Check your cough
Take a quiz to find out why you're coughing.Take cough quiz
Serious Cough or Non-serious Cough? A Doctor's Thought Process When You Walk in with Cough
Read what a doctor thinks about when you walk in with acute or chronic cough.
Posted on April 28, 2017 by Team Medicine after an interview with Dr. Mina Pirzadeh, MD
When a patient has cough, what do you think about first?
A few notes on Dr. Pirzadeh
When a patient has cough, what do you think about first?
In general for cough, there are different ways to classify cough. Most doctors will break it down by duration of symptoms - an acute cough that’s less than 3 weeks vs. a chronic cough, which is anything lasting longer than 3 weeks. The duration is really what determines what the next step is. If it's less than 3 weeks and if they had a clear trigger like a recent cold and now they have a dry cough that's lingering, that's one thing, but for me personally, after someone’s been coughing for a month and there's really no good explanation why, then I would take a chest x-ray to see if there’s anything abnormal that we can pick up on. Through a x-ray, you might see something obviously abnormal like an infection, or an old infection, you treat whatever you might see. We would probably do a chest x-ray first, and then you go on to see for further things, you can a do pulmonary function test. Then for asthma or COPD, if they are having reflux they may or may not know it, there are monitoring things for abnormalities. There is allergy testing and all this other stuff can happen. We do those test before going into more invasive stuff like moving cameras down the throat, CT scans, and stuff like that.
I usually anticipate that their PCP or someone’s ordered a chest x-ray before they get to me. That’s probably the extent of what they’ve done. Most people after coughing for 4 weeks without a trigger or 8 weeks after having a trigger will get a chest x-ray to make sure there is not some smoldering pneumonia that’s there that you can’t really tell from an exam. You would anticipate that they have had a chest x-ray and then that's probably all that they’ve really done at that point. And more likely than not, if they are smoker and have smoking history and they are older, there’s a high chance that they may have gotten a CT scan as well depending on their likelihood of potential malignancies.
It’s basically an inflammation in the upper part of your airway and it leads often times to a productive cough. It doesn’t have to be thick and nasty but usually is. Symptoms can last one to two weeks. They usually take time to resolve. What causes it can be similar like viruses, bacteria, most often it’s a viral thing going on. It’s basically a cough that lasts longer than 5 days and it can be associated with sputum. You can also have wheezing with it.
Bronchitis vs Pneumonia
The key difference lies in the location of where the cough is coming from. For patients with bronchitis, there’s no part of their actual lower part of their lung that has a deep infection - it’s all in the upper part of their airways that has an infection. It’s basically inflammation of your bronchi and it manifests as a cough and sputum. You can manage the symptoms because the majority of these are viruses as opposed to pneumonia which is a cough from a deeper infection of actual lung tissue. Those can be viruses or bacterial, fungal or things. Bronchitis is usually just a viral thing so you can treat the symptoms. The patient really shouldn’t be getting antibiotics for this. Sometimes they get certain medications that are antibiotics, but those medications aren't used to kill bacteria. They are using them for anti-inflammation properties more than anything else.
Asking if they have a wheeze or not can be helpful although sometimes it doesn't truly differentiate. You wouldn't expect someone with reflux to have wheezing or someone with postnasal drip from allergies to have wheezing, but wheezing could point to some type of viral inflammation.
The biggest thing is a change in color of sputum. I'm thinking of older smokers with COPD, they'll have a cough at baseline and it might always be whitish, but then they’ll come in and tell you it's turned yellow or turned green. It's the change in color that people always think about as being a more infectious type. There’s certain bacteria that cause certain color but in practice, I’ve never seen the color of sputum and said that’s a bacteria or a virus, but if they are having thick, yellow-green color, I err more on the bacteria side, but then you can usually pick that up on your x-ray findings. It’s helpful if it's significantly different than what their usual cough. When you get cold and you get snot and the snot is yellow it’s more than likely that it’s a viral problem.
Usually, I try to figure if it’s an infection from your upper airway or down deeper into your lower airways into your lungs. Then i think if it's allergies, or if there is a gastrointestinal reason for the patient to have a cough. What helps me would be the other associated symptoms that can lead to someone's cough. For example, most people don't realize that after a cold, you can have a lingering dry cough for up to six weeks. It sticks around and they get worried that something else is going on.
People who have seasonal allergies can have post nasal drip and that can cause a person to cough. And often they’ll feel the sensation of having a little bit of dripping in the back of their throat.
If the patient has a gastrointestinal issue, I see if they’re having any kind of reflux symptom because acid can trickle up and irritate the back of their throat, causing them to cough and it’s totally not related to the lungs and airways. That’s a big reason people have cough, but is actually from their stomach.
Position matters a lot in this case. People who say “I lay down and cough a lot,” that could be asthma or acid reflux or post nasal drip just because of the laying on the back so it drifts back.
Not gastrointestinal-induced cough or allergies
Then, depending on their risk factors like how old they are or how much do they smoke, I start thinking about an actual lung pathology that's not acute. For example, they could be coughing because of damage over time due to smoking that causes obstruction. In those cases, the patient typically produce sputum all the time along with a chronic cough. If they are not a smoker, I then look at the medications they are taking. Certain medications can make you cough. One of the commonly used ones is an ACE inhibitor, which is a blood pressure medication. I also ask if they cough more at night, because that could be a sign of asthma. But if the patient is having weight loss or night sweats, it could something more serious like cancer.
Thank you again. Our algorithm has an ACE inhibitor induced illness and a post-infectious cough exactly like you said for the 6 weeks. This is so helpful.
At home treatment options
For cough, some people will say they drink honey and lemon tea or stuff like that, but I don’t think that's necessarily geared for cough. It’s more to soothe the throat if they have irritation.
Really it depends on why. If it's post-nasal drip, they should buy over the counter drug like Flonase or an antihistamine. You can also try Guaifenesin, which helps you loosen the congestion up to get it out.
Often people will have really bad cough because they are sick and they can’t sleep at night because their cough is so bad. I would give them cough medicine with codeine just because that’s one of the things that works pretty well.If someone is having a productive cough they feel really congested and feel it’s a wet cough inside, Guaifenesin will help them loosen things up to let it come out. Antihistamines, if they are having sneezing, allergies or runny nose type symptoms, which are decongestant-type stuff. People who have asthma will use their albuterol inhaler and that gets rid of the cough. If they are having reflux like burning after they eat or they feel like a metal taste in the back of their mouth or get epigastric or throat pain and we think it’s reflux, for over the counter, there is antacid medicine.
So in general a lot of those old wives tales like gargling salt water, they are just overall soothing, there isn't really a cough-specific one right?
I would not tell my patients to do that. Usually we just try and target whatever the symptoms are. So if they are having a lot of stuff coming out, we’ll give them cough medicine. If they’re having a runny nose associated with it, we will give them the right antihistamines.
Disclaimer: The article does not replace an evaluation by a physician. Information on this page is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes.
A few notes on Dr. Pirzadeh
Do you have a particular area of interest where you’ve done research and you want to get your thoughts out there?
The research I do is on cardiovascular risk in smokers. I am going to be having a lot of patients who smoke next year, I already do but that’ll be my go-to thing. Oftentimes when your primary care doctor has seen you for your cough. Once it’s reached a point where it’s a chronic thing, they usually will send them to the lung doctors and do the next step in testing which is usually like a pulmonary function test or maybe CT scans and last steps like interventional bronchoscopy.
Dr. Mina Pirzadeh, MD
Physician at Boston Medical Center (BMC)