Clues About a Cough

When a Cough Isn’t “Just a Cough”
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From a discreet tickle in the throat to a relentless "smoker's cough," coughing is a reflex we can't resist. Though these odd noises that come up the respiratory tract and out the mouth are wordless, they have plenty to tell.

In fact, coughing is the top complaint people bring to doctors' offices. "Coughing is a very general symptom that can reflect minor irritation or serious problems in the airways or the lungs themselves," says internist and pulmonologist Norman Edelman, medical director of the American Lung Association.

So what's your cough saying? Here are five questions that lead to important clues.

How Long Has the Cough Been Going On?

_ Not long; minutes or hours. _

We cough because something irritates the nerves of the respiratory tract. The pest can be fleeting -- a cloud of perfume or bug spray, an inhaled hot chili pepper, water swallowed the wrong way so that it clogs the windpipe. Or it can be something that hangs around longer, like dust, mucus, or stomach acid.

With any cough, first we take a short breath and then the voice box (larynx) closes. The abdominal and chest muscles contract, and pressure builds to release air from the lungs when the larynx reopens -- whereupon whoosh, the fast burst of air whisks through the airways, clearing them. That's important, because invasive bodies in the lower respiratory system can harbor bacteria that cause an infection in the airways or even pneumonia (infection of the lung itself).

For many sudden coughs, the drama ends when the airway is cleared and/or the offending substance goes away.

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_ It's been less than a month. _

The common cold is the number-one reason for "acute" coughs (those lasting less than three weeks). Colds tend to run their course in seven to ten days. But the rule of thumb on the cough that usually accompanies a cold is that it can take as long as two to four weeks to end, says Edelman. That's because airways may continue to be inflamed and sensitive even after the infection has cleared.

Most coughs that come with colds clear on their own without any treatment, research shows.

_ Argh, it's been more than two months now. _

Between one and two months, coughs are considered "subacute" -- they might clear up or they might flag an underlying disease. After eight weeks, a cough is considered "chronic." Among the most common causes of a chronic cough:

  • Upper-airway cough syndrome (UACS), the newish term for postnasal drip syndrome. It's the most common cause of acute and common coughs.
  • Asthma, a constriction of the airways. A top cough-causer for kids, adults get it, too.
  • Chronic obstructive pulmonary disease (COPD). This can take the form of chronic bronchitis (damage to the bronchi or large air tubes) or emphysema (damage to the tiny air sacs deep in the lungs), or both. People who smoke are at highest risk.
  • Gastroesophageal reflux disease (GERD). (The old term "acid reflux" is fading because there's also nonacid reflux.) GERD happens when the stomach content backs up into the esophagus.

In many cases, when the problem is treated, a long-term cough disappears.



When Does the Cough Happen?

I cough at certain times of the year.

Does the cough seem to follow a calendar? Seasonal allergies can affect the airways to produce a cough right along with the most common hay fever symptoms of sinus blockage and eye irritation. Cold weather, especially exercising in it, can trigger a kind of asthma called "hyperactive airways."

I've coughed since starting new blood pressure medication.

A chronic dry cough afflicts 10 to 20 percent of people who take angiotensin-converting enzyme inhibitors (ACE inhibitors) for high blood pressure and heart failure. The cough may appear right away or months after beginning treatment. The throat also feels raw. This cough clears within a week to a few months of changing meds.

I cough before I speak.

Even though coughing is automatic, you can also cough voluntarily (as with blinking and swallowing). Some people develop the nervous habit of throat clearing before they talk -- ahem! -- or during public speaking. The phenomenon is so common that lung experts have given it a name: a "habit cough."

I cough whenever my body wants to; I can't control it.

This is the most common situation. A persistent, uncontrollable cough is usually linked to an underlying disease. More rarely, coughing and throat clearing can be a tic -- a semivoluntary movement that could be suppressed but that people feel a compelling urge to do anyway, partly because doing so brings a brief relaxing sensation.

What Type Is Your Cough? -- Do You Cough up Anything Yucky?

Nope, it's a dry cough.

A dry cough (in which nothing comes up from the lungs but air) is the usual aftermath of catching a cold. Depending on the severity of the infection, it can be muffled or loud, a series of short little coughs or great noisy hacks. Other coughs that are sometimes dry: a smoker's cough in early stages of lung dysfunction or some types of asthma-related coughs.

Yes, I cough up a light (clear to pale yellow) mucus.

Mucus is the stuff that moisturizes your nose and keeps the passages clean. (You might know it as phlegm or sputum -- same stuff.) Colds and the flu tend to produce colorless or pale mucus. Sometimes there's a lot of it, which must be blown out through the nose, coughed up, or swallowed. It's a myth, by the way, that it's bad for you to swallow the gunk.

A cough with excessive mucus (of any color) most days of the month is a key feature of chronic bronchitis.

Yes, I cough up greenish or tan phlegm.

"Green stuff," contrary to commonly held belief, does not particularly indicate a treatable bacterial infection, unless it's accompanied by other symptoms such as moderate-to-high fever or shortness of breath. Coughs producing green phlegm are common after viral infections, which are the most common cause of acute bronchitis. (Studies have found that people with garden-variety bronchitis don't benefit from antibiotics.) If you're worried that green phlegm might be pneumonia, talk to a doctor. If you have other worrisome symptoms, you may need a chest X-ray to check for pneumonia. (People who are over age 65 or who have a chronic lung or heart illness should consider the pneumonia vaccine, which can lessen symptoms if pneumonia develops.)

