Chronic cough. Who is to blame and what to do?

A dry cough can be a symptom of many pathological conditions in the body, ranging from a mild cold to very serious diseases. If it occurs, you need to consult a doctor for a diagnosis.

Author:

• Galkin Alexey Vladimirovich

  ENT pathology expert

3.33 (Votes: 15)

Coughing is a natural protective reflex of the body, a contraction of the chest muscles in response to the action of any irritant. Normally, it helps cleanse the mucous membranes of the respiratory tract from dust, mucus, and harmful microorganisms.

There are two types of cough: wet (productive) and dry (non-productive). In the first case, sputum is discharged, and the cough ultimately brings relief to the person. In the second, the cough is prolonged and painful, without sputum production, and is perceived by the person as much more painful. Most often, the disease begins with a dry cough, after which it transforms into a wet one, but sometimes this does not happen. A dry cough can be a symptom of many pathological conditions in the body - from a mild cold to serious illnesses. When it appears, even without signs of a cold or any other manifestations, you need to consult a doctor for a diagnosis. This will guarantee quick relief from dry cough, identification of the underlying disease or indication for lifestyle correction.

What is a dry cough?

Depending on its specifics, it can be:

• Long lasting. Usually it doesn't take at least a few minutes.
• Paroxysmal. Accompanied by difficulty breathing, severe wheezing, and a feeling of tightness in the chest.
• "Barking." So named due to its resemblance to the sounds made by animals.
• Suffocating. Accompanied by the inability to breathe air, usually for a few seconds. This is the most dangerous condition that requires urgent help.
• At night. Makes you wake up and doesn't go away for several minutes. Attacks of suffocation may occur.

This classification is needed so that you can describe your symptoms to the doctor in detail. It is important to talk about the time of occurrence of attacks, their duration, pain or absence thereof, impact on adjacent parts of the body, and other details.

Cough is the most common reason for visiting a doctor among respiratory manifestations; its feature is heterogeneity - development as a result of various factors. The scientific literature describes 53 possible causes of cough [1]. Establishing the etiology of cough is extremely important, since it is the elimination of its root cause that largely ensures the success of treatment. Acute cough is most often a symptom of a respiratory viral infection, lasts no more than 2 weeks, can be successfully treated and does not lead to serious complications. The cause of a persistent, difficult-to-treat cough is more difficult to determine, and in some patients there may be more than one factor causing the cough. Even in developed countries with a high level of healthcare, in more than 20% of cases the source of chronic cough remains unknown [1–8].

An intense dry cough as a result of a strong forced release of air from the respiratory tract significantly increases intrapulmonary and intrathoracic pressure, which reduces the flow of air into the alveoli, can contribute to the development of emphysema of the pulmonary tissue, the formation or enlargement of hernias, and has a negative impact on the functioning of the cardiovascular system. A tense cough often contributes to the development of heart rhythm disturbances; rare complications of cough are described as hemorrhages in the brain and retina in patients with vascular pathology. Against the background of increased intrathoracic pressure at the time of coughing, some patients develop bettolepsy - a short-term loss of consciousness or convulsions. In some cases, patients with intense long-term cough complain of fatigue, malaise, insomnia, voice changes, somatic pain, sweating, and urinary incontinence. Thus, persistent long-term cough significantly worsens the quality of life [1-3, 6, 7, 9].

One of the pathological varieties of cough is its reflex form, which is a symptom of a disease outside the pathology of the bronchopulmonary system. Reflex cough is a neurotic condition manifested by a dry paroxysmal cough during the day or night. Over time, a long-lasting cough almost always acquires a reflex character due to changes in the functional state of cough receptors and corresponding nerve centers [4, 5, 9, 10]. Coughing attacks may be accompanied by laryngospasm, a feeling of suffocation, and do not respond well to classical treatment methods. This condition can mimic bronchial asthma or be combined with it.

