Cough

Cough is one of the most common reasons for visits to health care providers. Normal coughing is important to keep your throat and airways clear. However, excessive coughing may mean you have an underlying disease or disorder.

Coughs can be dry or "productive" which means that you are bringing up sputum or phlegm when you cough. Coughs can be either acute (typically not lasting longer than two to three weeks) or chronic (lasting longer than two to three weeks).

Acute coughs usually begin suddenly and are often due to a cold, flu, or sinus infection. Coughs from a lung infection such as bronchitis can start out suddenly and then linger on. Other common causes of chronic or ongoing coughs include asthma, allergies (like hay fever called allergic rhinitis) chronic obstructive pulmonary disease (COPD from emphysema or chronic bronchitis), sinusitis leading to postnasal drip, smoking cigarettes or exposure to secondhand smoke, pollutants, and gastroesophageal reflux disease (GERD).

Signs and Symptoms

The symptoms that accompany your cough depend on the underlying cause and may include the following:

• Nasal congestion, headache, or postnasal drip from acute or chronic sinusitis (sinus inflammation)
• Wheezing from asthma
• Heartburn from GERD
• Fever, chills, night sweats from bronchitis, pneumonia, tuberculosis, or other lung infection
• Blood in the sputum or unintentional weight loss from lung cancer
• Chest pain, shortness of breath, or swelling of your legs from fluid retention (called edema) due to congestive heart failure

Causes

• Upper respiratory tract infection like sinusitis or bronchitis
• Lower respiratory tract infection like pneumonia or tuberculosis
• Irritants inhaled into the airway passages like cigarette smoke
• Cold, flu, or other viral infections
• Certain medications called ACE inhibitors (including benazapril, captopril, enalapril, fosinopril, lisinopril, quinapril, and ramipril) which are used for high blood pressure and heart disease
• Allergies, like hay fever (allergic rhinitis)
• Asthma
• Chronic obstructive pulmonary disease (COPD), which is from either emphysema or chronic bronchitis or both
• Aspiration (foreign matter drawn into the lungs)
• Congestive heart failure
• Lung tumor, in rare cases
• Gastroesophageal reflux disease

Diagnosis

Your health care provider will take a detailed history gathering information about the quality of the cough, how long you have had it, symptoms associated with the cough, etc. Your doctor will also conduct a thorough physical examination, paying particular attention to your nasal passages, throat, lungs, heart, and legs. Depending on what is suspected from the history and physical exam, your doctor may order cultures of the sputum (if you have a productive cough that may be bacterial), an electrocardiogram (EKG), lung function tests, or xrays of your chest or sinuses. Whether additional testing is needed will be determined from the results of these initial tests. Most often further testing is not necessary.

Treatment Approach

The goal of treatment is not only to soothe your cough, but to treat its underlying cause.

Your doctor will target the treatment toward that underlying cause if it has been identified. If there is a suspected but not confirmed cause, your doctor may suggest a trial period of certain medications that can help pinpoint the cause (for example, treatment with decongestants or antihistamines for suspected sinus inflammation or treatment with antacids or proton pump inhibitors for suspected GERD).

Other medications that may be prescribed either to relieve the cough or treat the underlying disorder include cough suppressants, inhalers, antibiotics, anithistamines, or expectorants.

A few supplements may be helpful in relieving your cough. Working with an herbalist may allow you to obtain an appropriate regimen of herbs that treat the underlying cause of your cough, especially if it is due to a cold.

Lifestyle

• Quit smoking or don't smoke in the first place
• Stay away from exposure to secondhand cigarette smoke and airborne irritants that may be present in your home or workplace.
• Your doctor may switch you from medications that trigger you to cough. If you take an ACE inhibitor or other medication that seems to bring on your cough, do not stop or make any adjustments to the dose without instructions from your doctor.
• If you have allergies, there are steps you can take to avoid the trigger (called an allergen). See monograph entitled allergic rhinitis for details.
• Cough lozenges or hard candy can help dry, tickling coughs. These should never be given to a child under 3 years old because of the risk of choking.

