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The Lingering Cough

September 15, 2013

So you’ve suffered a recent flu, and despite regaining some of your old pizzazz, you still have a nagging cough that you just can’t shake. What started as a nuisance, has now turned into a mounting concern.

You recall that old joke: What did one casket say to the other? “I hear you coffin.”

Don’t panic!Cough

The cough reflex, which employs a forceful rush of air to clear your breathing tubes, can be triggered by a wide variety of  particles or chemicals. Any throat irritant can lead to a vicious cycle of coughing and stimulate mucus production that results in postnasal drip. A cough that follows respiratory tract infection, such as a common cold or flu, is expected to last for only one or two weeks but can linger for several months. Doctors call this a “persistent post-infectious cough.” Persistent post-infectious cough (PPC) is reported to account for up to 25% of all cases of cough lasting longer than 2 months. The cough results from direct effects of viral infection ( irritating the airway and sensitizing the cough reflex ) or from postnasal drip. Often, patients with postnasal drip cough more at night when they assume a recumbent position. Mucus then drips down the back of the throat, and tickles those nerves responsible for eliciting cough.

Successful treatment of PPC hinges on making an accurate diagnosis. There are many causes of a chronic cough and your doctor needs to carefully consider the most likely source.

My treatment of a lingering cough due to PPC often follows a stepped approach.  Step one is to try antihistamines (eg, brompheniramine, chlorpheniramine, clemastine) or a combined antihistamine-decongestant (eg, brompheniramine-pseudoephedrine). Step two is to use nasal sprays, such as azelastine, steroids, and ipratropium bromide. Steps one and two specifically target irritation of the nose and sinuses.

Cough suppressants such as codeine and dextromethorphan are also used frequently in adults. In children, there is no evidence to support the use of most over-the-counter cough remedies.

Buckwheat honey can reduce the frequency of cough and improve quality of sleep for children with PPC, but honey should not be used in children younger than one year because of the risk of botulism.

Failure to respond to the above treatment, may be due to an irritable ( “hyperreactive” )  airway. Step 3 thus calls for a puffer and oral prednisone.

Cough resistant to the above steps warrants investigation for Bordetella pertussis (whooping cough) and a chest X-ray.

In summary, a lingering cough is not easy to treat. Treatment often involves trial and error. Some treatments, however, are better than others—just consider the following scenario:

The owner of a drug store walks in to find a guy leaning heavily against wall. The owner asks the clerk, “What’s with that guy over there by the wall?”
The clerk says, “Well, he came in here this morning to get something for his cough. I couldn’t find the cough syrup, so I gave him an entire bottle of laxative.”
The owner says, “You idiot! You can’t treat a cough with laxatives!”
The clerk says, “Oh yeah? Look at him, he’s afraid to cough!”


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