According to our clinic, in recent decades there has been an increase in patients with reflex cough, which corresponds to a general increase in the frequency of development of various neurotic conditions. A reflex cough can be of both central and peripheral origin, developing accordingly with pathological irritation of the cough center of the medulla oblongata or peripheral receptors of the vagus nerve. A number of researchers indicate that a reflex cough is formed against the background of neurogenic hyperventilation syndrome (HVS), while concomitant pathological processes are provoking factors for its manifestation. This point of view is confirmed by the results of our previous studies. This explains the long-term persistence of reflex cough even after the elimination of the factors that provoke it [4, 5, 9—11].

It is known that HVS is caused by psychogenic or organic (5% of cases) dysfunction of the central nervous system, manifests itself in various clinical disorders and leads to the formation of a stable pathological type of breathing, but to date the reasons for the development and maintenance of this syndrome remain unclear. Hyperventilation - an increase in the depth and frequency of breathing - disrupts gas exchange processes in the lungs, causes excessive release of carbon dioxide, the development of hypocapnia with a decrease in the partial pressure of carbon dioxide in the alveolar air and respiratory alkalosis. Unconscious, too deep and frequent breathing causes such patients to feel a lack of air. It is respiratory alkalosis, along with a decrease in the level of ionized calcium, that causes an increase in the level of neuromuscular excitability, including spasm of the laryngeal muscles, and provokes coughing attacks [9-12].

Signs of a reflex cough are its dry, hacking nature, gradual increase or sudden onset, inability to stop the attack, feeling of lack of air. It is characteristic that patients themselves localize the place of onset of reflex cough in the area of ​​the anterior surface of the neck. Factors that trigger the onset of an attack include deep breathing, talking, stressful situations, smoke inhalation, and fatigue. In addition to coughing, patients are concerned about dryness and sore throat, a feeling of lack of air and a “lump in the throat.” Against the background of HVS, various pathological changes can develop not only in the respiratory tract, but also in the cardiovascular and digestive systems, psycho-emotional status, thermoregulation, as well as motor disorders, tetany [10, 11]. Paradoxical manifestations of hyperventilation syndrome are periodic sighs, arrhythmic breathing, unmotivated yawning, snoring, licking lips, and coughing. Such signs, in the absence of deep respiratory movements, often do not attract the attention of doctors and patients, but can support hypocapnia and respiratory alkalosis [8, 10-12].

A reflex cough can develop against the background of inflammatory diseases of the ENT organs, with unilateral paralysis and paresis of the larynx, prolapse of the membranous part of the trachea, pathology of the pleura, pericardium, thyroid gland, gastrointestinal tract, the presence of a diaphragmatic hernia, increased sensitivity of the body to any substance, including allergies due to taking angiotensin-converting enzyme inhibitors. We observed patients whose trigger for reflex cough was surgery under anesthesia, childbirth, or tracheostomy. A dry paroxysmal cough can persist for a long time in patients after infectious processes such as whooping cough, mycoplasma and chlamydial infections, influenza and others. Against the background of whooping cough (pathogen Bordetella pertus sis

) cough is caused by constant irritation of the receptors of the respiratory tract, which leads to the formation of a focus of excitation of the dominant type in the respiratory center and its preservation for several years. In addition, the neurotropic pertussis toxin affects the cough center in the medulla oblongata and contributes to the formation of a vicious circle. Attacks of spastic whooping cough and post-whooping cough can also be provoked by nonspecific irritants [1-3, 5, 9-12].

Assessing the characteristics and parameters of cough against the background of various diseases helps the doctor make the correct diagnosis for a particular patient. It is necessary to conduct a thorough differential diagnostic search, including with the participation of various specialists - pulmonologist, cardiologist, otolaryngologist, endocrinologist, neurologist, psychiatrist. Undoubtedly, it is difficult to diagnose a type of reflex cough - psychogenic, especially in the absence of any organic disorders and when the patient is confident in the presence of a causative disease of the respiratory tract.

