The Carousel Of Chronic Cough

Allergist and immunologist Dr. Steve Dorman joins Dr. Michael Koren to discuss the causes, complications, and carousel of chronic cough. Dr. Dorman reviews what chronic cough is and how it may be due to anatomical changes, acid reflux, allergies, and so on. Because of this, the doctor explains, sufferers of cough may end up going around the "carousel" of chronic cough, where they end up seeing their primary care specialist, a GI doctor, an Ear, Nose & Throat (ENT) specialist, pulmonary physicians, and an allergist and immunologist like himself. The duo then tackle what can be done, from medications, new research, and non-medicinal treatments.

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Transcript

Welcome And Guest Introduction

Announcer 0:00

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren 0:11

Hello, I'm Dr. Michael Koren, the executive editor of MedEvidence! And I have my guest today, Steve Dorman, who is a local allergy immunologist, and he's going to talk to us about why we cough. So, Steve, thanks for being on MedEvidence! And start us off by just telling us a little bit about your background.

Dr. Steve Dorman 0:29

Yeah, thanks a lot. It's an honor to be here. I'm an board-certified allergy and immunology physician, also an internal medicine board certified. I practice allergy and immunology here in the Jacksonville area.

Dr. Michael Koren 0:40

And remember looking at your CV and your actual designation has a lot of A's in it. And I I made a joke at uh at a previous session that you don't have to put all the A's on your transcript from college on your on your C V.

Dr. Steve Dorman 0:54

Yeah. Yeah. So it just means being a fellow of the American College of Allergy, asthma, and immunology. A lot of A's there. Yeah.

Dr. Michael Koren 1:02

Any event. So thank you for being on MedEvidence! And let's start us off by just telling the audience. Why do we cough?

Why The Cough Reflex Exists

Dr. Michael Koren 1:10

Y

Dr. Steve Dorman 1:10

One of the main reasons we cough is our throat or our lungs or our upper airway in the nose and sinuses. We have nerve receptors there. So nerves help us to do everything from sense vision, our sense of smell, our sense of taste, our movements, our perception of heat, cold, pain, et cetera. But they also sense irritation in some of our inner cavities of our body, and they send a signal via some of the nerve endings to the brain, which provokes a cough response in our body.

Dr. Michael Koren 1:45

And that's not conscious. It's something that's happening in our brain at the unconscious level.

Dr. Steve Dorman 1:49

Yes.

Dr. Michael Koren 1:50

It's most often subconscious.

The Carousel Of Cough Causes

Dr. Steve Dorman 1:52

You're correct.

Dr. Michael Koren 1:52

So tell me about some of the medical conditions that cause people to cough.

Dr. Steve Dorman 1:57

Yeah. So I see a lot of patients who have acute cough or chronic cough in the clinic. It's one of the main reasons I see patients in our private practice clinic. When I see these patients, oftentimes they will see a number of different physician specialties. I kind of call it the carousel of cough. They'll see people like the gastroenterology physicians, the ear, nose, and throat physicians, the pulmonary specialists, as well as the allergy and immunology specialists. You know, looking at kind of this carousel, breaking it down a little bit more, you know, the gastroenterology people are many times focused on issues like gastroesophageal reflux or commonly known as GERD. That's when acid comes from the stomach into the esophagus, provoking cough due to irritation of different areas of the throat. When we look at the ear, nose, and throat physicians, they're mainly focused on structural or anatomic abnormalities of the sinuses like polyps or chronic rhinosinusitis or upper airway cough syndromes. So really these anatomic reasons that seem to provoke congestion in the nose and sinuses, resulting in drainage in the nose and sinuses going down the back of the throat, provoking cough. People like the pulmonary physicians, they're very focused on things like bronchiectasis or pulmonary fibrosis or other reasons for structural changes in the lungs that seem to provoke cough driven from irritation in the bronchial tissues. Myself as the allergy and immunology physician, I'm very focused on things like allergic rhinitis or allergic rhinosinusitis, as well as asthma that provoke cough. So, yeah, there's a number of reasons, and this is a non-inclusive list. I mean, it's there's many other reasons. So it can be very confusing.

How Specialists Test For Cough

Dr. Michael Koren 3:48

Yeah. So, Steve, tell us how you kind of sort this out. There's so many things that can cause a cough. How do you sort sort it out when a patient comes to you looking for advice on how to deal with their cough? Yeah, it can be really tough.

Dr. Steve Dorman 4:00

It's tough for patients and tough for physicians as well. People like the gastro neurology doctors, they get very focused on doing procedures like an upper endoscopy to look at signs of acid-related damage or changes in the throat that will provoke cough. The ENT physicians, they like to anatomically review the structures and the anatomy of the nose and sinuses via a procedure called rhinolaryngoscopy or via CAT scan or just simple autoscopy of the nose. The pulmonary physicians, they really enjoy getting data such as full pulmonary function testing or simple spirometry.

