Chronic Cough: Diagnosis, Management, and...It Sucks
A personal journey through a common medical condition
It was happening again. I can feel that tickle in my chest, in my lungs. It was my first year of psychiatric residency, and I had a chronic cough. I was pushing down the cough. Trying to make it stop. My lungs would heave. I had to interview a patient... Embarrassing!
Welcome to The Frontier Psychiatrists newsletter. It is a daily health-themed newsletter, and I am a psychiatrist, but I don't want it to be all about psychiatry. So, the newsletter is not only about that topic. I don't identify with the medical discipline of psychiatry as strongly as I do with being a physician. I care for human health. I evaluate, try to understand, try to empathize, and go through a thought process for any medical condition. We call this process differential diagnosis: Given the presenting symptoms, and the information we know about the person, what is the most likely cause of their problem? How do we drill down, through all the possibilities, to get the right treatment for the right problem? Today's column is about a non-psychiatric condition, chronic cough. Coughing all the time. We could've called it “coughing all the time without an obvious reason for months on end,” but chronic cough sounds… more medical. Now, back to the story, starting with my personal experience with a very chronic cough.
Thankfully, this took place before Covid-19, in the summer of 2011. I say thankfully because back then, a cough didn't mean impending death, nobody wore face masks, and people still blithely went to work acutely sick. I knew I had this chronic cough condition, which wasn’t infectious. I had been coughing, uncontrollably, sometimes leading to, in medical jargon, post-tussive emesis. That means you cough so hard that you end up throwing up. It's gross. It's disruptive. It's embarrassing. It was most days for at least 9 months at that time.
People love to hand me a glass of water. Water goes down your throat, not your lungs, if things are going well.
I went to see several specialists. Since I was coughing, I saw a primary care doctor, who referred me to a pulmonologist. The pulmonologist had me do a breathing test called spirometry, and then another more elaborate breathing test. Then I got a CT scan of my lungs. This revealed nothing wrong with my lungs. It did reveal something wrong with my liver, the very top of which was visible in the CT image. This led to an MRI of my liver.
This was before I knew about psoriatic arthritis it turns out I have had it all along, and this was one of the first signs that something was wrong systemically because they could see it in my liver. Fatty liver infiltrate. I had an elevated liver function test panel as well. Something was wrong.
I was still coughing. It wasn't a problem with my lungs. Chronic cough is a really common condition. I'm a psychiatrist, and even today, I am diagnosing in managing chronic cough, at least the first stages of it, because it's a primary care problem, Psychiatrists are primary care doctors for their patients, not infrequently. Here is a photo of me from that era.
Coughing happens because, in part, of inflammation. In “Acute Cough”—the cough you have abruptly because you are sick with an upper respiratory infection, or inhaled an irritant, etc.— the inflammation is restricted to the large airways.
In both syndromes, cough sensitivity is upregulated, but the inflammation giving rise to cough is localized to the larynx and large airways in acute cough.
However, when thinking about chronic cough, which is a very, very common presenting complaint, this “where does the cough come from” question, requires a broader assessment.
Whilst this is also true of cough-predominant asthma, the origin of cough in chronic disease may also lie in the esophagus, nose, or sinuses leading to errors in diagnosis and treatment.1
The most common causes of chronic cough? Well, there are three, followed by how they cause the problem.
Asthma
Post-nasal drip (otherwise known as “Rhinitis”…a.k.a. inflammation of the inside of the nose!)
Gastro-esophageal reflux disease (GERD)
How do non-lung things cause lung-related coughing?
Asthma causes hyper-reactivity (being ready to cough) in the small airways of your lungs. It’s not just wheezing, it can be coughing also.