Persistent Cough in Adults
Welcome to our Decision Health Guide on Persistent Cough. This guide is designed for people who have been coughing for at least 3 weeks.
Anyone with a persistent cough should be evaluated by a health care provider.
This guide will provide you with the likely possibilities for your persistent cough. You can use this guide either before or after you have been evaluated by a health care professional.
Most people are not concerned about a cough when it first begins, since it is so common to have a cough from a cold or viral bronchitis. At the start of your cough, you may also have had a dripping or congested nose, sore throat, fever, muscle aches, nausea, ear pain, or pink eye. Sometimes bronchitis or other upper respiratory infections result in a long-lasting cough.
When your cough began, did you have any other symptoms that suggest that you had a cold, bronchitis or a viral illness?
The fact that your cough began along with other symptoms of a cold, bronchitis or other upper respiratory infection makes it likely that you have developed ticklish and hyper-reactive airways in your lungs. You may also notice wheezing. Doctors often refer to this persistent cough (with or without wheezing) as "temporary asthma" or "asthmatic bronchitis."
Usually a cough that persists following an upper respiratory illness starts as a viral infection. The long-lasting cough does not mean your infection is still active. After the infection has cleared, your airways can remain irritated during the healing process. The cough (and wheeze) should resolve within a couple months. Sometimes it will last even longer.
Less often, the initial problem was a bacterial infection, such as pertussis (whooping cough) or mycoplasma. In the later stages of one of these bacterial infections, antibiotics are not usually very helpful.
If your cough has already lasted 3 weeks or more, contact your doctor.
If your cough is a lingering symptom from an upper respiratory infection, your doctor may suggest trying an inhaler. Most often doctors prescribe an albuterol inhaler as a short-term treatment to relax your airways and reduce the cough.
Although this is a likely explanation for your cough, let's explore some other possibilities.
Smoking is a leading cause of persistent cough.
Are you currently smoking or did you quit smoking within the past month?
Smoking is a leading cause of persistent cough.
Are you currently smoking or did you quit smoking within the past month?
Excellent. Congratulations on your good decision to not smoke.
It is possible that your cough is from a commonly prescribed medicine:
Angiotensin-converting enzyme inhibitors, commonly called ACE inhibitors, are frequently prescribed to treat hypertension, heart disease, and kidney problems related to diabetes. Examples of medicines in this group are lisinopril (Prinivil, Zestril), benazepril (Lotensin), enalapril (Vasotec), fosinopril (Monopril), moexipril (Univasc), quinapril (Accupril), ramipril (Altace), and trandolapril (Mavik).
ACE inhibitors cause slightly adjusted chemistry in the airways, and they trigger a dry persistent cough in a small fraction of people who use these medicines. The cough usually starts during the first month that the medicine is initiated, but it can occasionally begin much later.
Do you take an ACE inhibitor medicine?
Your cough may be from smoking. Smoking commonly results in a morning cough.
During the day, cigarette smoke deposits particles into the airway mucus. At the same time, toxins in the smoke prevent your airways from moving mucus out of the lung efficiently. So the mucus stays down in the lungs. At night, most smokers take a break from cigarettes because they are asleep. The airways have some time to recover their ability to move the mucus, triggering the cough.
Smoking can also cause extra mucus production, resulting in a chronic cough. This is called chronic bronchitis. It is an important part of chronic obstructive pulmonary disease (COPD), the name for chronic lung damage in smokers. COPD can include chronic bronchitis (airway damage), emphysema (air sac damage), or both problems. The best way to treat chronic bronchitis is to quit smoking. Inhalers and other treatments may also help.
Lung cancer occasionally causes a cough as its first symptom.
Contact your doctor.
As a smoker, your doctor will likely order a chest x-ray if your cough continues to persist or if you are producing dark yellow or green phlegm. Your doctor will want the x-ray right away if you are coughing up any blood.
Since your doctor is going to advise you to quit if you haven't already, take this opportunity to set your quit date now.
Please continue with this decision guide to learn about other reasons that may be contributing to your cough.
It is possible that your cough is from a commonly prescribed medicine.
Angiotensin-converting enzyme inhibitors, commonly called ACE inhibitors, are frequently prescribed to treat hypertension, heart disease, and kidney problems related to diabetes. Examples of medicines in this group are lisinopril (Prinivil, Zestril), benazepril (Lotensin), enalapril (Vasotec), fosinopril (Monopril), moexipril (Univasc), quinapril (Accupril), ramipril (Altace), and trandolapril (Mavik).