Medications

Different drugs, listed below, may be used to either relieve your cough or treat your underlying disorder.

• Cough suppressants include dextromethorphan, benzonatate, codeine, and hydrocodone. These medications are used to lessen your cough.
• Decongestants, like pseudoephedrine and phenylephrine, are used to clear a stuffy, runny nose accompanying and contributing to your cough, especially if you have post-nasal drip. These should not be used if you have high blood pressure or for a child under six years old without explicit instruction from your doctor.
• Cough expectorant (namely, guaifenesin and iodinated glycerol) is used to thin secretions and help you bring up phlegm.
• Antihistamines (including brompheniramine, chlorpheniramine, clemastine, dexchlorpheniramine, fexofenadine, hydroxyzine, loratadine, promehtazine, tripelennamine, and triprolidine) are used to relieve symptoms related to allergies.
• Inhaled anticholinergic agent (ipratropium bromide) are used to relax your airways and improve your breathing if your cough is related to asthma, bronchitis, or emphysema.
• Inhaled corticosteroids (beclomethasone, budesnide, flunisolide, fluticasone, and triamcinolone) are used to reduce irritation in the airways
• Intranasal steroids (beclomethasone, budesnide, flunisolide, fluticasone, and triamcinolone) may be used for allergic rhinitis; these medicines reduce swelling and irritation in the nose
• Antibiotics may be prescribed for sinusitis

Nutrition and Dietary Supplements

Because supplements may have side effects or interact with medications, they should be taken only under the supervision of a knowledgeable healthcare provider.

Bromelain
Bromelain supplements may help suppress your cough, reduce nasal mucus associated with sinusitis, and relieve swelling and inflammation caused by hay fever. This supplement is often administered with quercetin.

Iron
One preliminary study suggested that iron supplementation may soothe and even prevent cough associated with a class of medications known as angiotensin-converting enzyme (ACE) inhibitors (such as enalapril, captopril, and lisinopril). ACE inhibitors are medications commonly used to treat high blood pressure and heart failure, but dry cough is a side effect that leads many people to discontinue their use. Despite this encouraging information, it is premature to conclude that taking iron with ACE inhibitors to reduce dry cough is safe or effective.

Plus, it is important to note that taking ACE inhibitors at the same time as iron may diminish the absorption of this nutrient. Therefore, if used together, the two should be taken at least two hours apart. Also, iron is associated with some risk for heart disease. For this reason, it should not be used if you have high blood pressure, heart disease, or heart failure without the consent and supervision of your physician.

Quercetin
Often, bromelain is used together with quercetin, a flavonoid (plant pigment responsible for the colors found in fruits and vegetables). Quercetin has anti-histamine properties and, therefore, may be helpful if your cough is related to allergies.

Zinc
Several important studies have revealed that zinc lozenges may reduce the intensity of the symptoms associated with a cold, particularly cough, and the length of time that a cold lingers. Similarly, nasal zinc gel seems to shorten the duration of a cold. However, zinc nasal spray does not appear to have the same benefit.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care and only under the supervision of a practitioner knowledgeable in the field of herbal medicine. Also, your physician should know about all herbs you are taking or considering taking.

Echinacea (Echinacea angustifolia/E. pallida/E. purpurea)
Echinacea is used to reduce the symptoms and duration of the common cold and flu and to alleviate the symptoms associated with them, such as sore throat (pharyngitis), cough, and fever.

Ephedra (Ephedra sinica)
The decongestant pseudoephedrine is a synthetic version of this herb that has been used traditionally to treat upper respiratory infections. The World Health Organization supports the use of ephedra as part of treatment for the common cold, hay fever, and sinusitis. Because of some serious risks associated with this herb (like stroke and irregular heart rhythm), use of ephedra should only take place under strict guidance and supervision by an herbal specialist and physician and only for short periods of time.

