From allergies to influenza, colds to coronavirus, a long list of irritants can spur a cough, the body’s natural way of expelling everything from pollen to microorganisms.

It’s not uncommon to have a nagging cough for a few days or even weeks, but once you pass the eight-week mark, your cough is considered chronic. For some people, the discomfort, sleep disruption, worry, and even stress incontinence can go on for many months, years, or even decades.

To learn more about managing this bothersome condition, Bottom Line Health interviewed Rachel Taliercio, doctor of osteopathic medicine (DO), a pulmonologist and codirector of the Chronic Cough Clinic at the Cleveland Clinic.

Bottom Line Health: Chronic cough is one of the most common reasons for people to visit the doctor. What causes a cough to linger for a long time?

Rachel Taliercio, DO: Among nonsmokers, a chronic cough is most often caused by one or more of three conditions:

  • Cough variant-asthma. While most people with asthma experience breathlessness, wheezing, and chest tightness, some have only a cough. Treatment with inhaled corticosteroids, with or without long-acting bronchodilators, or pills called leukotriene modifiers can provide relief from coughing and treat the inflammation caused by asthma.
  • Upper airway cough syndrome consists of chronic sinus irritation or infection, post-nasal drip, and allergies or non-allergens that irritate the upper airway. Treatment may include intranasal steroids, antihistamines, decongestants, or antibiotics.
  • Gastroesophageal reflux disease (GERD). When people have GERD, acidic and nonacidic stomach contents leak into the esophagus, the tube that runs from the throat to the stomach. It can then irritate the nerve that serves both the esophagus and the trachea, the tube that runs from the throat to the lungs. While GERD often causes heartburn symptoms, it can also be silent, causing nothing more than a cough.

BLH: What causes chronic cough in people who don’t have any of these conditions?

Dr. Taliercio: A cough that is unexplained despite looking for and treating the most common causes is called a chronic refractory cough. When we meet such patients at the Cleveland Clinic, we take a thorough history, which can provide valuable clues. The story of the cough is incredibly important. What triggers it? What came before it? What is the character of the cough? What makes it better? Worse?

We also often repeat testing for asthma, upper-airway cough syndrome, and GERD. We have found that initially negative results can turn out to be positive, allowing our interdisciplinary team to treat those conditions.

If that doesn’t explain or address the cough and we have ruled out all known triggers and causes, we think about cough hypersensitivity syndrome if the patient’s history suggests this condition. Often, a chronic cough starts as part of an illness such as bronchitis, but when the illness resolves, the cough does not.

We think that this may be caused by a neural irritation or injury in the throat or larynx (the voice box). Changes in the peripheral and central nervous system may lead to hypersensitization of the cough reflex.

BLH: What treatments are available for patients with cough hypersensitivity syndrome?

Dr. Taliercio: The first approach for nerve-related coughing is called neuromodulation therapy. We use low doses of medications that are normally used for nerve pain to try to calm the nerves in the throat. These drugs, such as tricyclic antidepressants and gabapentin, are used off-label when treating chronic cough.

In a 2014 study, we found that neuromodulators helped 68 percent of patients. For about a third of them, however, the effects of the medication wore off over time. We call this tachyphylaxis. Ideally, if we find a medication that controls the cough, we continue it for six months, but in 27 percent of patients in our study, the cough returned when the medication dosage was lowered or stopped.

If neuromodulation therapy does not provide relief and we suspect that the person is experiencing laryngeal spasm as a component of the chronic cough, we can perform injection therapy with onabotulinumtoxinA (Botox) or a procedure known as a superior laryngeal nerve block. The nerve block uses a combination of numbing medication and a steroid injection.

BLH: Are there any approaches that do not require medication?

Dr. Taliercio: Behavioral cough suppression therapy is very promising. Speech language pathologists (SLP) can help patients regain control of the cough spasms without any need for medication. An SLP may start with strategies to interrupt or prevent the cough. For example, a patient can learn how to alter the sensation of an oncoming cough by using breathing techniques, distraction, forceful swallowing, and even voice therapy. The SLP will also educate the patient on how to reduce laryngeal irritation. That includes eliminating irritants (mouth breathing, smoking, and drinking excessive alcohol and caffeine) and increasing hydration. Chewing gum or sucking on hard candies can help some patients by encouraging more swallowing. Some patients can soothe the larynx by learning how to speak in slightly different ways.

BLH: What advice do you have for patients who are still looking for the cause of their chronic cough?

Dr. Taliercio: You know your body best. When you are reading articles like this and feel like you know what is causing your cough, share that information with your physician. Don’t be afraid to get a second opinion if you’re not finding answers.

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