Causes and Approaches to an Ongoing Cough
- Victoria Wermers, RN,MSN,FNP, PMHNP
- Jan 15
- 8 min read
Updated: 6 days ago
When the Persistent Cough Lingers - The Chronic Cough - Causes and Approaches
A cough that persists beyond eight weeks needs to be investigated. The following provides tips on different causes and approaches to an ongoing, persistent cough.
1. ASTHMA/ALLERGIES
This dry cough can last for weeks—sometimes longer—and tends to recur. The airways become inflamed when exposed to various substances or environmental irritants. The immune system causes hyper-responsive lung tissue, which, in turn, causes cough and sometimes wheezing.
An asthmatic cough is similar (cough variant asthma). Sometimes, people with a history of asthma as a child, exercise-induced asthma, environmental allergies, or those sensitive to the cold get this type of cough as well. Most medical people believe that asthma never really goes away - it goes into "remission" but can get triggered by upper and lower respiratory conditions and allergens. Typically, people with asthma tend to get bronchitis more often than others.
If you do not have a history of allergies or asthma, ask yourself if a close member of your family has any history of asthma or allergies. These often run in families, and it is possible you inherited them. Is the cough seasonal? Do you get a cough at the same time every year? Were you mowing your lawn just before you developed the cough? People sometimes say, "Well, I have never had allergies before". Unfortunately, just because you have never had something before does not mean you cannot develop it in the future.
2. REFLUX AND GERD
Few people think about GERD as the cause of a cough. Acid reflux—the backwash of stomach contents—enters the throat and lungs and sometimes causes a chronic cough. Most of the time, this goes unrecognized: Some people do not even know that they have a reflux problem ("silent reflux"), particularly when it occurs during sleep. Interestingly, GERD is also a little-known cause of recurrent sinus problems.
If you cannot identify the cause of your chronic cough, this is something to consider. If you have not been tested for reflux and think it might be the underlying cause, discuss it with your PCP. You can also try a trial of GERD medication (like Prevacid, Protonix, Nexium, and others.) to see if the cough improves. If it does help the cough stay on for up to fourteen days, then discuss it with your healthcare provider to discuss other options.
3. CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Chronic Bronchitis and Emphysema
Chronic bronchitis and emphysema are fairly well-known long-term progressive forms of lung disease (chronic obstructive pulmonary disease). These problems often cause a long-term nagging cough.
Unlike acute bronchitis, chronic bronchitis's cough is ongoing, keeps returning, and never really disappears. This condition results from swelling and inflammation of bronchial tubes and a loss of tiny hairs (cilia) that line the airway and "sweep" foreign materials from the airways.
Emphysema is caused by the destruction of the tiny sacs (alveoli) in the lungs, where oxygen is absorbed in your lungs, and carbon dioxide is released from the body. With emphysema, there is significant long-term damage in these airways, so no matter how much oxygen goes into the lungs, it cannot be "absorbed" by the lungs to go to the rest of your body. A person with emphysema quickly tires, becomes short of breath, develops a productive cough, and sometimes wheezing. I equate it with a fish's sensation of suffocation outside a fish bowl. You don't want this kind of bronchitis because it lingers, is progressive, and makes breathing very difficult; this leads to misery and associated irritability as it worsens. Some medicines may help with symptoms but do not make the disease go away. This is why you don't want to put smoke or other inhalants in your lungs. You may feel great today and cannot feel the damage taking place, but what about tomorrow?
Smoking, inhaling particulate matter, pollutants, and chemicals, or suffering recurrent respiratory illness over a long period are the most common causes of airway damage in chronic bronchitis and emphysema. And vapers - sorry, but COPD is more common in vapers than non-vapers. You just shouldn't put garbage in your lungs. The body is a well-oiled machine—built to expel garbage.
Signs and symptoms of the above include:
Chronic productive cough for over three months (Coughing up mucus is often worse in the morning).
Fatigue.
Shortness of breath.
Occasional fever and chills.
Chest discomfort
Excess mucus production
Frequent recurrence of symptoms
Because of the excess mucus production, expectorants (e.g., guaifenesin/Mucinex) are often helpful in reducing the excess mucus associated with chronic bronchitis. In addition, prescription steroids and bronchodilators, such as INHALERS, are also very helpful in maintaining optimal lung function.
IF YOU THINK YOU HAVE CHRONIC BRONCHITIS, YOU SHOULD BE EVALUATED BY A HEALTHCARE PROVIDER. THERE ARE MEDICATIONS AND OTHER THINGS THAT THEY CAN DO TO HELP.
If you haven't quit smoking, don't you think it's time to get that monkey off your back? (In fact, you can reverse 90% of smoking damage if you quit in your 30's!). The longer you smoke, the less likely it is that you can quickly reverse the effects of cigarettes. Let's get started!
What about vaping? Let's face it: if you put any foreign substance into your lungs, your lungs will rebel. Studies show that this is not a great option as was once thought. People are getting very sick from it, and there have been a few vape-related deaths. Find something else to do with your mouth, hands, and mind. Don't let these things control you!
4. MEDICATIONS
Certain medications can cause you to chronically cough. Certain common blood pressure medications, ace inhibitors are in this category. Are you on a blood pressure medicine called lisinopril, benzepril, or analapril (or one that ends in “pril”) for high blood pressure? There are other types of medications, such as Flonase (fluticasone), Carvedilol, Simvastatin, Actonel, Fosamax, and Keppra. While less than 10% of people who take the latter medications get a chronic cough, it can happen. Many of these folks develop chronic, dry, hacky coughs and spend A LOT of money and time going from specialist to specialist to determine the cause of their coughing problem. Then suddenly, someone gets the idea to check the patient’s medicine, and low and behold, they are on one of those medicines that can cause such a cough! Some people are just sensitive to these meds. This can suddenly occur even if you have taken the medication for years!