When examining patients with reflex cough during medical history collection, it is extremely important to pay attention to the presence of a chronic psychotraumatic situation, the occurrence of coughing attacks against the background of stress, increased physical or prolonged vocal stress. An attack of reflex cough usually begins with a sharp dryness and soreness in the throat. When performing laryngoscopy, you should pay attention to such characteristic signs as an increased pharyngeal reflex, a wide glottis - 20 mm or more (usually up to 15 mm), spasm of the vocal folds during inspiration, sometimes convulsive closure of the vocal folds, the occurrence of a coughing attack at the time of examination . When studying the function of external respiration, moderate hyperventilation is detected in 1/3 of patients, while in the rest, the indicators remain within normal limits. Additional diagnostic criteria are a positive hyperventilation test and an electromyographic test for latent tetany, a low level of ionized calcium in the blood, and the lack of effect from the use of antitussive drugs [9–11].

The management tactics for such patients are largely determined by the etiotropic factor; if possible, it must be eliminated. It is also advisable to prescribe symptomatic (cough suppressant) and sedative medications. Doctors have at their disposal antitussive drugs of central, peripheral and combined action. Irrational use of antitussive, mucoactive, antibacterial and anti-inflammatory drugs, including hormonal drugs, and repeated diagnostic procedures can contribute to the development of side effects, lead to unsatisfactory results and adverse iatrogenic consequences. Treatment of such patients should be personalized, using pharmacotherapy, non-drug methods, and in some cases the possibility of surgical intervention is discussed [1, 9, 10, 12-15].

Our clinic has accumulated some experience in treating patients with laryngoneurosis in the form of reflex cough. Based on a fairly large volume of clinical data (more than 500 patients), we came to the conclusion that the management of such patients should include identification and elimination of the causative factor, breathing exercises to relieve hyperventilation, sedation and psychotherapy, reflexology - intradermal novocaine blockade of the Zakharyin-Ged zones for larynx and auricular reflexology, B vitamins, calcium supplements as indicated. The doctor needs to establish psychological contact with the patient, explain the mechanism of development of the disease and convince him of the effectiveness of treatment, as well as the absence of the risk of suffocation. The patient’s understanding that all pathological manifestations are caused by an excess, not a lack of air, and strict adherence to the doctor’s recommendations are extremely important for recovery. Breathing exercises involve switching to the diaphragmatic type of breathing, shortening the time of inhalation relative to exhalation by half, and reducing the breathing rate. The method of intradermal novocaine blockade of the Zakharyin-Ged zones for the larynx was developed and patented by an employee of our clinic, Prof. O.Yu. Karpova [16] and is based on the idea that internal organs and their corresponding dermatomes are associated with the same structures of the central nervous system. When exposed through novocaine blockades to skin receptors in the corresponding Zakharyin-Ged zones, inadequate impulses from the pharynx and larynx are reduced, the central pathological dominant is gradually eliminated and the normal function of the interested structures is restored, which is manifested by the cessation of reflex cough.

Currently, in the Clinic of Ear, Nose and Throat Diseases of the First Moscow State Medical University named after. THEM. Sechenov examined and successfully treated more than 500 patients with reflex cough. Clinical manifestations and anamnestic data, as well as a laryngoscopic picture (anatomically wide glottis, spasm of the vocal folds during inspiration, high pharyngeal reflex) confirmed the diagnosis. Considering that the psychogenic factor plays a significant role in the occurrence of reflex cough, 26 patients underwent a psychodiagnostic study using the SMOL-EXPERT computer system.

In 22 cases, a change in personality structure was revealed with a predominance of psychasthenic, hypochondriacal and depressive changes. Internal tension, decreased mood and anxiety, and increased sensitivity to stress were the leading personality traits. In 4 patients, hysterical-hypochondriacal radicals were determined; therefore, they were characterized by anxious and suspicious traits and a predisposition to anxious reactions to any events [17]. Also, before the start of treatment, patients were monitored the level of ionized fraction of calcium in the blood.

All patients underwent complex treatment, including 10 procedures of intradermal novocaine blockade of the Zakharyin-Ged zones for the larynx and auricular reflexology, breathing exercises aimed at relieving hyperventilation, sedatives, muscle relaxants to relieve pathologically increased tone of the laryngeal muscles, calcium supplements as indicated, as well as antitussive drugs.

