Possible Causes and Evaluation of a Lingering Cough

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A persistent cough or a chronic cough is a common symptom with many possible causes. Annoying effects of coughing, such as loss of sleep, sore chest muscles, and leaking urine can affect your quality of life and interfere with your daily activities.

If your cough is lingering, you might also be wondering if it could be something worse than a cold or allergies. What does it mean if you have a cough that just won't go away?

What Is a Persistent Cough?

A persistent cough is defined as a cough that persists for a period of eight weeks or longer. The cough may be dry or productive, in other words, you may or many not cough up mucus (sputum). The cough may also be referred to as "chronic," "lingering," or "nagging."

An "acute" cough, in contrast, refers to a cough that lasts less than eight weeks, such as those that occur with the common cold.

Possible Causes

There are many possible causes of a persistent cough. Though the most common causes are not usually serious, it's important to talk about the less common but significant causes as well, especially for those who are over the age of 50. A significant number of people who are diagnosed with lung cancer are first diagnosed—in error—with some of these more common causes.

The most common causes of a persistent cough include:

  • Postnasal drip from hay fever (allergic rhinitis), sinus infections, nasal polyps, or other conditions is the most common cause of a chronic cough. With seasonal allergic rhinitis, you may note a pattern to the cough, but year round causes of allergies may not suggest a pattern.
  • Asthma - Though people with asthma often have other symptoms, such as wheezing and shortness of breath, in some people with asthma a cough is the only symptom (cough-variant asthma).
  • Acid reflux - Gastroesophageal reflux disease (GERD) is the 3rd most common cause of a chronic cough and is often overlooked. For some people, typical symptoms such as heartburn may not be present, and the only symptom may be a chronic cough. A cough due to GERD is usually worst at night after lying down in bed.

    Other common causes:

    • Smoking - Unfortunately, it is often difficult to distinguish a "smoker's cough" from a cough due to other conditions such as lung cancer.
    • Infection. One fairly common cause of a persistent cough is the lingering cough of whooping cough (pertussis). Children who have been immunized may still get whooping cough and the incidence in adults is increasing. Worldwide, tuberculosis is a very common cause of a chronic cough, and the incidence in the United States has been increasing, especially in immigrants to the country.
    • Some medications, especially a category of drugs used to treat high blood pressure and heart disease. Roughly 10 to 20 percent of people treated with ACE inhibitors develop a chronic cough. Examples include Vasotec (enalapril) and Zestril (lisinopril).
    • Eosinophilic bronchitis
    • A post-infectious cough (upper airway cough syndrome) -  A cough can sometimes linger for many weeks following an upper respiratory infection.
    • Chronic bronchitis - Chronic bronchitis is a form of COPD that often occurs in people who smoke but may also be related to environmental exposures and other factors.

    Less common but important causes of a persistent cough include:

    • Other benign and malignant lung tumors - A chronic cough may occur due to other tumors in the chest such as lymphomas. A persistent cough may also occur due to lung metastases from other cancers such as breast cancer, colon cancer, bladder cancer, and prostate cancer.
    • Lung diseases such as emphysema, bronchiectasis, and sarcoidosis.
    • Fungal infections such as coccidiomycosis, histoplasmosis, and tuberculosis.
    • Inhaling a foreign object
    • Heart failure
    • Sarcoidosis - Sarcoidosis is a poorly understood disease in which granulomas form throughout the body including the lungs. It usually causes a dry cough.

      There are more causes of a persistent cough, but the important point is to note that there are a number of causes and a careful evaluation is needed if your cough is not going away.

      When to Worry

      Many people worry about a chronic cough being a symptom of lung cancer, and this is for good reason. Roughly half of people with lung cancer have a persistent cough at the time of diagnosis, and two percent of people who present to their doctor with a chronic cough will have lung cancer.

      Currently, the average time between the onset of symptoms (such as a persistent cough) and a diagnosis of lung cancer is almost 12 months, and we know that lung cancer is most curable in the early stages.

