Every week I see several patients who complain of a persistent cough. Most of these cases are benign and self-limiting-part of a cold or minor bronchitis. Occasionally, however, the cough persists and acquires a life of its own (also, in the process, it often acquires the life of the singer-auditions, performances, and all!)
Why do we cough, and what can we do about it?
Coughing is a normal and potentially life-saving reflex. It keeps the airways clear of foreign material and allows the lungs to work freely. Normally, small particles such as dust are trapped by the mucus that coats the trachea and bronchi. Using the cilia, tiny hairs which line these tubes, the debris is slowly moved “north,” up the trachea and into the pharynx. Once the offending material is in the pharynx, we can choose to either spit or swallow. But the point is, the airways have been cleared, and the debris-laden mucus is safely out of the way.
If, however, the particle inhaled is too big, or the material accumulating in the bronchi and the trachea is excessive, the cough reflex is triggered. The vocal folds forcefully squeeze together, and pressure below them builds rapidly as the abdominal muscles contract against a closed glottis. Then, suddenly, the vocal folds are blown apart and the cough bursts forth. A mini-hurricane of air is shot out at speeds up to 70 mph. It sweeps past the walls of the airway, (hopefully) carrying any offending material with it, into the pharynx, often out the mouth, and hopefully not into the face of an unsuspecting passer-by.
Dramatic? You bet! But it is not overdramatic to say that without a good cough reflex, most of us would at some point aspirate, block off our respiratory apparatus, and die.
What happens if the cough persists, either triggered inappropriately, or with repetitive and potentially harmful frequency? We know that the vocal folds sustain some trauma during the cough, but normally they are able to withstand it. At risk are singers whose vocal folds are structurally weak: these are prone to hemorrhage. Vocal folds with abnormally dilated blood vessels are vulnerable. The likelihood of hemorrhage increases further when the folds are dry (not enough water!), or the singer is menstruating or taking blood-thinning medications such as aspirin or vitamin E. The cardinal sign of vocal fold hemorrhage is sudden, painless hoarseness after a particularly harsh or persistent cough. If this happens, do not panic, but immediately begin strict voice rest and see your laryngologist as soon as you can, to confirm the diagnosis and to stop the cough.
The other problem is less dramatic but equally distressing: the cough that won’t stop.
This may occur after a viral infection, or for no apparent reason. This is often a cough that is non-productive (i.e. not clearing mucus from the windpipe), tickly, and irritating (to the larynx, the singer, and often her friends). The treatment of such persistent coughing is important, since it does interfere with singing and can unnecessarily traumatize the larynx. Treatment of chronic cough depends on correctly identifying its cause. These causes are multiple and varied. They can include conditions as diverse as bronchitis, postnasal drip, nervous habit, asthma or reactive airway, allergy, chronic tracheitis, and gastroesophageal reflux (GERD). Once or twice a year I will even see a patient whose chronic cough is caused by a hair in the ear canal, tickling the ear drum!
Proper management of a cough, which is a symptom, really depends on identifying and treating its trigger. Treatment of the cough itself should be with a medication which is not excessively drying: drying the airways defeats the purpose and effectiveness of the cough reflex. Most cough suppressants, especially “compounds,” include drying antihistamines and decongestants. So drink a lot of water and consider taking a mucus thinner to help your body rid itself of the irritant.
How can one cough safely and effectively? Just remember the Beach Boys’ song: Good Hydration! (which will of course lead to Good Vibration of the vocal folds). Folds which are hydrated and covered by a mucous film are less likely to traumatize and hemorrhage. Polyps and other injuries are minimized. You may try inhaling steam, or even using a nebulizer with a physiologic solution (such as physiologic saline, or salt water in a concentration similar to that found in body fluids, available at drugstores) to loosen adherent secretions. The nebulizer breaks up salt water particles into tiny droplets that can be inhaled. Of course, don’t overdo this-once or twice a day for three minutes should be enough.
If you sense secretions on the vocal folds, try clearing them with a “silent” cough, only partially closing the glottis and voluntarily expelling air from the lungs. Habitual throat clearing can also be minimized by increased hydration and good nasal hygiene, using a Neti Pot or another nasal irrigation device.
So, cough if you must, but know why and how!
Disclaimer: The suggestions given by Dr. Jahn in these columns are for general information only, and are not to be construed as specific medical advice or advocating specific treatment which should be obtained only following a visit and consultation with your own physician.