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The mucus coughed up with chronic bronchitis or emphysema tends to be in the green-brown-tan family. During a COPD exacerbation -- a sudden worsening of symptoms -- the secreted mucus may get thicker, darker, and harder to cough up. That's because the airways are narrowing further.

Yes, I cough up a little red stuff.

Seeing blood (any reddish shade from pink to rust) in mucus warrants consulting a doctor. Sometimes blood-streaked mucus shows up in the smoker's cough associated with COPD. Pneumonia, tuberculosis, and lung cancer are other serious concerns producing bloodied sputum. Frothy pinkish mucus may indicate pulmonary edema, an accumulation of fluid in the lungs' air sacs, which can be caused by a bad lung infection or a problem such as heart failure. Shortness of breath with frothy pink mucus is usually considered an emergency-room situation.

What Does the Cough Sound Like?

It's loud and hacking.

Many smokers write off coughing as the price of their vice; unfortunately this thinking makes them less likely to view a bad cough as a red flag to have checked out. People who smoke should be especially wary of a chronic cough, whether it produces mucus or not, and especially if it's loud and long or raspy.

It's wheezy.

A sound that's a cross between a cough and a gasp for breath is often heard in an asthma cough. It's often worse at night or first thing in the morning, because lying flat helps mucus collect in the airways.

It makes a "whoop."

The sound of a cough comes from the sudden release of air from the lungs after the larynx, which had temporarily closed, reopens. In the disease pertussis, though, the sound comes from the first part of a cough, the inhalation. So desperate and sharp is the gasping for breath that it produces a distinctive whooping noise -- the "whoop" in whooping cough. In adults, the whoop may sound more like long spasms of coughs (a coughing fit). The Chinese call pertussis "the cough of 100 days". "It's a very severe, persistent cough," says Dr. Edelman. "A child can break a rib from coughing so hard."

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Once common, highly contagious, and deadly, pertussis grew rare after a vaccine was developed for it; by 1976, there were just 1,000 cases, the all-time low. (It's the "P" component in the DPT or DTaP inoculation.) But by 2005, some 25,000 cases were reported to the Centers for Disease Control, and estimates of true annual incidence are as high as 2 million -- 28 percent of them in adults. Why? Probably a combination of unfounded concern over vaccine safety and weakening immunity over time since the childhood vaccine. (A booster is recommended for all adolescents and adults up to age 65, especially for those in contact with babies and young children, who are most vulnerable to getting extremely sick from whooping cough.)

Do You Experience Other Symptoms Along With Cough?

Not really.

Sometimes a chronic cough is the only sign of asthma a person experiences. (Others also experience wheezing, tightness in the chest, and feeling out of breath.) Another possibility for a lone cough is gastroesophageal disease. As many as half of people with GERD who cough don't experience its other classic symptoms, heartburn or a bad taste in the mouth.

Cough plus shortness of breath.

Shortness of breath is the major symptom of COPD. Some people experience it only when they exercise or exert themselves (as when walking up a flight of stairs); for others, it's continuous. So if you've got cough you can't shake and it seems harder to catch your breath, get checked. "People often lose 40 percent of their lung function before they notice," says Edelman. "It sneaks up on you over time." In the United States, most people who get COPD are smokers. Worldwide, chronic bronchitis and emphysema can also be caused by air pollution and by breathing fumes from cooking over an open stove. Asthma also causes shortness of breath in some people.

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Cough plus fever.

Fever, with or without chills and night sweats, indicates an infection. This can be a mild viral infection such as a cold or a sign of something more serious, like pneumonia or tuberculosis (TB, a serious bacterial infection of the lungs). Weight loss is another feature of TB.

Cough plus "snorting" and "trickling."

Some people describe postnasal drip -- now known as upper airway cough syndrome -- as "like having a runny nose in the back of your throat." To cope with excessive mucus produced by the sinuses, a person may snort (clear the nose by pulling air and mucus up through it) or feel like they are gagging on a constant trickling sensation at the back of the throat that causes them to try to cough it up. The person might also have bad breath, a constant sore throat, nausea, or vomiting as side effects. The causes of chronic postnasal drip include allergies and sinusitis -- even the changing hormonal levels of pregnancy can be to blame. Depending on the findings of a complete physical exam, the treatments range from nasal irrigation, allergy medications, and antibiotics to surgery.

Cough plus chest pain or heartburn.

In people who have reflux disease, a chronic cough and sore throat may be accompanied by GERD's classic symptoms: a heaviness in the chest or a sensation of something stuck there, or heartburn after eating a heavy meal, lying down, or bending over. Symptoms usually worsen at night, and coughing can disturb sleep.

The Bottom Line: Now What?

A physical exam and diagnostic testing can reveal more clues. A doctor will look at the lungs, for example, for signs of asthma or structural problems such as emphysema or lung cancer. A look at the stomach can confirm GERD, while the sinuses reveal signs of postnasal drip. Other tests that help decide how to treat a cough include pulmonary function testing (to measure how well lungs work), a chest X-ray, a CT scan, and an endoscopy (to examine nasal passages, bronchial tubes, or the esophagus). Often, more than one condition is causing a cough.

The good news: Doctors can pinpoint the problem(s) in the vast majority of cases.

Paula Spencer Scott

Paula Spencer Scott is the author of Surviving Alzheimer's: Practical Tips and Soul-Saving Wisdom for Caregivers and much of the Alzheimer's and caregiving content on Caring. See full bio