In 2021, the use of the drug rengalin began as part of complex therapy for patients with reflex cough. Rengalin contains polyclonal, affinity-purified antibodies to bradykinin, histamine and morphine in the form of technologically processed (potentiated) ultra-high dilutions. The drug is release-active, i.e. it has a special modifying activity that is released during the technological processing of the original antibodies. Antibodies to bradykinin, histamine and morphine in a release-active form are capable of changing the activity of endogenous regulatory molecules, and therefore the processes associated with them. A special feature of the drug is its ability to influence the central and peripheral parts of the cough reflex, changing the interaction of endogenous regulators with the corresponding receptors involved in the formation of cough. The components of the drug modify the activity of the ligand-receptor interaction of endogenous regulators (opioids, histamine and bradykinin) with the corresponding receptors; in this case, the combined use of the components leads to an increase in the antitussive effect. In addition to the antitussive effect, the complex drug rengalin, due to its constituent components, has anti-inflammatory, decongestant, antiallergic, antispasmodic and analgesic effects. Unlike narcotic analgesics, it does not cause respiratory depression, drug dependence, and does not have a narcotic or hypnotic effect. Rengalin is indicated for adult patients and children over 3 years of age with acute and chronic respiratory tract diseases, accompanied by cough and bronchospasm, for any cough against the background of influenza and ARVI, acute pharyngitis, laryngotracheitis, acute obstructive laryngitis, chronic bronchitis and other infectious-inflammatory and allergic diseases upper and lower respiratory tract.

In the Clinic of Ear, Nose and Throat Diseases of the First Moscow State Medical University named after. THEM. Sechenov, 15 patients with reflex cough received the previously proposed complex conservative treatment in combination with the innovative drug rengalin. The age of the patients ranged from 28 to 76 years. The duration of the disease history ranged from several weeks to 6 years. 3 patients had concomitant unilateral recurrent laryngeal nerve palsy, 2 had a history of whooping cough. The main complaint of all patients was a prolonged unproductive paroxysmal cough, periodically interrupted by laryngospasms; they were also concerned about a feeling of lack of air and rapid voice fatigue. The severity of cough was assessed by patients on a scale from 0 to 10 during the day and at night, depending on the frequency and intensity of attacks (according to the “Cough Severity Scale”); the provoking factor was also taken into account.

The duration of the study was 10 days, during which patients received Rengalin 2 tablets 3 times a day and filled out a questionnaire, noting the frequency of coughing attacks, the impact of symptoms on daily activity/sleep, recording factors that provoke the development of a coughing attack, monitoring the presence or absence of sputum, as well as voice changes. The average cough severity score at the beginning of treatment was 6.2 points during the day and 3.5 points at night. The most common triggers for paroxysmal dry cough in patients were talking, laughing and physical activity.

All patients showed a significant improvement in their condition on average from the 3rd day of therapy, with the exception of one patient, who on the 8th day of treatment experienced the appearance of acute catarrhal symptoms, as well as stress, against the background of which the severity of the cough began to increase again. Complete recovery was observed in 6 patients on the 10th day of treatment. Our results demonstrate the effectiveness of the drug rengalin against cough of a reflex nature as part of complex therapy.

Thus, in our opinion, the treatment of patients with reflex cough and laryngoneurosis should be carried out by an otorhinolaryngologist who has the necessary skills in diagnosing and treating such a contingent of patients, including methods of reflexology, breathing exercises and psychotherapy. In cases where a reflex cough is only one of the manifestations of severe general neurosis, it is advisable to refer patients for treatment to a psychoneurologist. When a reflex cough is combined with another pathology, its relief is necessary, since the elimination of this pathological symptom facilitates the course of concomitant diseases and improves the quality of life.

The authors declare no conflict of interest.

*e-mail: [email protected] ; https://orcid.org/0000-0001-7414-1293

What diseases can cause cough?