      There are some ways in which a lung cancer cough can be different, but the truth is that there is much overlap, and you can't really tell from a cough alone whether someone is likely to have lung cancer.

      It's also important to note that a chest x-ray can easily miss lung cancer. A significant number of people who are diagnosed with lung cancer have had a "normal" chest x-ray in the year preceding their diagnosis.

      As a final note about lung cancer, keep in mind that non-smokers get lung cancer too, and lung cancer in never smokers is currently the 6th leading cause of cancer-related deaths in the United States.

      When to See Your Doctor

      It is important to make a doctor appointment if you have a cough that persists, even if you believe there is a reason to explain your cough, such as continued smoking or allergies. You should call your doctor immediately if you experience chest pain, shortness of breath or lightheadedness, or are coughing up blood.

      Questions your doctor may ask include:

      • How long have you been coughing? 
      • Has the cough been worsening?
      • Is the cough steady or does it come and go?
      • Is it worse after meals or is it worse at night?
      • Is the cough dry, or have you been coughing up phlegm (mucus)?
      • Have you coughed up blood?
      • What other symptoms have you been experiencing? For example, fever, shortness of breath, allergy symptoms, wheezing, or unexplained weight loss?
      • What other medical problems do you have?
      • Has anyone in your family had similar symptoms? Do you have a family history of bronchitis, asthma, emphysema, or lung cancer?
      • Do you, or have you ever, smoked?
      • Have you been exposed to secondhand smoke?
      • What medications are you taking (including herbal supplements)?

      Evaluation

      Depending on the severity of your cough, your doctor will first want to control your symptoms to make you feel more comfortable. She will then recommend tests to determine the cause.

      She will first take a careful history, asking you about any risk factors for conditions which may cause a cough as well as whether you have recently traveled. Blood tests may be done to look for any evidence of infection.

      A chest x-ray is often done first, but it's important to note that a chest -ray can sometimes miss the causes of a chronic cough. A CT scan can give further information when looking to see if there is any evidence of a tumor or infection. If you have symptoms of sinusitis, a CT scan of your sinuses may be recommended. Other tests which may be recommended include:

      • Allergy tests
      • Pulmonary function tests to screen for lung conditions such as asthma and emphysema
      • Esophageal pH testing to test for present acid reflux as a possible cause of a persistent cough
      • Bronchoscopy to check for foreign bodies or evaluate your airways for a tumor
      • Laryngoscopy to examine your throat and voice box

      Treatments

      Treatment will depend on the underlying cause, as well as the degree to which your cough is interfering with your day-to-day activities.

      A Word From Verywell

      If you have a chronic cough, the importance of getting checked out can't be stressed enough. It can be frustrating, especially if nothing seems to show up on tests, but hang in there. A chronic cough is not normal.

      Get a second opinion if you do not feel like you are being heard, or if you are not getting answers. Many of the causes—some of which are difficult to diagnose—of a chronic cough require treatment, and treatment may be more effective if these conditions are found earlier rather than later.

      Sources:

      Dabrowska, M., Grabczak, E., and M. Arcimowicz. Causes of Chronic Cough in Non-Smoking Patients. Advances in Experimental Medicine and Biology. 2015. 873:25-33.

      Damaraju, D., Steiner, T., Wade, J., Gin, K., and M. FitzGerald. A Surprising Cause of Chronic Cough. The New England Journal of Medicine. 2015. 4=373:561-566A

      Gibson, P., Wang, G., McGarvey, L., Vertigan, A., Altman, K., and S. Birring. Treatment of Unexplained Chronic Cough: CHEST Guideline and Expert Panel Report. Chest. 2016. 149(1):27-44.

      Kasper, Dennis L.., Anthony S. Fauci, and Stephen L.. Hauser. Harrison's Principles of Internal Medicine. New York: Mc Graw Hill Education, 2015. Print.

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