If you are reading this, you probably have a cough now, or had one in the past that came back. Like all symptoms patients bring to doctors, as a physician, we would need to know how long you have had the cough, what makes it worse, what makes it better, and when it occurs. Do you have asthma or COPD? We would also like to know your full medical history, your age, if you smoke or smoked, and if you have associated symptoms, such as shortness of breath, fever, or chills. Additionally, we want to know what medications you are taking, as those ending in the suffix “pril” used to treat high blood pressure often do cause a cough. And we want to know if the cough is productive of phlegm, or a dry, hacking, tickling in your throat.
A recent cough associated with a cold in a younger person is probably just that, a cold and a cough.
In older people (that is over 40), a cough that is chronic is most commonly a symptom of something wrong with either your cardiovascular system, or your lungs. It might be something else, especially if it comes and goes and is associated with a runny nose. If that is the case, it could be allergy-mediated. The inhalant allergy could be to mold, animal dander, dust mites, trees, grass, and foods, especially dairy products. Interestingly enough, a cough can also be a sign of gastroesophageal reflux disease, where when you lie down, stomach acid trickles into your trachea and causes a cough. The types of coughs usually occur while sleeping or early in the morning.
As the patient trying to diagnose yourself, try to remember that common things are common, and rare things are rare. What we mean is that if you are under 40 and you have a cough and never smoked, it is very unlikely that your cough is cancer or heart failure. If you have been diagnosed with asthma, then your cough is more likely related to asthma than congestive heart failure. If you are older and had numerous bouts of pneumonia and have a productive cough with fever and chills, then your cough could be a recurrent pneumonia or bronchitis. Yes, that means you will have to go see your doctor and get a chest x-ray and blood work.
Similarly, if you have a history of congestive heart failure and have a cough, it might be worsening congestive heart failure that is causing the cough.
As we do with all topics that we delve deeper into, we will look at the more common and serious issues first and then drill down to the less common to get you pointed in the right direction.
Let’s consider patients with no prior persistent cough who are under age 40 and don’t smoke. If you have a nagging cough that just refuses to go away, the first thing to do is determine if it produces sputum. If it doesn’t, that is a good thing. If it does, and the sputum is yellow, brown or green, you will want to see your doctor, because that will likely require antibiotics and a chest x-ray.
If you never had asthma, you could still develop it at any time. If you wheeze with the cough, it might well be asthma. If so, see your doctor and get some pulmonary function tests (blow into a tube) and a chest x-ray, and maybe some blood work.
If you happen to have high blood pressure, look on the medicine bottle and see if the generic name ends in “pril”. If so, have your doctor change it to something else. One of the most common causes of cough that I see, other than an intrinsic lung disease (which will be addressed later), is a blood pressure medicine that ends in the suffix –pril. Be advised that hypertension medication like these, also known as ACE Inhibitors, whether they be lisinopril, accupril, benazepril, or any other medicine ending in “pril”, to treat hypertension can cause a cough. The cough is described as dry,non-productive, hacking cough. This coughing can occur either shortly after the administration of an ACE inhibitor or weeks to months after starting them. Once the medication is stopped, the cough takes 7 to 10 days, and sometimes even longer, to resolve. The good news is that we have other medications, including ARBs (angiotensin receptor blockers) that we can replace the ACE inhibitor to treat your high blood pressure or protect your kidneys from the dangers of diabetes. We should also note that both of these classes of medications are thought to prolong life and quality of life in those afflicted with congestive heart failure, so there is good reason to use them, and they are frequently prescribed. So don’t stop these without consulting with your prescribing physician first.
Though rare, some medications used to prevent clots from forming in newly implanted heart artery stents can cause a cough or shortness of breath. Never stop these without talking with your cardiologist first.
For those over 40 or who might have other health issues, a chronic cough can be a sign of something more worrisome. This is true especially for those who smoke.
In older patients, the most common cause of cough, however, is usually some sort of issue going on with the lungs, but we still have to consider the heart if nothing is found in the lungs.
The most worrisome issue for sudden onset or gradual onset of a cough associated with fever and chills is the presence of pneumonia. These coughs can be productive, but sometimes they are not. If they are productive, they are usually productive of yellow, green, or brown phlegm. Patients afflicted with pneumonia usually have shortness of breath and a fever, and sometimes shaking chills and rigors.
Pneumonia would normally show up on a chest x-ray, although walking pneumonia, frequently caused by a mycoplasma organism, may not show up on a chest x-ray. Sometimes the x-ray abnormalities follows the presence of pneumonia by a day or two.
Pneumococcal pneumonia almost certainly would show up on a chest x-ray and be associated with an elevated white blood cell count, fever, and chills and would need to be treated with appropriate antibiotics. Patients over 50 years of age, and those with diabetes are more prone to pneumococcal pneumonia, one of the more commonly community acquired pneumonias. Though the vaccine to prevent it is recommended in many patients, sometimes it still occurs.
There are many types of pneumonia. Some are caused by bacteria that can be treated with antibiotics, and some pneumonias are viral in origin. Though therapy for viral pneumonias is progressing, antibiotics don’t treat a viral cause. It is important to understand that a pneumonia that started as a virus can decompensate and progress to a bacterial pneumonia, making the situation worse. It might require blood tests, a chest x-ray and a sputum sample to distinguish between a bacterial and viral cause of pneumonia. If you are given antibiotics by your doctor for pneumonia and start feeling better, resist the temptation to terminate the therapy early, because this might result in a sort of super pneumonia relapse.
