It can be hard to get away from the sound of coughing, with cases of infections such as whooping cough and Covid-19 on the rise – on top of the one in ten people who suffer from chronic, or long-term, coughs.
Chronic coughs are so common that last month a joint team from Imperial College London and the University of Manchester, who research and treat the condition launched a project, ‘Let’s Talk About Cough,’ to raise awareness about the impact of the problem on those affected.
A cough is described as chronic if it doesn’t go away after eight weeks, says Jacky Smith, a professor of respiratory medicine at the University of Manchester.
‘It can persist for decades and severely affects a person’s health, quality of life and mental wellbeing.’
There can be many possible causes of a persistent cough from a respiratory problem or viral infection, to an allergy or acid reflux
If you have a persistent cough, always get it checked by your GP.
That’s because there can be many possible causes – from a respiratory problem or viral infection, to an allergy or acid reflux – and management depends on its underlying cause.
So what could be causing your cough and what signs should you look – and listen – out for? We asked the experts…
Hacking cough that does not produce mucus
IT COULD BE: INDIGESTION
If you develop a chronic dry cough that seems to get worse after meals or at night-time, it may be due to acid reflux.
This is where acid from your stomach leaks upwards into your oesophagus (food pipe) – if tiny droplets of stomach acid land on the voice box or throat, they cause irritation and trigger a cough.
Dr Anindo Banerjee, a consultant respiratory physician at Southampton General Hospital, advises sleeping with your bed slightly propped up to help relieve coughing
It’s more likely at meal times because that’s when the stomach produces more acid to help with digestion, and at night-time because lying down allows acid to travel up the food pipe from the stomach. Sometimes it is the only symptom of acid reflux as not everyone suffers heartburn.
For a chronic cough, a lung function test and bronchoscopy (where a tiny camera is used to examine the lungs) should be given first and if these rule out a respiratory cause, then checks for acid reflux may be done. This includes endoscopy (where a tiny camera is used to examine the lining of your oesophagus and stomach) as well as tests of the acid levels in your oesophagus.
TREATMENT: Try to avoid eating after 8pm and sleep with your bed slightly propped up as this will keep acid out of the oesophagus, says Dr Anindo Banerjee, a consultant respiratory physician at Southampton General Hospital.
Antacids and drugs called proton pump inhibitors – available over the counter and on prescription – can reduce the stomach’s acid production.
Dry cough, with coughing fits that can last several minutes; may trigger incontinence
IT COULD BE: HYPERSENSITIVITY
Certain triggers such as pollen or dust can cause hypersensitivity, causing coughing up to 400 times a day
CAUSE: These coughs are not caused by a disease itself, but hypersensitivity – once the tissue in the throat has been irritated by a specific trigger (e.g. pollen, dust or even acid from reflux), it can become hypersensitive and reacts more readily to other triggers that come into contact with it – causing you to cough more regularly in response. Sufferers can cough up to 400 times a day.
‘The cough can spontaneously settle down but can recur many times a day,’ says Ashley Woodcock, a professor of respiratory medicine at the University of Manchester.
‘And because the action of coughing can cause muscles in the pelvis to contract, it can result in incontinence, which is deeply distressing. Some sufferers have even fractured ribs as a result of the intense pressure put on their rib cage caused by coughing, which is very painful.’
TREATMENT: As with all chronic coughs, it’s important all potential triggers are investigated and ruled in or out. ‘Where no specific cause is identified, soothing the cough is the only option – perhaps by sucking a strong menthol lozenge,’ says Professor Woodcock. These help by providing a cooling sensation to the throat, which can help counter the ‘irritation that makes you want to cough’, he says. ‘But the impact in terms of controlling your cough will likely be only partial and only last 20 minutes or so.’
For severe cases, patients seen in speciality centres may be prescribed low-dose morphine, which can be helpful in reducing irritation, though the exact mechanism for how this works is not clear.
Tickly, nagging cough, can be dry or wet (producing mucus)
IT COULD BE: POST-NASAL DRIP
Post-nasal drip is the cause of about 7 per cent of persistent coughs, says Dr Banerjee – it’s caused by a steady trickle of mucus from the back of the sinuses that irritates the throat, so you constantly cough or have to clear your throat.
Normally, we produce up to four pints of clear thin mucus every day from the glands that line the nose and sinuses, which drips – unnoticed – down your throat.