A dry cough can be a consequence of:

• Inflammation of the larynx. At the same time, the sound is “barking”, the voice becomes hoarse, and the attacks themselves more often occur at night.
• Inflammation of the trachea and bronchi. A dry cough lasts 2-3 days, after which it turns into a wet cough and sputum begins to be released.
• Tuberculosis. A cough with tuberculosis does not end for several weeks in a row, despite taking any medications. The cough characteristic of this disease is frequent, dry and hacking, intensifying over time, accompanied by wheezing and sputum, and may be accompanied by hemoptysis.
• Pneumonia. At first it is “barking” and dry; from the 2-3rd day of the disease, sputum begins to be released, sometimes mixed with blood.
• Bronchial asthma. The cough is painful, with attacks of suffocation. The condition is dangerous, as with any attack of suffocation.
• Malignant tumors in the respiratory system. In oncology, the cough may be mild, depending on the type of tumor and its size. Shortness of breath is typical, chest pain and coughing up blood are possible. Any cancer is accompanied by weight loss and weakness.
• Whooping cough. The cough is severe and paroxysmal, often ending in vomiting. It is not blocked by any dry cough medications and can last for several months.
• Corey. Associated symptoms are fever and skin rash.
• Entry of foreign bodies into the respiratory tract. In this case, emergency medical care is important, as the condition can cause suffocation.
• Allergies. An allergic dry cough occurs directly upon contact with an allergen - dust, pollen, gases, chemicals, household chemicals. It can develop in industrial workers through inhalation of dust and small particles. This condition is usually accompanied by an allergic runny nose without other signs of a cold. If there is no exposure to the allergen, it stops.
• Smoking. “Smoker's cough” usually appears in the morning; it can be long-lasting, dry, with poorly separated sputum.
• Pleurisy. The cough is very painful, to the point that it is difficult for a person to change body position and gives off severe pain in the chest. Fever, chills, shortness of breath, and weakness appear.

HOW TO RELIEF A NIGHT COUGH AND RELIEVE AN ATTACK?

Calming a night cough in a child or adult is not an easy, but completely doable task. By following the recommendations listed below, you will significantly improve not only the quality of your sleep, but also your recovery from an illness accompanied by a cough.

• Take care of full nasal breathing. A stuffy nose forces you to breathe through your mouth, which leads to drying out of the mucous membrane of the throat, soreness and... a coughing attack is repeated again and again, as the body tries to moisten the airways in this way, pushing mucus out of the bronchi.
• Lower the room temperature. If your comfortable bedroom temperature is 22 degrees, lower it to 20 degrees. The lower the temperature, the higher the air humidity and the easier it is for you to breathe. But don’t get carried away: an excessive decrease in degrees will have the opposite effect, and the cough will begin due to spasms when inhaling cold air. Don’t forget: during colds, bronchitis and other ailments, the mucous membranes are very sensitive - use your own well-being as an indicator, and not just a thermometer.
• Warm your feet. The feet and bronchi are far from each other, but still within the same circulatory system. The warmer the legs, the greater the blood flow to them and, as a result, its outflow from the upper respiratory tract. This will help calm the cough, easing the swelling of the mucous membranes and making the discharge of mucus from the bronchi more efficient.
• Warm, plenty of drink. It is generally accepted that consuming large amounts of fluid makes sense only in case of viral diseases that are accompanied by an increase in body temperature. But with a wet night cough, drinking plenty of fluids helps no less: compotes and tea that you drink during the day reduce the viscosity of not only blood, but also other liquids, including mucus, which your bronchi try to push out during coughing attacks. Make their job easier: don’t forget to drink more.
• Don't eat at night. A full stomach is one of the provocateurs of night cough, even in a healthy person. Moreover, a late dinner can worsen the condition of bronchitis. Make sure that your last meal is no later than 2 hours before you take a horizontal position and the likelihood that a night cough will interfere with sleep will be much lower.

Diagnosis and treatment

To identify the root cause, your doctor may order the following tests:

• X-ray;
• fluorography;
• bronchoscopy;
• auscultation;
• percussion;
• blood tests for allergens.

The main goal of treating a dry cough is to transform it into a wet cough - productive with sputum discharge. Treatment is complex, using medications, physiotherapy, and in some cases traditional medicine.