If you think your cough may be caused by your medicine, talk to your healthcare provider before stopping it. Please only stop your medicine after discussing it with your provider!
5. PERTUSSIS - The "Hundred Day Cough"
This is caused by a bacteria. While it is more common in children, adults can and do get pertussis or "whooping cough." Pertussis was starting to decline in the US because of mass, effective vaccinations (TDaP), but cases are once again increasing—partially because the vaccination’s protective effects are “wearing off” much earlier than was anticipated and also because people are declining vaccinations.
Pertussis is also known as “whooping cough”. It is a highly contagious bacterial infection that initially starts with a cold and develops into a bad cough after about two weeks. The person develops a spasmodic cough that causes shortness of breath and a classic “whoop” at the end of each cough. Sometimes, they cough so hard that it brings the victim to their knees, gasping for air or may make them vomit. The cough seems to come in spasms and may last for ten weeks - this is why it is also called the "100-day cough".
A test can be done with a lab to detect it (primarily blood or nasal swabs), but it is still quite expensive. In addition, antibiotics are effective against it, particularly if used before three weeks into the illness. The test is recommended before treatment with antibiotics.
Teens and adults may not present with a bad cough; infants often do not have the cough at all but show periods of apnea – periods where they stop breathing. So it is hard to tell they have whooping cough - By the time a person realizes, it can be too late. This is the reason parents and relatives are asked to get a TDAP when they are going to be around a newborn baby. The preventive vaccine is given only in combination with tetanus vaccination (which is not necessarily a bad thing). Hate “shots”? It's okay, only normal. Just close your eyes, deep breathe and think about the beach!
6. TICS
There are various types of tics. These persistent, recurrent disorders can result in repetitive movement, twitch, or sound.
VOCAL TICS
Vocal Tics: These are manifested by periodic dry coughing "spells." They may sound like a cough or might be manifested by repeated sounds like incessant throat clearing. Oftentimes, a person with these tics is not aware that they are occurring, and when they are aware of them, they can be difficult to control, frustrating and embarrassing for the sufferer. They can be temporary or chronic, occurring several times a day to several times a year, or they may just disappear one day. While tics can and do occur in adults, they are primarily a disorder of childhood.
Why do they occur? These sounds are involuntary. A tic disorder like this - or "psychogenic cough"- occurs in the absence of physical problems. There are a variety of causes - changes in the brain, a response to anxiety, or an inherited disorder. They can be related to positive emotions, may be due to fatigue, stress, and anxiety (particularly social anxiety).
There are several possible approaches that may help with anxiety-related tics:
Mental health approaches to tics:
Relaxation techniques may help.
Stress avoidance
Deep breathing
Relaxation techniques
Behavior therapy
Natural Remedies:
L-theanine—According to the NIH, L-theanine may help with anxiety-related tics by enhancing the calming effect of the natural substance GABA in our brains.
Prescriptive Possibilities From a Healthcare Provider (many are off-label - not approved yet by the FDA - for tics but still sometimes help)
Gabapentin
Clonidine
Guanfacine
Second generation antipsychotic medications (aripiprazole, olanzapine)
Botulinum toxin injection
If you feel you may have tics and they are bothersome, discuss it with your healthcare provider - you can talk about possible options for treatment and support.
OTHER UNDERLYING MEDICAL CONDITIONS THAT CAN CAUSE A COUGH
The following are worse-case scenarios that can cause a chronic cough. Sometimes, folks read these things online and imagine the worst. While it is good to be aware, it is not healthy to live in a "worst-case scenario world." Worry is not healthy.
Most long-term coughs (over eight weeks) are due to a postnasal drip or GERD.
Other, more remote issues that can cause a chronic cough include thyroid problems. Hypothyroidism, an enlarged thyroid or thyroid nodules, can cause an ongoing cough. Usually, lab tests, ultrasounds, or CT scans can help diagnose thyroid disorders. Other disorders include (but are not limited to) the following:
Tuberculosis
Heart failure
Lung cancer
Neuromuscular diseases that may affect swallowing, like ALS and Parkinson's,
Sarcoidosis
Treatment for a short-term cough or cold-related cough is relatively easy. If that is not the cause, consider the other causes: Allergies/asthma, reflux, or medications.
Many people tend to over-worry when they read about symptoms, and they start imagining the worst-case scenario. Most people do not have the "worst-case scenario" ailment. But if you cannot solve the problem or if you have any of the following, I would recommend you see your healthcare provider:
Cough beyond 6-8 weeks a chronic - ongoing and not responding to any treatment (above)
If you have been producing large amounts of mucus
Unintended weight loss
Drenching nighttime sweats
History or symptoms of underlying chronic disease (e.g., asthma, COPD, or GERD)
A cough that comes and goes over weeks - that keeps coming back
Cough accompanied by “whooping.”
Swelling of your ankles
Go to urgent care or ER if you have a sudden onset of:
Sudden shortness of breath
Chest pain (especially if unrelated to cough)
Aspiration of a foreign object or the feeling that you have something you choked on caught in your throat
A sudden, severe, bark-like cough that you cannot control
Purplish/dark pink discoloration of nailbeds along with breathing problems