Dr. Michael Koren 4:39

They enjoy strange things, those pulmonologists.

Dr. Steve Dorman 4:41

They do. They do. Yeah, yeah. Even bronchoscopy at times. You know, I myself, I can do strange things too. You know, I do like pricking people do percutaneous allergy testing to diagnose allergic rhinosinusitis or allergic asthma. Interesting. In conjunction with breathing tests. So yeah, we all we all have our thing.

When Treatment Gets Complicated

Dr. Michael Koren 5:00

Okay. So sometimes I imagine that it's pretty clear why people are coughing. You provide a solution. Does it always work? Or what happens when you evaluate the treatment?

Dr. Steve Dorman 5:12

Yeah, great question. Many times cough is an elusive thing to capture or an elusive thing to really get under control. It can be multifactorial. You know, patients oftentimes who have allergic rhinitis, many of them have asthma as well, or patients who are more advanced or senior in their years are more prone to issues like gastroesophageal reflux. Individuals who have chronic rhinosinusitis with nasal polyps many times have asthma. And so there's often overlapping causes of cough, and so we have to treat many of these things. There also are patients who get ruled out for asthma or lung diseases, for sinus diseases or structural changes in the sinuses, as well as reflux and still cough. And so it can be very challenging.

Dr. Michael Koren 6:00

Interesting.

Unexplained Cough And Nerve Signals

Dr. Michael Koren 6:02

Now I know that you have a research interest in cough, and as I understand it, it's for those situations where we're not really sure why people are coughing. So just help the audience understand what percentage of all the patients you see fall into that category and what your approach might be, including how you might get them involved in clinical research.

Dr. Steve Dorman 6:21

Yeah, we certainly do have patients, a fair number of patients who cough for really unexplained reasons. After reviewing data by different subspecialists or data that we've done in our primary clinic for allergy and immunology, there's not a clear explanation. And so many times we will have them enter a clinical trial.

Dr. Michael Koren 6:41

Yeah. It's interesting. And there's work in our community ongoing as we speak?

Dr. Steve Dorman 6:47

Yes. There is.

Dr. Michael Koren 6:47

Okay. What a coincidence.

Dr. Steve Dorman 6:49

Yeah. Yeah.

Dr. Michael Koren 6:51

And can you tell us a little bit about the kind of mechanisms that people are looking at to try to deal with the situation when people have a cough and we don't really know exactly why?

Dr. Steve Dorman 7:00

Yeah. Sometimes the cough can be driven by an aberrancy or an abnormality in the way our body senses irritation in the throat, in the chest, or in the upper airway. And so these nerve endings that will sense things like post-nasal drip or bronchial irritation or reflux, they'll sense it when it's not there. They'll sense these processes when there's an absence of reflux. And so those nerve endings send a signal to the brain, which then provokes a cough subconsciously.

Dr. Michael Koren 7:34

So this is the the work that you're doing is looking at the neurological mechanisms of cough. Yes. So Steve, your the research is fascinating, but let me ask you a basic question.

OTC Syrups Vs Targeted Drugs

Dr. Michael Koren 7:44

Like, why do we need a fancy new drug when we have something like robitussin to treat this problem? I think that's guaifenesin, if not, if I'm correct. But you know, tell us why would you choose one versus the other?

Dr. Steve Dorman 7:55

Yeah, robitussin is a mixture of medicines. Many times it will contain guaifenesin.

Dr. Michael Koren 8:02

Exactly. We sometimes use trade names when we shouldn't, probably.

Dr. Steve Dorman 8:05

Yeah. Yeah. Yeah.

Dr. Michael Koren 8:06

We're not being sponsored by any company for this project, just to be clear.

Dr. Steve Dorman 8:11

Yeah. Yeah. We actually don't know why guaifenesin seems to help some people. It seems to mu- it's it will increase mucus secretions and loosen things up, but we don't really know why or if it truly does that.

Dr. Michael Koren 8:25

Interesting. Yeah, sometimes we find that newer drugs that are investigational are actually more well understood than things that have been around forever because those older drugs never through went through the scrutiny that newer drugs go through these days.

Dr. Steve Dorman 8:39

You're totally right. Totally right.

Dr. Michael Koren 8:41

Yeah, interesting. Any other medicines that you use to suppress cough when people just have those nagging coughs that are interrupting their day-to-day activities?

Dr. Steve Dorman 8:49

Yeah. A common medicine we use sometimes will be something called gabapentin. It's another medicine that helps to modulate some of the nerve receptors or our perception of irritation in the throat, the upper airway, the lungs that will help to modulate neurogenic cough

Why Chronic Cough Matters

Dr. Steve Dorman 9:06

specifically.

Dr. Michael Koren 9:06

l Cough isn't a big deal, is it? Like why would you want to be really that worried about it? Why don't you just tell patients that I live with it?

