Oh, That Cough (Cough, Cough): Getting Help for Your Chronic Cough

Podcast Transcript

Raed Dweik, MD:

Hello and welcome to the Respiratory Inspirations Podcast. I'm Raed Dweik, chief of the Integrated Hospital Care Institute at Cleveland Clinic. This podcast series of short digestible episodes is intended for patients and families and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of lung health, critical illness, sleep, infectious disease, and related disciplines. We will share with you information that will help you take better care of yourself and your loved ones. I hope you enjoy today's episode.

Rachel Taliercio, DO:

Hello and welcome. My name is Rachel Taliercio. I am a pulmonologist and a faculty member at Cleveland Clinic, and also a member of the chronic cough team. I want to welcome our listeners to what we call Respiratory Inspirations, and today we're going to be talking about chronic cough. So, if you've hit play, you are a patient who suffers from chronic cough or you are a family member of somebody who is struggling with chronic cough, a spouse, a partner, a good friend. Thank you for listening today. We appreciate you wanting to hear more about chronic cough, to learn about it. Patient education and advocacy around this is critical. So, thank you for listening. I'm here with Dr. Ghobrial, who is the director of our chronic cough clinic, somebody that I have worked with for many years and who is an expert in this area. So Michael, I'll give you a chance to introduce yourself.

Michael Ghobrial, MD:

Thank you, Rachel, for having me. My name is Michael Ghobrial. I've been with Cleveland Clinic for the last 15 years and I'm happy to help patients with chronic cough and help their families try to get rid of this chronic condition.

Rachel Taliercio, DO:

Let's start with the basics, and it's basic, yet it's vitally important to how we can help patients with this condition. Tell me how you define chronic cough.

Michael Ghobrial, MD:

So, the current definition for chronic cough is cough that's been lasting more than eight weeks. What we typically would see patients in clinic in our chronic cough clinic is patients who have been coughing for months and years. So it can be there for decades until patients would come and see us, and we see patients from probably every state in the nation. I wouldn't necessarily label eight weeks to be the true duration for the chronic cough. We have seen patients typically who have been coughing for at least one year being referred to our chronic cough clinic.

Rachel Taliercio, DO:

And that's one of what we hope is the benefits of what we're talking about today. We want to decrease the time to recovery, decrease the time to cough reduction. We want it so that patients are able to see us sooner, that they're connected to chronic cough care earlier because we recognize how disabling these coughs can be, the burden that this cough can place on patients, on their family members, the concern that their friends have. So we think of a chronic cough as eight weeks or more. We know and we see a lot of patients in clinic that cough for months and even years. And what do you see when you think of how you evaluate a patient in clinic and in your mind you're going through what could be the cause of the cough, what are some of the most common causes of chronic cough?

Michael Ghobrial, MD:

That's true. Let me just rephrase about the duration of cough. We understand that there are studies to show the longer your cough has been going on, the less likely or the harder it is for you to get rid of it. So when we talk about eight weeks or more than eight weeks, earlier referral afterwards if no diagnosis has been secured and no treatment has been shown to provide at least some relief, getting to see a specialized provider for chronic cough is a key. Most common causes for chronic cough are asthma, gastroesophageal reflux disease, upper-airway cough syndrome, or what we call postnasal drip. And then there is another condition called non-asthmatic eosinophilic bronchitis. These are the most common causes for chronic cough, but also we don't want to be forgetting about chronic bronchitis, bronchiectasis and cough related to COPD.

And even for those patients who smoke and have a cough, that does not necessarily mean that your cough is what we call, or some people would call a smoker's cough. It could imply that there is some inflammation happening in your airways and even though you are currently smoking, you still can be evaluated and treated for this chronic cough.

Rachel Taliercio, DO:

We don't want patients to dismiss their cough. If, as you know, a common condition that could be associated with things like their occupation or smoking, we definitely still want these patients to get evaluated.

(05:10)

Michael Ghobrial, MD:

Correct. And even though these are the most common causes for chronic cough, sometimes it's not just one cause that is causing this chronic cough. Sometimes it's happening because of multifactorial to the extent that nowadays we are able to identify a certain phenotype of what we call refractory chronic cough, which is happening because of cough reflects hypersensitivity. So it may be true that you have really severe asthma and your asthma is being well-controlled treatment, but you still continue to cough. What can be done about this refractory chronic cough? And sometimes patients would not be diagnosed with typical asthma because they don't have the shortness of breath, chest tightness, the wheezing, but they just have a predominant feature of cough, and there is a type of asthma called cough variant asthma that could be associated with just a chronic cough, and patients need to be evaluated and treated for this condition as such.

Rachel Taliercio, DO:

Not all cough is the same. And what I'm hearing is that the longer a patient has coughed, the harder it is to manage the cough, the more likely the cough is due to more than one underlying condition.

Michael Ghobrial, MD:

Correct. Correct. It takes, we say it takes a village to find really what's causing your cough sometimes, especially when it's been going on for long time when you have been seen with different providers from different specialties, had so many tests, tried so many different treatments and inhalers and really nothing seems to be working.

