Chronic Cough and Asthma: Q and A with Dr. Mark Titi

Coughing is a normal and necessary event. It is part of our body’s cleaning routine for the lungs. It is needed to clear unwanted mucous or phlegm from the breathing tubes and to remove potentially dangerous particles such as dust. It becomes a problem when it is persistent or chronic or when it results in complications such as pain, fatigue and trouble sleeping. For some people cough causes concern about an underlying serious illness. Dr. Mark Titi,of the Allergy and Asthma Center is an allergist, sportsman, skier and all-around outdoorsman. In addition, he has had personal experience with asthma.

Q - Dr. Titi, let's start by defining chronic cough .

Dr. Titi - I would say a chronic cough is a cough that has been persisting for longer than three weeks. Frequently, patients will seek evaluation of a specialist if they have had it for more than one month.

Q - How does a cough work?

Dr. Titi - A cough is a reflex response , as you had mentioned, clearing mucous from the lower respiratory tract. It is a body defense mechanism to remove viruses, bacteria, particulate matter that is irritating. It has to do with a nerve reflex going from the throat, the lungs, and then back to the nerve fibers to the brain. Then this produces a cough, which is a contraction of the diaphragm and other muscles.

Q - Can airways become extra sensitive to such things as cold air or exercise or emotion which would not normally trigger the cough reflex?

Dr. Titi - They can. Usually, patients who have asthma would have trouble with these triggers because their airways are hypersensitive.

Q - Let's talk about some of the most common causes of a chronic cough, in addition to asthma.

Dr. Titi - Asthma is surely high up on the list , and also any type of upper airway problem having to do with the nose or throat. We are usually talking about a prolonged sinus infection as a possible cause, a nasal allergy, or a non-allergic nasal problem that leads to postnasal drip . Nasal problems are number one, number two would be asthma, and number three would probably be gastroesophageal reflux . The last is frequently somewhat of a surprise to the patient because they may not actually have obvious reflux symptoms.

Q - What are reflux symptoms?

Dr. Titi - The most common one is heartburn where patients will feel a burning sensation beneath their sternum. Other symptoms a patient might associate with reflux are tasting acid or some sour material in the back of their throat and frequent belching. In children it may be more of a tummy ache and cough. When asthma is the cause, often the patients have allergies, although there are patients who don't have allergies who do have asthma. Asthmatics can be sensitive to multiple triggers both allergic and non-allergic.

Q - Like what?

Dr. Titi - Exposure to pet dander, dust mite particles, mold spores and pollen, for example would be allergic triggers. Hair spray and perfume would be examples of non-allergic triggers.

Q - During any season?

Dr. Titi - It could be any season. Obviously, pollen causes your spring and fall type allergy or asthma flare-up. During the winter it is more of a problem with dust mites, animal danders and mold within the home or workplace.

Q - I have also read that certain medications such as beta blockers or ACE inhibitors used for blood pressure reduction can cause coughs.

Dr. Titi - Yes. It's much more common with the ACE inhibitor group . A lot of those drugs end in the suffix pril like Lisinopril, and Enalapril. So, one of the first things I would look at when I am examining a patient with chronic cough is to look at their medication list and see if they are on one of these medications because stopping the cough may be as easy as changing to another antihypertensive.

Q - How does the cough affect the body in terms of an ongoing inflammatory process?

Dr. Titi - It certainly can disrupt sleep, which can lead to fatigue and perhaps difficulty with day to day tasks. The inflammation is not usually that global. It is usually located either in the chest, throat, or in the nose itself, or the sinuses. Certainly the chest wall can suffer. People can get to the point where they are having pain in their chest from coughing. In very rare cases they may even suffer a fractured rib.

Q - If that happens, what do you do?

Dr. Titi - That patient should probably be checked for osteoporosis.

Q - But would a chronic cough make someone think of the possibility of asthma?

Dr. Titi - Yes and no. It depends on how much research the patient has done . Also if they have had someone in their family with asthma then they might think their cough is due to asthma.

Q - So when is it important to see your doctor, and which one?

Dr. Titi - A lot of coughs are due to colds, viruses, flu bugs. Those are usually self- limited in that they frequently won't last past one to two weeks. Patients can try over-the counter (OTC) medications, but it is important that patients read the package and information on OTC medications, because there are some interactions with other drugs. But, more commonly there might be interactions with particular medical problems like heart problems or high blood pressure . They can try OTC remedies first and if they are not getting better in a week or two depending on how severe the symptoms are, it would be reasonable to see their doctor if they are still having problems . I would say see your family physician, internist or pediatrician first. If you are still having trouble over the next month or so, if there are complications, if is unclear what is causing the cough then, probably, at that point you should see a specialist.