ACE inhibitors can trigger a dry persistent cough in a small fraction of people who use these medicines. The cough usually starts during the first month that the medicine is initiated, but it can occasionally begin much later.
Do you take an ACE inhibitor medicine?
One of the most common triggers for a cough is mucus draining down the back of the throat, called post-nasal drip.
Allergic rhinitis (also called hay fever) can cause post-nasal drip with a cough. Some people also produce clear nasal mucus with no allergy trigger, reacting to temperature change or irritants in the air. Nasal symptoms with no allergy trigger are sometimes named "vasomotor rhinitis."
Symptoms that suggest post-nasal drip as a likely cause of your cough might include:
- Frequent nose dripping or discharge
- A frequent need to clear your throat
- A feeling of liquid dripping into the back of the throat
- Nasal congestion
- Allergy symptoms such as sneezing or itchy, red eyes
Do you have any of these symptoms, which are suggestive for post-nasal drip?
The ACE inhibitor is likely to be contributing to your cough and may be the sole cause. Talk with your doctor. You may be able to switch to a different medicine, such as an angiotensin receptor blocker, or ARB. These drugs are similar except they don't usually cause a cough.
If you would like, you may continue with this decision guide to learn about other reasons that may be contributing to your cough.
One of the most common triggers for a cough is mucus draining down the back of the throat, called post-nasal drip.
Allergic rhinitis (also called hay fever) can cause post-nasal drip with a cough. Some people also produce clear nasal mucus with no allergy trigger, reacting to temperature change or irritants in the air. Nasal symptoms with no allergy trigger are sometimes named "vasomotor rhinitis."
Symptoms that suggest post-nasal drip as a likely cause of your cough might include:
- Frequent nose dripping or discharge
- A frequent need to clear your throat
- A feeling of liquid dripping into the back of the throat
- Nasal congestion
- Allergy symptoms such as sneezing or itchy, red eyes
Do you have any of these symptoms, which are suggestive for post-nasal drip?
Even without obvious symptoms of post-nasal drip, you may want to consider trying out a combination antihistamine-decongestant medicine to see if it relieves your cough. Post-nasal drip sometimes causes very subtle symptoms in the nose and throat, and a cough can be the only obvious symptom of allergic irritation in the nose and throat.
Another very common cause of persistent cough is asthma. Usually asthma causes a fairly obvious wheezing noise with your breathing (this can sound like a harmonica note or a raspy noise), and it causes you to feel short of breath.
Do you sometimes make a wheezing noise or feel short of breath?
Your cough is likely the result of irritating mucus or irritants in your throat or nose.
Most people who have these symptoms can relieve their persistent cough by using a combination antihistamine-decongestant medicine, because this can diminish allergy symptoms and reduce nasal mucus production. A prescription nasal spray containing a corticosteroid is another treatment that may help, and some people benefit from using the oral medicine montelukast (Singulair).
Contact your doctor if your cough does not completely resolve with over-the-counter antihistamine-decongestant products.
Click here if you want to learn about other reasons for persistent cough.
Another very common cause of persistent cough is asthma. Usually asthma causes a fairly obvious wheezing noise with your breathing (this can sound like a harmonica note or a raspy noise), and it causes you to feel short of breath.
Do you sometimes make a wheezing noise or feel short of breath?
Without these symptoms, it is not as likely that your cough is caused by asthma. Still, it is possible for a persistent cough to be the only symptom from asthma. If your cough is not easily explained by another diagnosis, your doctor may test you for asthma with breathing tests called "spirometry." Your doctor may also choose to try out an inhaler that is used to treat asthma to see if this relieves your symptoms.
One important trigger of a persistent cough is acid reflux from the stomach (which is known as gastroesophageal reflux disease, or GERD).
Do you have a recurring sour taste in your mouth, or do you frequently notice burning pain (called heartburn) behind your breastbone (sternum)?
You don't have the most obvious symptoms of acid reflux, but you should not discount reflux as a possible cause of your symptoms. By one study's estimate, 40% of people who have a persistent cough that is caused by reflux have their cough without a sour taste and without heartburn.
Your symptoms don't give us obvious clues that direct us to one of the most common causes of a persistent cough. A cough that has persisted for longer than 8 weeks should be evaluated by your doctor, and it is reasonable to have a chest x-ray.