Dr. Steve Dorman 9:13

Yeah, cough can be a big deal. It really can be. If it's something like uncontrolled asthma, it could lead to bronchial structural changes, which can, which can be worse and worse and worse over the course of your life. Same thing with things like COPD or chronic obstructive pulmonary disease or hypersensitivity pneumonitis. Uncontrolled cough due to reflux could lead to precancerous or cancer-related changes in the throat. And nasal polyp disease that seems to provoke cough in some individuals that can also cause structural changes in the sinuses, which can be more severe if left unchecked.

Winter Viruses And Seasonal Pollen

Dr. Michael Koren 9:51

Steve, I I have this uh memory of uh of a piece that I saw, I think it was on National Public Radio, maybe about 20 years ago, that made a big impression on me. Yeah. And during that piece, they were showing what the sound of Carnegie Hall in New York City was before a performance started. Okay. In December or January versus in a summer month. Yeah. And if you listen to that before any music started, you heard everybody coughing and and sneezing and all kinds of sounds from the audience in December, January. And very, very little noise in June. So two questions. One, is your business like really seasonal? Like do you just leave in June? Is that really true? Is that just maybe in certain climates and and and things being maybe a little different here in Florida? And does that give you some insight into what people are suffering from?

Dr. Steve Dorman 10:48

Yeah, the traditional thinking is that in the winter there's more infectious causes of cough, things like cold due to influenza or respiratory syncytial virus, RSV. Recently, COVID has kind of come to light, but these respiratory illnesses seem to be more prolific during winter months. Certainly there's seasonal causes of cough. They're mainly driven by pollen. For example, trees pollinate in the spring, grasses pollinate in the summer, and weeds pollinate in the fall. And so people who have more seasonal coughs directed at a specific season, you know, we we do think pollen.

Dr. Michael Koren 11:28

Interesting. So you see it all. So the cough business is 24-7, 12 months a year?

Dr. Steve Dorman 11:34

It's great. Yeah. Yeah.

Kids Vs Older Adults

Dr. Michael Koren 11:36

Steve, you know, one of the things that we deal with all the time when we have young kids, I don't have them now, but when my kids were young, they were constantly coughing in one way or another. And is there a difference in what kids suffer from in people who are adults or people who are elderly?

Dr. Steve Dorman 11:51

Yeah, certainly. Kids or children by far, they have more infectious related causes of cough. For example, RSV or respiratory syncytial virus, that is a virus that can provoke cough for sometimes weeks to months. Even after the virus is cleared from the body, it can cause irritation of the airway.

Dr. Michael Koren 12:10

So And uh how about people who are elderly when they tend to cough?

Dr. Steve Dorman 12:15

Yeah, we tend to think more of issues like gastroesophageal reflux or lung-related changes, bronchiectasis, asthma, COPD, et cetera.

Dr. Michael Koren 12:27

So And uh I remember from my internal medicine days that mycoplasma pneumonia is one of those things that can cause a cough for a very extended period of time.

Dr. Steve Dorman 12:36

You're absolutely correct. Absolutely correct.

Dr. Michael Koren 12:38

Steve, why don't you brief us on some non-medicines that may help people that have cough?

Home Remedies Worth Trying

Dr. Steve Dorman 12:43

Yeah, probably one of my favorite non-pharmacologic agents for cough would be neti pot or saline rinses. We oftentimes will have patients use distilled water and add certain amounts of saline or salt to it and gargle it if we believe the cough is in the throat or relating to mucin in the throat, or do high or low volume irrigation in the nares, kind of in one in the right, outside the coming out the left, or vice versa, to really irrigate the nose and sinuses. What we like about that in particular is it does two things. The first thing is it helps on a macroscopic level to flush out the mucin, but also on a microscopic level, it stimulates the ciliary hair structures that are microscopic. It helps to the mucociliary transport system to work quicker.

Dr. Michael Koren 13:33

How about just going into a steam room? Would that work?

Dr. Steve Dorman 13:37

Kind of a controversial thing. There are anecdotal studies showing that, you know, does this help in small groups? Possibly, but I'm not aware of any large or meta-analysis type papers showing that really helps.

Dr. Michael Koren 13:51

How about a grandmother's honey or lozenges? Do they work?

Dr. Steve Dorman 13:55

Yeah, there have been some recent publications that I've seen indicating that honey may help, but for a different reason than many people think. A lot of times the farmers market people will market honey as an allergy treatment or something that seems to help allergies. But actually, what's happening with honey is warm honey in particular used in drinks like tea or something a little bit warmer, not cold drinks, but it helps to coat the back of the throat to decrease irritation from people who've been coughing chronically.

Cough Research And Closing

Dr. Michael Koren 14:30

For folks that may be interested in getting involved in cough research, how would you advise them?

Dr. Steve Dorman 14:35

Yeah, look at the website link at the end of the show notes.

Dr. Michael Koren 14:39

Okay, much appreciated. Thank you for being part of MedEvidence!

Dr. Steve Dorman 14:42

Thank you.

Announcer 14:43

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