Q - Like an allergist?

Dr. Titi - Yes, like an allergist. If there is an abnormal chest x-ray or infectious symptoms associated with this then it may be better to see a pulmonologist . But, in general , an allergist should be able to manage most chronic coughs. Sometimes allergists refer to pulmonologists for this problem and sometimes pulmonologists refer to allergists to determine the cause. But, in general an allergist would be a good place to start.

Q - So the nature of the cough can be kind of a mystery and you have to almost be a detective to track down the problem, because there are so many other things that can cause the cough, right?

Dr. Titi - That is true. The list of things that can cause the cough is very long. Like most ailments we diagnose , it's the history that is critically important. It is important that your doctor take a careful history. The doctor should be asking questions related to your nose, your throat, and your chest. Also the presence of fevers, chills and weight loss should be discussed.

Q - That doesn't sound like a short process.

Dr. Titi - No it is not very short but I would say probably in one-half hour or so of intense questioning and a good examination, we usually have a pretty good idea where the cough is coming from. We may then do tests to help confirm our diagnosis.

Q - Does the character of the cough help you in the diagnosis, for example whether it is dry or wet or productive or unproductive or barking or honking?

Dr. Titi - Sometimes it does help. Usually one of the first things I want to know is, is it a dry cough or a wet cough. A wet cough is most likely due to a nasal or sinus problem with drainage. A wet cough could also be due to chronic bronchitis perhaps, in a smoker. Some people who have reflux may have a wet cough because they have excessive mucous at the bottom of their throat near their larynx. A dry cough is more suggestive of asthma and an associated barking type cough is more suggestive of asthma. It is more common in children with asthma in particular . Probably the most helpful thing to know is if the cough is occurring during the night . If the cough occurs within one-half hour of lying down it may be suggestive of a nasal sinus related cough (because when the patient lies down the sinuses are able to drain) and that triggers a cough. If the cough is occurring the in the middle of the night it is a bit more suggestive of asthma as a cause.

Q - How often is chronic cough the only symptom of asthma?

Dr. Titi - I would say in my experience close to 30 to 40%.

Q - Can chronic cough be prevented?

Dr. Titi - That is a good question. If someone has allergies and takes good care of their allergies that may prevent them from getting a chronic cough . If they have asthma and take their medicines regularly they may be less prone to a chronic cough that might sometimes follow a cold. The same thing is true with reflux. If reflux is well treated patients are less likely to develop a chronic cough.

Q - I have heard of cough variant asthma, what is that?

Dr. Titi - It is what you alluded to before, the patient who only coughs, but who doesn't develop shortness of breath or wheezing with their cough. It is fairly frequent as we discussed and it is very common in children. Many years ago it was not readily diagnosed .

Q - So, what do you do? Pick the worst one first and try to curtail that one?

Dr. Titi - Sometimes it may be easy to pick out the most important factor, sometimes it may require further testing perhaps to see if allergies are involved. We may do breathing tests. Usually on the first visit we will do a breathing test and an allergy test. We also collect a detailed history. We often treat one entity at a time but there are some patients who have symptoms to suggest multiple causes and we may treat for two or three things at once.

Q - What other techniques, in addition to a chest x-ray, may be needed to arrive at a cough variant asthma diagnosis?

Dr. Titi - Spirometry is helpful. Spirometry looks at the airways in a dynamic fashion. We can pick up abnormalities in how air passes through the lungs and that can be an important clue to the possibility of asthma.

Q - How does spirometry work?

Dr. Titi - You take a deep breath and you blow out as hard, fast, and long as you can. We usually have the patients repeat these three times so we are sure they are doing it with a good technique.

Q - How does what is known as COPD or chronic obstructive pulmonary disease fit into this diagnostic procedure? Is this outside the practice of an allergist?

Dr. Titi - COPD is not outside the practice of an allergist. COPD mostly occurs when a patient has been smoking for a number of years. There are two main types. There is chronic bronchitis and emphysema. With the chronic bronchitis they have more sputum production, phlegm. The patient who has emphysema has more problems with shortness of breath although there is certainly an overlap in what type of symptoms they have. Asthma type medicines can be helpful. We do see quite a few people who have COPD in our practice.

Q - Once you have diagnosed cough variant asthma, how do you treat it?