Drug therapy includes: antiviral, antitussive, antihistamine, mucolytic agents, antibiotics. It is important to know that taking antitussive drugs without a doctor’s instructions is strictly prohibited - this can cause the accumulation of mucus in the respiratory tract and lead to stagnation of mucus in the lungs, and this will lead to serious complications.

Physiotherapeutic procedures include:

• warming up;
• inhalation;
• UHF;
• acupuncture;
• electrophoresis.

The most common causes of chronic cough

Allergic rhinitis
, untreated non-allergic rhinitis and sinusitis.
This cough is caused by irritation of the nasopharynx with mucus coming from the nasal cavity. Chronic cough in this case is accompanied by constant nasal congestion. Asthma.
One of the most common causes of cough.
The severity of a chronic cough may increase during the cold season, after a cold or other illness. Heartburn.
The reflux of stomach contents into the esophagus and pharynx, characteristic of heartburn, causes irritation of the mucous membrane and leads to a constant cough.
Smoking.
Smoker's cough is a consequence of the development of
chronic bronchitis
, which affects most tobacco product users.
Most often, this cough occurs in the morning and is accompanied by active expectoration of mucus from the bronchi. Less common causes of chronic cough include benign and malignant lung tumors
, emphysema, the development of fungal infections of the respiratory tract,
tuberculosis
, and heart failure.

When is it time to see a doctor?

If the cough becomes persistent, you should consult a doctor. This must be done even if you are sure that you know the cause. If your cough is accompanied by shortness of breath, chest pain, dizziness, or coughing up blood, you should immediately
consult a specialist. To correctly determine the cause of a cough, you may need not only a visit to the doctor, but also the following laboratory tests:

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• Blood test – to look for signs of infection.
• Chest X-ray - to exclude oncological processes in the lungs.
• CT scan of the chest or sinuses - to look for signs of inflammation or swelling.
• Functional tests of the respiratory system - to detect diseases such as asthma or emphysema.
• A visit to a gastroenterologist to rule out the development of acid reflux (reflux of stomach contents into the esophagus and pharynx).
• Bronchoscopy - to check the condition of the bronchi, search for a foreign body or tumor.
• Laryngoscopy – to examine the throat and vocal cords.

How to remove symptoms

When symptoms of the disease appear, a logical question arises - how to treat cough with laryngitis. The first thing to do is to moisturize the mucous membrane. To do this, you need to carry out the following manipulations:

1. Inhalations. They help relieve inflammation and increase the lumen of the larynx. It is effective to carry out steam inhalations (but only if the disease is viral) with sea salt: they dilute and remove mucus, and have bactericidal and anti-inflammatory effects.

2. For non-productive cough, it is recommended to treat with antitussive drugs. It is important to choose non-narcotic drugs (without codeine and morphine), since they do not cause addiction or complications and are allowed for therapy in childhood.

3. The disease can provoke pain in the larynx, therefore, it is recommended to gargle as often as possible with antiseptic solutions or warm water with salt and soda. A child can properly gargle from the age of four.

4. Special spirea and aerosols will help relieve inflammation and eliminate dry mucous membranes.

5. Absorbable tablets will help stop attacks and reduce inflammation of the larynx.

IMPORTANT: Any actions related to the treatment or relief of symptoms of cough with laryngitis should be carried out under the professional guidance of a doctor.

In addition to drug therapy, it is important to consider a few more points:

• drinking plenty of fluids;
• speak quietly, without straining your ligaments;
• protect your throat from the cold;
• stop smoking;
• regularly humidify the indoor air;
• Ventilate the room 2 times a day.

If on the fifth day the cough becomes wet, this is an indicator of proper treatment. Now it is important to choose effective drugs that can quickly remove accumulated phlegm from the lungs.

Treatment of laryngitis cough will be useless if the cause of the inflammatory process in the larynx is incorrectly determined and not eliminated. At the first signs of the disease, it is important to contact a therapist. Timely initiation of treatment will reduce the risk of complications!