However, when mucus becomes thick or if there is a lot of it – usually due to an allergy or infection – it causes post-nasal drip.
‘As well as feeling the drip you may well also sound congested,’ explains Dr Banerjee. ‘ It can feel like there is a lump in the throat, eased by continually clearing it’.
TREATMENT: Some home remedies are said to reduce postnasal drip – for example, chicken soup and staying generally hydrated can help thin mucus, while propping up your pillows at night means the mucus doesn’t collect in the back of your throat.
Antihistamines and decongestants can often help with postnasal drip caused by sinusitis and viral infections. If it’s due to an allergy, such as an allergy to dust, a steroid nasal spray will ease the inflammation causing the drip.
Administer the drops with the head down and forward, so that the liquid flows into the sinuses – don’t tip your head back or the drops will go straight into your stomach.
But limit the use to a few days, advises Peter Barnes, a professor of thoracic medicine at the National Heart and Lung Institute in London.
‘If used for longer, once you stop you get a rebound effect [when more severe congestion of the nose develops] and the condition gets worse.’
A topical nasal steroid, such as Beconase, may also be used to dampen down the inflammatory responses causing the drip, adds Dr Banerjee.
Tickly cough, usually dry, though some people produce thick mucus
IT COULD BE: POST-COVID COUGH
Some patients suffer a persistent cough up to six months after being infected with a virus such as Covid-19
About 5 per cent of people infected by the Covid-19 virus will suffer a cough long after they have tested negative for infection and cleared other symptoms – some people report still coughing up to six months after. This is because the virus can cause inflammation in the airways and tissue irritation that takes time to heal.
TREATMENT: This cough should slowly disappear. The NHS notes that it can be difficult to control this type of cough but there are a few ways to help, such as drinking a warm drink (honey and lemon) if you feel yourself starting to cough; or sucking a sugary sweet. If it’s a cough that brings up mucus, steam inhalation can help, as can lying on either side as flat as you can to help drain the phlegm.
Breathing physiotherapists can teach exercises in how to control or suppress the cough, explains Dr Banerjee.
Severe hacking cough which usually brings up mucus; loud, high pitched ‘whooping’ sound
IT COULD BE: WHOOPING COUGH
Nearly 5,000 cases of the illness, also known as pertussis or the ‘100-day cough’, have been recorded so far this year by the UK Health Security Agency — more than five times the number recorded across the entirety of 2023.
It’s caused by a bacterial infection of the lungs and airways, which results in symptoms such as a runny nose or congestion, sneezing or fever. And of course is marked by a severe hacking cough and high-pitched intake of breath in between that sounds like ‘whoop’.
The infection is highly contagious – easily passed on to others in the tiny droplets from coughs and sneezes.
Many patients getting whooping cough develop chronic cough for many months or even years, says Professor Woodcock.
TREATMENT: If whooping cough is diagnosed within three weeks of the infection, antibiotics can be given to reduce the length of the infection – although this won’t have much impact on the symptoms. After the three-week mark, people won’t normally need any specific treatment, as they’re no longer contagious and antibiotics are unlikely to help.
The NHS recommends patients get plenty of rest, drink lots of fluids and take painkillers such as paracetamol or ibuprofen for a fever.
Wheezy, chesty crackling cough with a lot of phlegm
IT COULD BE: Chronic obstructive pulmonary disease (COPD) — the collective name for lung conditions, such as chronic bronchitis and emphysema — causes progressive and permanent damage to the lungs.
The damaged airways make more mucus than normal and this builds up – causing an ongoing cough which brings up lots of phlegm. As it affects lung function there can also be wheezing, chest tightness and breathing difficulties. Symptoms are often worse in the mornings and the winter, as they are exacerbated by viruses that affect the lungs.
COPD is commonly caused by smoking, but about 10 per cent of sufferers are non-smokers so it’s more recently been linked with exposure to dust and air pollution. It can be diagnosed with breathing tests such as spirometry (this measures how much air you can breathe in and out), as well as chest scans.
TREATMENT: There is no cure for COPD, but steps can be taken to reduce symptoms or slow the lung damage.
‘The most important steps are to stop smoking, avoid passive exposure and exercise as much as you can ,’ says Dr Edward Nash, a consultant respiratory physician at the George Eliot Hospital in Nuneaton.
