Tuesday, 26 July 2011


Published in Panorama

When Cough Can Be cause for Concern

Cough is a symptom rather than a disease and is a common complaint, shared by children and adults alike. “Even as there are many causes of cough,” says Dr.P.G.Jacob, Physician, Shams Specialist Medical Centre,“while a cough may merely be annoying, it could be an indication of more serious underlying problems requiring medical attention.”

“Cough, in fact is a protective mechanism for us,” explains Dr.Jacob. “It helps in clearing our respiratory tract of some secretions and foreign body; in this sense it is merely an explosive expression of air which helps to free the airways.”

“A cough probably begins with irritation of nerves in the respiratory tract, explains Dr.Jacob. “While a host of conditions can cause cough about a handful of conditions are more frequent. A leading cause of cough irritants getting into the air passages, either through inhalation, as in the case of smoke or dust, or by aspiration as in the case of accumulation of secretions in the upper respiratory tract or even from the abdomen as when acid can come up and get aspirated, or when you vomit – this can get into the windpipe or trachea. All these can cause a cough when you try to expel whatever substance.”

Apart from this, the main causes of cough can be classified into four groups – inflammation, constriction, infiltration and compression, says Dr.Jacob. “Inflammation and infection of the respiratory tract on account of virus or bacteria can bring on conditions like Bronchitis and Bronchiectasis. Chronic Bronchitis is a frequent cause of chronic cough, especially in smokers since their airways get inflamed and there is excessive mucus secretion which is difficult to expel. Also, since they “expect” to cough anyway, very often they miss out an important warning signal for cancer!”

“Bronchiectasis”, explains Dr.Jacob, “ is a lung disease in which cough is one of the most important symptoms of the disease. The bronchial tree is dilated and chronically invaded by bacteria. This is a common condition in individuals with cystic fibrosis and people who have multiple respiratory infections, especially in childhood.”

“Constriction typically happens in problems like Asthma,” continues Dr.Jacob. The broncho-spasms associated with asthma can bring on a cough which is seen in both children and adults. While cough may be the only symptom of asthma in some people, in others, symptoms include wheezing, breathlessness and a constricted feeling in the chest region. Asthma is a serious medical condition that requires diagnosis, monitoring and treatment and if these are done properly, the cough too disappears,” assures Dr.Jacob.

Infiltration refers to cancer cells or tuberculosis bacteria invading the lungs and bronchioles and this can trigger cough. Lung cancer is an uncommon cause of chronic cough in nonsmokers; hence smokers must beware of chronic cough, warns Dr.Jacob.

Cough may result from compression on the trachea due to enlarged lymph nodes or due to aortic aneurysm. Alternatively, outside the lungs some tumour could be pressing on it and cause a cough, explains Dr.Jacob.

Various other conditions also present with cough as a symptom, says Dr.Jacob. “For instance, heart failure can also cause cough. Also people experience cough as a side effect of taking certain drugs. We refer to them as ACE (Angiotensin-converting enzyme) Inhibitor-Induced Cough and these include drugs taken to lower hypertension. In about 10% of high blood pressure patients taking these drugs, we may see a chronic cough which is typically dry and hacking. Once the drugs are withdrawn, the patient’s cough improves and resolves.”

While conditions leading to cough can be seasonal, cough itself is not season-determined, opines Dr.Jacob. Cough is usually associated with viral or bacterial fevers which may be commoner during the winter months. These Post-infectious Coughs may persists for 3 or more weeks and are a result of persisting inflammation after infection and in the normal course of things, will usually go away in time.”

Dr.Jacob cautions, “Haemoptysis is a condition in which the cough brings sputum containing blood. This is a serious condition, symptomatic of infections like pneumonia and tuberculosis or cancer, heart failure and heart conditions. Blood in the sputum, depending on the colour and quantity is a danger signal requiring immediate attention since people can even die of massive, frothy haemoptysis. Having said that, in 20-30% of cases, it is possible that cough brings up streaks of blood in the sputum and cause cannot be found out and it subsides by itself.”

Gastroesophageal Reflux Disease (GERD) is caused when contents from the stomach backs up into the food pipe. This action can trigger chronic cough in adults and children. Often certain items of food may bring on this condition on account of causing acidity, then diet, indirectly becomes a trigger for cough! Most often, people with cough may not be aware that it is due to GERD since they may not experience any other abdominal symptoms, making diagnosis difficult. Also, GERD may be only one of two or more causes for cough. Similarly some people with Bronchial asthma may be allergic to certain foods which can cause an exacerbations of asthma and consequent cough.

Habit Cough can be seen in persons with nervous disposition and Psychogenic cough which again has no apparent cause may be seen in individuals, particularly children who are emotionally and psychologically disturbed.

What circumstances should lead one to seek medical help for cough?
1. If there is prolonged cough for over a week.
2. When cough is accompanied by fever, wheezing.
3. If cough produces sputum which is green, yellow or red.
4. If the cough is chronic as in the case of smokers and asthmatics.
5. If prolonged cough is associated with weight loss.
6. If cough is associated with chest pain while walking and if there is shortness of breath.
7. Cough which is more pronounced at night.

Diagnostic measures, besides history and clinical examination require chest X Ray, testing of sputum and blood count as a first step. If there is infection or any kind of growth, tunour, the X Ray will reveal these conditions. Bronchoscopy may be required to confirm diagnosis. If asthma is suspected, the Pulmonary Function Test has to be done.

Treatment of cough is treating the underlying medical conditions, explains Dr.Jacob. “However, if after all the investigations you find that the cough is only an irritating one with no underlying medical conditions, we treat it for the symptom only. We don’t usually suppress the cough because it is better for the sputum to come out.”

Can cough, by itself, lead to any complications? “Yes, it can,” emphasizes Dr.Jacob.
1. A paroxym of severe cough can cause a Syncope, that is, the person falls down and becomes unconscious. The patient collapses suddenly because of lack of blood supply to the brain, caused by increased pressure due to cough. Once he falls down, blood flow to the brain will be restored and he will get up.
2. People with chronic cough can have hernia, again resulting from the pressure exerted in the region while coughing.
3. Some old people can have fractures of the ribs due to cough.
4. Haemorrhage in the eye is another complication associated simply with the act of coughing which puts pressure on various parts of the body.


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