there are always options. Sometimes it requires us to just start over and try everything again in a certain order until we can figure out what it is that’s giving you the cough so that we can get it better.

I think we covered most of the things. All right, follow us for more content.

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