Dr. Titi - For milder cases that may only occur with colds or certain exposures a bronchodilator medicine would be helpful such as albuterol. The one that people are most familiar with is the squeeze and breathe albuterol, the quick relieving medicine. They usually have a positive effect for four to six hours after they are used. If the patient is having more frequent symptoms or if we think there are signs of inflammation or swelling or too much mucous in the lungs after examining them and looking at their breathing tests, we may recommend daily preventative medicines. In general, inhaled corticosteroids are the most effective medicines for asthma because they are the best at blocking inflammation.

Q - What about the use of prednisone?

Dr. Titi - Prednisone is very effective for treating inflammatory diseases throughout the body and it is used for more severe exacerbations of asthma. It can in some cases help in sinus conditions or more severe nasal allergies. Most commonly in our practice it is used for asthma flare-ups because it takes down the inflammation quickly, probably over two to four hours. An inhaled steroid medicine may easily take two weeks to reach its peak effect.

Q - Tell me about one of the best ways to test the patient's success; and those red, yellow and green markings on what is known as a peak flow meter.

Dr. Titi - I like to think of the peak flow meter as an asthma thermometer with three zone markings . It's a tube into which patients blow. The green zone indicates that the patient is doing well. The yellow zone is a caution zone and indicates the person may need to change some of their medicines or routine for a while. If patients keep going into the yellow zone we would probably change their plan. If they go in the red zone we may recommend that they start taking a certain medicine and then see us or go to the emergency room. In our practice we try to prevent people from needing the emergency room, but it is still possible they may need an ER visit. Some patients will not use their peak flow meter every day. They may stop using it after a while because they feel better. But if they get a cold or have any other respiratory symptoms then they should start using the peak flow meter more frequently and follow the plan we have worked out.

Q - Speaking of metered dose inhalers, a recent study by the Allergy and Asthma Network, Mothers of Asthmatics, showed that most people do not know how to tell if their metered dose inhaler has run out of medication. Do you think it would be helpful if manufacturers routinely incorporated dose counters into their metered dose inhalers?

Dr. Titi -Yes, it is very difficult to tell how much medicine is left in a partially used inhaler. We now, at least, have two steroid inhalers that have dose counters, Pulmicort and Advair.

Q - This brings up the whole subject of doctor/patient communication as well as those micro/mini package inserts. For example, there are patients who have not been told to rinse out their mouths after using an inhaler such as Advair. Others, who after rinsing, do not know whether to swallow it or spit it out. And still others who assumed they could pick up a nebulizer with their prescription at the drugstore. Before we move on, that is something we did not talk about. Tell me about the nebulizer.

Dr. Titi - A nebulizer creates a fine mist which the patient inhales. It is very easy to use because it does not require coordination in terms of squeezing and breathing. In general, the nebulized bronchodilator medicines like albuterol are at a higher dose than they are in the inhaler so you tend to get a better effect. One of the down sides is that it takes five to ten minutes to nebulize a treatment whereas with a metered dose inhaler you could finish the treatment in a minute or so.

Q - Is a possible solution to this not to leave the doctor's office until you have had the process explained and the opportunity to practice it to demonstrate you know how to do it right?

Dr. Titi - Yes, that is a very good idea. Usually when I prescribe the medication I have my nurse come in if it is the first time and show my patients how to use the device properly. That works well.

Q - What damage or complications can be caused by not treating a chronic cough. You had mentioned the possibility of a rib fracture and you mentioned stress incontinence. Dr. Titi - You can also tear muscles. And I have occasionally seen patients who may develop problems with their back or neck. Also a chronic cough can lead to hoarseness or headaches.

Q - Can it also cause dizziness or fainting?

Dr. Titi - Yes, that is a good point. There is a thing called cough syncope. Syncope means passing out. So there are some patients who do cough so severely they actually pass out. It occurs because they have so much congestion in their chest the blood flow from their heart to brain is diminished

Q - So the so-called chronic cough can be frustrating,painful, exhausting and sometimes seriously debilitating. What's your best advice to those suffering from this chronic cough?

Dr. Titi - I would just encourage patients to first see their family doctor if their cough is persisting for more than one to two weeks. Also, to see their doctors if there are unusual or bothersome symptoms . If they are having problems with their chests getting particularly sore they should see their family doctor. If they are not getting better working with the family doctor or primary care doctor then they should ask to see a specialist to see if the specialist can resolve the cough and determine the cause.

Q - An allergist?

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