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Spokane, Washington  Est. May 19, 1883

Simple Cough? Don’t Be Too Sure


Dr. Brian Levine examines sinuses with a fiber-optic camera. Sinusitis is a common cause of cough.
 (Los Angeles Times / The Spokesman-Review)
Shari Roan Los Angeles Times

His ordeal began 24 years ago with an upper respiratory infection. That was when George Gharabeigie began to cough.

And cough and cough.

“At first it was sporadic,” says the Irvine, Calif., man, 59. “But then any time I ate ice cream or had a can of soda, I had uncontrollable coughing. If I had a cold, I would cough and cough. Sometimes it was so bad that, at the end of the day, I had a headache and my chest muscles were sore and ached.”

Over the years, Gharabeigie saw dozens of doctors about his hacking. But the cough persisted.

Experts say that’s not unusual. Cough accounts for an estimated 23 million doctor visits annually, making it the No. 1 reason people see a physician. But even though a cough can take a physical and personal toll, until recently many doctors failed to see it as anything more than the vestige of a recent illness. Nor were they sure how best to diagnose and treat it.

Now, however, cough specialists are crafting treatment guidelines for chronic cough. Research is homing in on the many causes, and two cough specialists recently began publishing an online journal (appropriately named Cough) devoted to the topic. Perhaps most visibly, cough clinics are springing up around the nation, typically at university medical centers.

“For years there were very few of us working in this area,” says Dr. Richard S. Irwin, a professor of medicine and nursing at the University of Massachusetts who pioneered the concept of cough clinics. “It seems all of a sudden it’s becoming a hot area of research.”

But to benefit, patients often must find their way to a doctor who specializes in cough, says Dr. Kaiser Lim, a pulmonologist who studies cough at the Mayo Clinic in Rochester, Minn.

“Cough crosses so many disciplines,” Lim says, “and (nonspecialist) doctors usually aren’t cross-trained in allergy, immunology, pulmonary medicine and gastroenterology.”

Like with other symptoms for which there can be many causes – pain, for instance – it’s not always apparent what is triggering a cough. The most common causes are allergies, asthma, sinusitis, rhinitis and gastroesophageal reflux disease.

Some people may not suspect that their cough is due to asthma, for instance, because they don’t have wheezing and shortness of breath. Likewise, cough can be linked to reflux, in which the contents of the stomach back up into the esophagus, even without the classic symptoms of heartburn and regurgitation.

In a recent study, Lim found that sinusitis, which is inflammation of the sinuses, was the cause of chronic cough in one-third of the patients studied. They typically had no other symptoms, such as a runny nose or headache.

“The shame of it is that many of the people had been coughing due to something you could potentially treat,” Lim says of his study, which was recently presented at the annual meeting of the American College of Chest Physicians. The sinusitis patients had been coughing, on average, for 52 months.

Less common triggers of cough include lung cancer, chronic bronchitis (usually linked to smoking) and pertussis, which in the United States has seen a dramatic upswing in cases in the last year. Even ACE inhibitors, used to treat blood pressure, can cause chronic cough.

A cough can even have multiple causes, further complicating treatment, says Dr. Brian Levine, medical director of a newly opened Cough Center in Mission Viejo, Calif.

And some people seem to simply develop a coughing habit, long after a physiological cause, such as the flu, has disappeared.

“There are many, many causes; that is where the real problem comes in,” Levine says. “There are a lot of excellent physicians, but they don’t have the time to spend on chronic cough. Patients throw up their hands. They don’t know where to turn.”

Coughs cause frustration with the medical system, anxiety about the cause, anger, sleep problems and relationship problems, Lim found in another study presented last month. Among patients younger than 65, one-third of the coughers’ spouses or roommates had to move out of the bedroom.

“One woman had to quit the choir. A gentleman from Chicago fainted every time he coughed. Another man crashed his car in his neighbor’s pool while coughing,” Lim says. “People break ribs. They have hernias. Women have urinary incontinence.”

Irwin has also studied the lifestyle destruction left in the wake of a chronic cough. Studies show that many people with chronic cough suffer for four years on average before receiving successful treatment.

“Cough can be devastating to a person’s quality of life,” he says. He’s known sufferers to quit school, lose jobs or get divorced because of a persistent, hacking cough.

“That’s why we need to get the message out to the public that if the right (doctor) is taking care of you – following cough management protocols that have been developed according to the best available evidence – people have a very good chance of having their cough improved or cured.”

Cough treatment guidelines for the American College of Chest Physicians were released in 1998 and will be published with revisions in the journal Chest. The updated guidelines will have more information on treating cough in children, says Irwin, who helped create the guidelines.

The report, he says, “will cover in detail not only everything you want to know about cough in adults, it covers in a robust way pediatric cough.”

Likewise the American Academy of Allergy, Asthma and Immunology has formed a task force on cough to educate members on the best treatment approaches and to reach out to patients who need help.

“We want to treat patients in the most cost-effective way,” says Dr. Pramod Kelkar, chairman of the task force and a Minneapolis allergist and immunologist. “If you order all the tests in the world, you will find something. But that isn’t cost-effective.”

A simplified, cost-effective approach to cough is the goal of cough centers as well. Levine says he looks for the most common causes and treats the patient or sends him or her to an appropriate specialist if the problem is more serious – for example, if lung cancer is suspected.

Given the proper work-up, coughs are curable in at least 90 percent of cases.

“It’s a new direction in healthcare based on a symptom,” he says. “This is more cost-effective, and it’s a way to coordinate all of the various subspecialties.”

Gharabeigie finally found relief with two inhaled medications prescribed by Levine.

The cough was due to allergies and an acute sensitivity to particles, odors, temperature changes and certain foods. Now he’s happy – and so are his co-workers.

“Everyone around me was getting so annoyed with my coughing. But the lady next to me said, `You’re not coughing anymore,’ ” Gharabeigie says.

“And now I eat ice cream. Nothing triggers my cough.”