Your cough could be coming from one of the common causes that we have already reviewed, even though you don't have obvious associated symptoms. This is true for most people who have a persistent cough. Among non-smokers who have a normal chest x-ray and who do not take a medicine in the ACE-inhibitor group, 99.4% of persistent coughs arise from either post-nasal drip (or other upper airway irritation), asthma, or GERD (reflux).
You and your doctor can consider treatments for one or more of the common causes to see if your cough improves. Your doctor can also consider rare causes of a persistent cough, with a complete physical exam and additional tests if these seem reasonable.
Your cough may be a symptom of asthma--your other symptoms make this very likely. It is especially likely that your symptoms are from asthma if you have a history of eczema or other allergic rashes, if your symptoms come and go depending upon the season, if your symptoms began as an upper respiratory illness but persisted afterwards, or if you get worse with exposure to cold, chemical smells or fragrances.
You need to be evaluated by your doctor. Asthma symptoms, including cough, can be relieved with inhalers or other medication. In order to diagnose asthma, your doctor may want to do a breathing test to measure how well you move air through your airways. These tests are named "spirometry" tests. Sometimes asthma can be diagnosed by simply trying out treatment with an inhaler that is a usual treatment for asthma, to see if it relieves your cough symptoms.
One important trigger of asthma and cough is acid reflux from the stomach (known as gastroesophageal reflux disease, or GERD). If you have symptoms that suggest you are having reflux, then GERD may be another important thing to consider as a source of your symptoms.
Do you have a recurring sour taste in your mouth, or do you frequently notice burning pain (called heartburn) behind your breastbone (sternum)?
Your symptoms fit well with a diagnosis of allergic asthma.
Call your doctor's office. Let your doctor know if you have had new possible allergic exposures that might have triggered asthma, such as a new pet, a move to a new living location, or a new job location. If you are diagnosed with asthma by your doctor, then treatment can be started even if no allergy or other trigger has been identified.
Some of the other conditions that can cause a persistent cough are very common conditions and some of them are rare. Usually, other symptoms that you may have can direct your doctor toward a diagnosis. If your cough is not explained, you should consider these problems together with your doctor:
- Angina (coronary artery disease)
- Congestive heart failure
- Aspiration of food or saliva due to abnormal swallowing
- Ear problems, such as debris in the ear canal
- Eosinophilic bronchitis, an asthma-like problem that does not quickly improve with bronchodilator inhaler treatments
- Lung cancer
- Bronchiectasis (airway scarring) from a serious prior lung infection
- An abscess in the lung
- Interstitial lung disease
- A vocal cord nodule
- Irritation of the diaphragm
With GERD, stomach acid can move into the esophagus and go all the way to your throat. The acid can then trickle down into your upper airways, causing a persistent cough and/or wheezing. The cough is often more noticeable in the mornings (after you have been lying down) or after meals.
Besides cough, other symptoms of GERD include:
- Sharp or burning chest pain behind the breastbone (heartburn)
- Regurgitation of sour tasting liquid from your stomach
- Swallowing difficulty or pain
- Excessive saliva production
- A feeling of a lump in your throat
- A need to repeatedly clear your throat
Avoiding reflux triggers may help you to minimize your reflux. Common triggers of reflux are smoking, alcohol, fatty foods, peppermint, chocolate, caffeine, and carbonated beverages. You can minimize reflux by eating small meals and eating slowly. You should eat your evening meal well ahead of your bedtime since lying down after eating can promote more severe reflux. Consider putting a rigid foam wedge beneath your mattress or wooden blocks beneath the legs at the head of your bed to raise your head 6 inches above your foot level.
You can also treat acid reflux with antacid medicines.
"H2 blockers" are available over-the-counter or in higher doses by prescription. They reduce the production of stomach acid. Examples include famotidine (Pepcid), ranitidine (Zantac), and cimetidine (Tagamet).
Medications called "proton pump inhibitors" are able to powerfully reduce the quantity of acid that the stomach produces, especially when they are taken in high doses. Examples include omeprazole (Prilosec OTC, Prilosec, or generic omeprazole), esomeprazole (Nexium), lansoprazole (Prevacid), pantoprazole (Protonix), and rabeprazole (Aciphex).
Consider starting treatment of the reflux yourself. See if the cough improves over the next week. You may be one step ahead when you do contact your doctor.
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