Different types of inhalers and other medication can be prescribed depending on the severity of symptoms; these make breathing easier by relaxing and widening your airways, or by reducing inflammation that can lead to flare-ups. Very severe cases may need surgery, such as to remove a badly damaged section of lung to allow the healthier parts to work better, or even a lung transplant.
Dry and chesty with a high-pitched whistling wheeze
IT COULD BE: ASTHMA
One of the most common causes of a persistent cough, asthma causes inflammation of the lungs and airways.
The inflamed, narrowed airways react more readily to irritants – such as pollen, pet dander, exercise or cold air – triggering symptoms to try and get rid of whatever is causing irritation.
While patients often experience a whistling or wheezing sound in the chest in addition to coughing, sometimes a chronic cough is the only symptom – this is known as cough-variant asthma. It’s diagnosed with different breathing tests such as the FeNO test – where you breathe into a machine that measures the level of nitric oxide in your breath, which is a sign of inflammation in your lungs – or peak flow and spirometry, to measure how much air you can breathe out.
TREATMENT: Treatment can help control the symptoms – this mainly involves using inhalers – a blue ‘reliever’ inhaler, containing a muscle-relaxing drug such as salbutamol, is frequently prescribed to immediately relieve wheezing, explains Professor Woodcock.
There are also ‘preventer’ inhalers (containing drugs such as beclomethasone, budesonide or fluticasone) that control inflammation and stop symptoms developing.
Patients now mostly use a combination inhaler to use every day – even if they do not have symptoms – to help stop symptoms occurring and provide long-lasting relief if they do.
‘These are taken once daily (Relvar) or twice (Symbicort, Fostair) daily,’ says Professor Woodcock.
Loud, dry and hoarse cough
IT COULD BE: MEDICATION-COUGH
About 15 per cent of people who take certain medications, such as ACE inhibitors, experience a persistent cough
‘This kind of coughing fit starts as a tickle at the back of the throat after taking medication particularly ACE inhibitors, prescribed for high blood pressure’, explains Dr Banerjee. After stopping treatment the cough can persist for a few weeks.
This happens in about 15 per cent of people who take these medications. It’s thought to be because the drugs stop the breakdown of a naturally-occurring chemical called bradykinin which can cause inflammation – this in turn makes the nerve endings in the lungs more sensitive to irritation.
TREATMENT: Speak to your GP about alternative medication, says Dr Banerjee. Around 90 per cent of users who swap medication clear their cough within a week or so, although it can take up to three months.
Dry and hacking with a kind of bark or rasp at the end of it, coloured phlegm, sore throat
IT COULD BE: INFECTION
Acute bronchitis, an infection of the large airways of the lungs (bronchi), causes them to become irritated and inflamed. This often starts after a respiratory infection, such as a cold.
It brings up thick yellowy/grey or green/rust-coloured mucus and may also cause pain behind the breast bone, a sore throat, wheezing and a blocked nose.
Acute bronchitis itself is usually caused by a virus — but around 5 to 10 per cent of cases are triggered by bacteria; in bacterial infections, the phlegm will be green or rust coloured.
TREATMENT: Bed rest and drinking lots of fluids to prevent dehydration and to thin the mucus, making it easier to cough up.
Over-the-counter products might relieve your cough, although they won’t speed up your recovery from the infection.
Paracetamol will help with headaches, fever and pain. However if you also take over-the-counter cough medicines be aware they also contain paracetamol, so if you are already taking it to relieve your headaches or fever, make sure you don’t exceed the maximum dose.
If you are breathless, feel unwell or the cough lasts longer than a week, or the phlegm coughed up is a green, rusty colour, see your GP.
P.S. RED FLAG SYMPTOMS
Make an appointment to visit your GP if you experience shortness of breath and blood-stained phlegm
A chesty cough accompanied by coughing up blood-stained phlegm and shortness of breath, especially if there is a change in a long-standing cough – along with unexplained weight loss and tiredness – are potential signs of long cancer.
Though this is quite rare, it’s vital you don’t ignore these symptoms.
‘The problem is that it’s possible to mistake symptoms such as constant coughing for a chest infection,’ explains Dr Jesme Fox, medical director of the Roy Castle Lung Cancer Foundation.
‘If you have had a cough for three weeks or more, or your cough has changed or got worse, you must see your GP.
‘Chances are everything will be OK but it’s always best to check because if it is cancer, catching it early can make all the difference.’
