In the year 2010, there were one billion physician office visits in the United States. The most common reason for visiting the doctor was not headache, arthritis or diabetes. It wasn’t hypertension, sinusitis or the flu. It was “coughing.”
Coughing is a presenting symptom associated with some underlying disorder that varies from the trivial to cancer. Although it can be very annoying, it’s there to help us rather than to hurt us.
We need the cough reflex for our body to function normally. It clears secretions and foreign matter from the throat, lungs and breathing passages.
Coughing can present itself in various disguises. Doctors often look at coughing through the eyes of their own specialty. To an allergist, it’s a tickle in the back of the throat and a symptom of post nasal drip. To a gastroenterologist, coughing is due to reflux disease; to a psychiatrist it’s a nervous reaction. The infectious disease specialist wants to know if the cough could be due to HIV.
Janet is a 47 y/o advertising executive complaining of a dry cough almost on a daily basis for the previous nine months. She doesn’t have a fever or previous history of an upper respiratory infection. A chest X-ray was normal. She takes Lestril for her high blood pressure and has no other health issues.
Lestril is an ACE inhibitor and one of the side effects of this medication is coughing. Her doctor discontinued that medication and switched her to a different one for her blood pressure. Janet’s cough gradually went away.
For ENT specialists, coughing can be the first sign of laryngitis, sinusitis or cancer. The pulmonologist thinks about bronchitis and viral infections of the lungs and for the thoracic surgeon, cancer of the lungs must be ruled out. The primary care physician (P.C.P.) considers the side effects of medications as culprits.
Below are some questions that doctors ask, which might also be of value to patients with a coughing problem.
WHAT DOCTORS ASK THEIR PATIENTS…
Your doctor wants to know the character of the cough. Is it dry or wet, i.e. productive of sputum (phlegm)? What’s the appearance of the sputum? Is it clear, yellow or blood stained?
Is it seasonal as in allergies or periodic as in asthma attacks? Does the cough wake you up in the middle of the night? Could it be reflux, cancer of the esophagus or something else?
Do you have wheezing, heartburn or a sore throat? Do you have hoarseness, difficulty swallowing or a fever?
What aggravates the cough? Is it made worse after eating/drinking, smoking or speaking? Does pollen, exercise or lying down make the cough worse?
What relieves the cough? Does resting your voice, lozenges, sipping water or medication alleviate the coughing?
Evelyn has had a persistent dry cough since May of 2012. A few months before the onset of the coughing, she had a bad case of the flu with an elevated temperature, muscle aches and an upset stomach that lasted for a several weeks.
She’s been to several specialists, undergoing a variety of tests, costing her time, money with no relief of her problem. She was evaluated and treated by an allergist, gastroenterologist and pulmonologist without success. After much frustration, a laryngologist diagnosed and treated her condition as a neurogenic cough and Evelyn gradually got relief.
One important question the physician wants to know, is whether the cough is associated with other symptoms? Also, the physician wants to know the duration of the cough. How long have you had the cough — Acute, less than three weeks; chronic, more than eight weeks? Does it date from a chest cold or flu as in Evelyn’s case?
SOME CAUSES OF ACUTE COUGH
- Common cold (URI)
- Acute bronchitis
- Allergic rhinitis
- Acute sinusitis
- Flare-up of COPD — Chronic Obstructive Pulmonary Disease
The common causes of acute cough result in symptoms that last less than three weeks and, in general, are not life threatening. Pulmonary embolus and pneumonia are two examples of acute cough that are potentially life threatening illnesses.
SOME CAUSES OF CHRONIC COUGH
- Post nasal drip
- Asthma
- GERD — Gastroesophageal Reflux Disease
- NAEB — Nonasthmatic Eosinophilic Bronchitis
- Post-infectious cough
- ACE inhibitors
- Neurogenic
- Chronic bronchitis
Chronic cough is one that lasts longer than eight weeks. NAEB is sometimes overlooked as a significant cause of chronic cough. The eosinophil is a white blood cell of the immune system implicated in allergic disorders. This diagnosis is made with the finding of these cells (>3%) in the sputum.
SUMMARY
Coughing can be associated with more than one disease process requiring the consultation of specialists making it a challenge to diagnose and treat. Anticipating some of the questions mentioned above might make the doctor’s visit more beneficial for you and for your physician.
Most coughs are of minor concern, often secondary to a URI that lasts less than three weeks.
However, coughing associated with spitting up blood, shortness of breath or weight loss are warning signs urging you to visit your physician.
References:
- CDC; Summary Health Statistics US Adults: National Health Interview Survey, 2012.
- Altman, Kenneth W. et al; Challenging Cough Cases; Otolaryngology — Head and Neck Surgery; August, 24 2015
- Anticaglia, Joseph, R.; The Cough Reflex; 2015