Eucalyptus (Eucalyptus globulus)
Eucalyptus oil acts as an expectorant (loosens phlegm in the respiratory passages). For this reason, it is commonly used to treat colds and coughs. It can be found in many lozenges, cough syrups, and vapor baths throughout the United States and Europe. Herbalists recommend the use of fresh leaves in teas and gargles to soothe sore throats and treat bronchitis and sinusitis. Ointments containing eucalyptus leaves are also applied to the nose and chest to relieve congestion. Eucalyptus oil helps loosen phlegm, so many herbal practitioners recommend inhaling eucalyptus vapors to help treat bronchitis, coughs, and the flu.

Garlic (Allium sativum)
People often use garlic to help reduce symptoms of colds, coughs, and bronchitis. In fact, studies suggest that garlic can help prevent colds and shorten the duration of symptoms (such as cough) once you have a cold.

Ginger (Zingiber officinale)
Ginger is valued around the world as an important cooking spice and is believed to help common cold and flu-like symptoms, which may include cough. Scientific proof of this traditional use is lacking, but it may work for certain individuals. Talk to your doctor about whether it is safe for you to try ginger.

Jamaica Dogwood (Piscidia erythrina/Piscidia piscipula)
Based on clinical experience, a professional herbalist may recommend Jamaica dogwood to relieve cough. It is important to note, however, that there has been little to no scientific research on Jamaica dogwood, so the safety and effectiveness of this herb is relatively unknown. Jamaica dogwood is a potent herb and should be used only under the guidance of a qualified healthcare professional.

Licorice (Glycyrrhiza glabra)
This herb has long been valued as a demulcent (soothing, coating agent) and continues to be used by professional herbalists today to relieve respiratory ailments from allergies, bronchitis, colds, and sore throats.

People who regularly consume large amounts of licorice (more than 20 g/day) may inadvertently raise blood levels of the hormone aldosterone, which can cause serious side effects including headache, high blood pressure, and heart problems.

People with high blood pressure, obesity, diabetes, or kidney, heart, or liver conditions should avoid licorice. This herb should also not be used by pregnant or breastfeeding women or by men with decreased libido or other sexual dysfunctions. Use of any licorice product is not recommended for longer than four to six weeks.

Linden (Tilia cordata/platypus )
Linden flowers may be recommended by an herbalist for colds, cough, or fever.

Lobelia (Lobelia inflata)
Lobelia, also called Indian tobacco, has a long history of use as an herbal remedy for respiratory ailments such as asthma, bronchitis, pneumonia, and cough. Today, lobelia is considered an effective expectorant, meaning that it helps clear mucus from the respiratory tract. Although few studies have thoroughly evaluated the safety and effectiveness of lobelia, a qualified healthcare practitioner may recommend lobelia (usually in combination with other herbs) for the treatment of cough, especially if due to either asthma or bronchitis.

It is important to note, however, that lobelia is a potentially toxic herb. Lobelia can be safely used in very small doses (particularly homeopathic doses), but moderate to large doses can cause serious adverse effects ranging from dry mouth and nausea to convulsions and even coma. Under the guidance of a qualified healthcare practitioner, however, lobelia, in combination with other herbs that affect the respiratory system, is considered relatively safe.

Marshmallow (Althaea officinalis)
A professional herbalist might consider using marshmallow for cough, based on long-standing, traditional use.

Peppermint (Mentha x piperita)
Menthol, the main active ingredient in peppermint thins mucus, and is, therefore, a good expectorant, meaning that it helps loosen and break up the phlegm of productive coughs. It is soothing and calming for sore throats (pharyngitis) and dry coughs as well.

Slippery elm (Ulmus fulva)
Slippery elm has been used as an herbal remedy in North America for centuries including by the Cherokee who used it for coughs and other conditions. In fact, slippery elm has received recognition from the U.S. Food and Drug Administration (FDA) as a safe and effective option for sore throat (pharyngitis) and respiratory symptoms, such as cough.