Chemical exposure and allergen exposure can cause a chronic cough that is often associated with wheezing. The cough may or may not be productive. Patients can be sensitive to mold, pet dander, dust mites and other allergens. These coughs tend to come and go and are associated with shortness of breath and wheezing. If that is the case, then you might need to see an allergist. Rarely would that sort of cough need antibiotics, though inhaled steroids and beta agonist inhalers might be indicated. This is a discussion you will have to have with your physician once the diagnosis is made.
Chronic obstructive pulmonary disease (defined as just that, or COPD) or recurrent bronchitis, which is a cough associated with expiratory wheezing, are frequent causes of chronic coughs. This is particularly exacerbated in the presence of ongoing tobacco dependence or smoking including marijuana. The presence of emphysema with a history of smoking can result in coughing. Certainly, cystic fibrosis can cause a cough, but that is usually diagnosed in childhood.
If you have a cough that is chronic, you might have chronic bronchitis, particularly if you are a smoker and have underlying lung disease. In that circumstance, you will need to nurture a close relationship with your personal physician and/or a pulmonologist who will prescribe what we call a pulmonary toilet. Pulmonary toilet usually includes inhaled steroids potentially as well as other inhaled medications, which will cause your bronchi to dilate and ease your breathing and reduce your coughing episodes. If you smoke and have a cough, the best thing you can do is stop smoking. You might also be put on medication to reduce the effect of allergens, either in the air or within your home. These would include medications that you might find in Zyrtec or Claritin.
More ominous causes of a cough include chronic circumstances such as bronchiectasis, where you have had previous lung issues and are prone to recurrent bouts of pneumonia and localized areas of bacterial infection within your lungs.
A less common cause of a chronic cough is certainly lung cancer, or metastatic disease to your lungs from cancer located elsewhere. Please do not panic, as these are rare situations. If you are over 40 and you smoke and cough, see your doctor.
Sudden and abnormally fast heart dysrhythmias can precipitate sudden onset of a cough, as can chronic congestive heart failure. This is true particularly at night when you are lying down and have swelling in your legs. As you lie down and the swelling moves from your legs and gets back into your vascular system, it can overwhelm your lungs and precipitate a middle of the night cough that is relieved upon sitting or standing.
Valvular heart disease, such as a leaky mitral valve or a leaky aortic valve can do the same. Diastolic congestive heart failure where your heart is thick and has difficulty relaxing to fill adequately can act much in the same way as can chronic kidney disease, where you are retaining too much fluid.
Pulmonary fibrosis is not a very common disease, but can be the side effect of certain medications to include amiodarone used to treat heart rhythm disorders, and nitrofurantoin used to treat chronic urinary tract infections. This usually takes quite a while to develop, but needs to be monitored for with either one of these medications when either one is prescribed for protracted periods of time. Pulmonary fibrosis is diagnosed by a high resolution CT scan and Pulmonary Function Tests. If you have pulmonary fibrosis, you will need to see a pulmonologist and avoid these medications.
There is also pneumonitis, which is simply inflammation of the lungs. This can be caused by autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus (or SLE), and sarcoidosis (a disease in and of itself). It can also be idiopathic, meaning we are not smart enough to figure out what causes it. It can also be inherited and be a result of exposure to silica and other toxic agents. And again, some medications can cause it.
Mesothelioma is inflammation in nodules in the lining of the lungs against the chest wall. This is usually associated with asbestos exposure.
In days long gone by, chronic tuberculosis caused a chronic hacking cough. Usually this is diagnosed on a chest x-ray and through a tuberculin skin test. On a chest x-ray the radiologist might see abnormalities in the tops (or apexes) of the lungs. Tuberculosis is rather rare these days, and healthcare providers are asked to get TB tests annually.
Patients with a cold can get a cough, but the cough normally only lasts a few days or weeks. If the cough persists, we would encourage you to see your physician to get a chest x-ray and blood work and a CT scan if indicated. If the cough is productive of yellow, green, or brown phlegm and you have fevers, you might likely have pneumonia and need to go to the emergency room or to your doctor as soon as possible.
Sudden pulmonary emboli, which are blood clots traveling from the legs to the lungs, can precipitate a cough as well, but more likely chest pain and shortness of breath.
Fluid around the bag of the heart, called pericardial effusion, can rarely cause a cough. Usually, the chest x-ray will alert the doctor to an enlarged heart, and your feet would likely be swollen. This condition is rare.
Inflammation of the trachea, called tracheitis, can result in a fairly nonproductive cough. This situation can last for days, weeks and months. Some patients get it annually for no obvious reason. It might have to be treated with systemic or inhaled steroids and other allergy medication.
These are not all of the causes of cough, but they are representative of the most common causes of cough, both productive and nonproductive. Recall, if you have a cough that does not resolve, then you need to see a doctor.
There are certainly more esoteric causes of coughs that are not addressed. Any persistent cough needs to be evaluated, particularly when no obvious cause is found. Somewhat rarely, a chronic cough can be a sign of a hiding cancer within the bronchi of the lungs. This is typically true in smokers. Any time you cough up blood, call your physician and call 911 or go to the hospital immediately, especially if it is more than a teaspoon.
We hope this information has helped you understand your chronic cough and makes your visit with your physician more valuable.
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