Stinging nettle (Urtica dioica/Urtica urens)
Stinging nettle may act as an expectorant (meaning that it can loosen and break up a cough). Nettle may also be effective for treating certain individuals with allergic rhinitis (hay fever). This traditional use has had a lot of historical value for individuals. Early studies of people suggest that this historic use is likely scientifically valid. However, while the studies thus far have been favorable, they have not been overwhelmingly so. More research would be helpful. In the meantime, talk to your doctor about whether it is safe for you to try nettle as a possible alternative treatment during allergy season if you are prone to hay fever, which often manifests as cough.

Homeopathy

Although very few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of coughs based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type. A constitutional type is defined as a person's physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

• Aconitum — taken within the first 24 hours of a cough that comes on suddenly, particularly if symptoms develop following exposure to cold weather; this remedy is considered most appropriate for individuals with a hoarse, dry cough who complain of dry mouth, thirst, restlessness, and symptoms that worsen in the cold or when the individual is lying on his or her side.
• Antimonium tartareicum — for wet, rattling cough (although the cough is usually too weak to bring up mucus material from the lungs) that is accompanied by extreme fatigue and difficulty breathing; symptoms usually worsen when the person is lying down; this remedy is generally used during the later stages of a cough and is particularly useful for children and the elderly.
• Bryonia — for dry, painful cough that tends to worsen with movement and deep inhalation; this remedy is most appropriate for individuals who are generally thirsty, chilly, and irritable.
• Causticum — for laryngitis and a cough that cannot dislodge mucus in the chest and may cause the individual to leak urine during coughing fits; symptoms tend to improve with sips of cold water but worsen with cold air.
• Drosera — for dry, spasmodic cough accompanied by sharp chest pain and a tickling sensation in the throat that may cause the individual to gag, choke or vomit; the individual may be hoarse or may perspire in the evenings and symptoms may worsen when the individual is lying down.
• Ipecacuanha — for deep, wet cough—often with gagging, nausea, and vomiting; this remedy is especially useful for bronchitis in infants.
• Phosphorous — for chest tightness associated with a variety of coughs, particularly a dry, harsh cough with a persistent tickle in the chest and significant chest pain; symptoms tend to worsen in cold air and when the individual is talking; this remedy is most appropriate for individuals who are often worn out and exhausted, suffer from unnecessary anxiety (even fear of death), and require a lot of reassurance.
• Rumex — for dry, shallow cough that begins with a tickling sensation in the throat or with the inhalation of cold air.
• Spongia — for harsh, barking cough without mucus production; this type of cough is associated with a tickling in the throat or chest; it tends to worsen when the person is lying down and improves when the individual eats or drinks warm liquids; this remedy is often used if a trial of Aconite was not successful.

Acupuncture

Acupuncturists treat people with coughs based on an individualized evaluation of the excesses and deficiencies of qi (energy flow) located in various meridians as well as an assessment of the quality of food choices. In the case of most coughs, a qi deficiency is usually detected in the lung, spleen, and liver meridians. A variety of other treatments to clear qi blockage in the chest area are also administered. Such treatments may include specialized massage, moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points), breathing exercises, lifestyle counseling, and suggestions about herbal remedies.

Other Considerations

Use the remedies that work best for you and follow the instructions of your health care provider. Be sure to get rest and drink plenty of water.

Warnings and Precautions

Call your health care provider right away if you have any of the following characateristics to or symptoms accompanying your cough:

• Violent cough that begins suddenly
• High pitched sound (called stridor) when inhaling
• Cough that produces blood
• Cough in an infant less than 3 months old
• Shortness of breath or difficulty breathing
• Fever
• Abdominal swelling
• Unintentional weight loss
• Thick, foul-smelling, green phlegm

Prognosis and Complications

Severe coughing can cause rib fractures. If this happens, your provider may investigate the possibility of an underlying bone disorder, such as osteoporosis.

Most causes of cough are very treatable and the prognosis depends on the underlying reason for your cough.

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