Rachel Taliercio, DO:

It takes a village. It absolutely does. And what I hear from patients is that the longer they've coughed and the harder it's been to control their cough, they sometimes start to feel personally responsible for this cough like this cough is their fault, like they're doing something wrong. Can you tell me what you would say to a patient that says that to you in clinic?

Michael Ghobrial, MD:

You first need to have a candid discussion and typically patients would be coming with their very close family members and this has to be an open discussion. This cough has put a lot of strain on some relationships. It has affected marriage in a negative way. Couples may sleep in different rooms because of chronic cough. Some patients have avoided certain activities, would not go to church or would not visit families because they are coughing. Some people would not travel in airplanes because they are being looked at because of coughing. So you have to have a candid discussion. You need to validate their symptoms, explain to them that you understand and you realize the impact of chronic cough, and you are here to help. You're here to provide relief, and even if we may not be able to completely get rid of the cough, but we are targeting significant reduction of the cough and its burden on you.

Rachel Taliercio, DO:

So for our listeners today, whether you suffer from a chronic cough, whether your friend or family member does, you are not alone and it's not your fault that the cough is not getting better. This can be a very challenging condition to treat.

Michael Ghobrial, MD:

That's true. No one should be feeling guilty. They are coughing. No one should get a blame or get yelled at because they are coughing-

Rachel Taliercio, DO:

Yeah.

Michael Ghobrial, MD:

... which we have all heard when we have been seeing patients in clinical practice.

Rachel Taliercio, DO:

Absolutely. We are here to help. And you know, we've all, even us as physicians, I have been my own Dr. Google. Right, you know?

Michael Ghobrial, MD:

Right. Right.

Rachel Taliercio, DO:

(laughs) And we all know the challenge of Dr. Google, because often the worst stuff is at the top or the scariest stuff.

Michael Ghobrial, MD:

Right.

Rachel Taliercio, DO:

When a patient has a chronic cough, what should they be worried about? We call them red flags, but what, when you have a chronic cough, when do you want to make sure you get seen right away, connected to care as soon as possible?

Michael Ghobrial, MD:

Definitely. If this cough has been going on for some time, it doesn't seem to be getting better, now it is associated with mucus production or shortness of breath. You develop a fever, you are coughing up blood, you are having weight loss, especially if you have been a smoker. Now you are seeing some changes in your voice because of this chronic cough or worsening of voice, or you have been labeled as someone who is having recurrent upper respiratory tract infections and you are getting prescriptions for antibiotics or steroids. These are all red flags that any patient should be very aware of. And if they are happening, please do not settle for these symptoms as that's my cough or that's how I am or it's been going on for whatever weeks, months or years. No, if any of these symptoms are occurring, please seek medical attention.

(10:00)

Rachel Taliercio, DO:

So we often think, or when we talk about chronic cough, we talk about it in isolation, and what I'm hearing from you is the importance of yes, I have a chronic cough, and if I have breathlessness, if I'm producing a lot of mucus, if I have chest tightness, that escalates things. That elevates things to a different level.

Michael Ghobrial, MD:

That's absolutely correct. And I always advise patients when I'm seeing them in the offices, be mindful and pay close attention to the pattern of your cough. Is it a dry cough, is it a productive cough? Is it worse during certain times in the day? Does it wake you up at night? What typically triggers you to cough? Is there any seasonality for your cough? Do you feel worse at certain times in the year compared to others? How is the cough impacting your social activities and the activities of daily living, and are there any complications? We talk about trip fractures, hernias that can occur related to chronic cough and urinary incontinence, bladder prolapse or rectal prolapse. So what other complications chronic cough has been causing to you? And please do not wait until you have any of these complications before you get evaluated and treated for it.

Rachel Taliercio, DO:

I love hearing about this from you because it also helps prepare patients for the visit so they will then know what to expect, and what questions they're going to be asked. You know, what is the pattern of my cough, what makes it better, what makes it worse, what has helped, what hasn't helped.

Michael Ghobrial, MD:

Yeah.

Rachel Taliercio, DO:

So thinking through this also is good preparation for when you see your physician, your APP, when you see a cough provider. What should patients expect with respect to testing?

Michael Ghobrial, MD:

So first, we will get a chest x-ray. Everyone who has not had a chest x-ray within the last year should get a chest x-ray, especially if their cough has been chronic and refractory in nature. Patients will get pulmonary function tests. We primarily perform spirometry with bronchodilator and exhale nitroxide to try to identify common causes and certain types of inflammation in the airways. If patients are producing mucus, we would typically send this mucus for inflammatory cells as well as looking for some types of infections that could be causing this mucus production. Sometimes we order blood tests. Oftentimes, we would follow this disease testing by possible CT scan or more advanced breathing tests like Methacholine challenge tests on patients. We may offer them a bronchoscopy to go in, take a deeper look in their airways, and maybe get some samples from their mucus. If there is no mucus, we can do what we call bronchoalveolar lavage, and sometimes we may perform endobronchial biopsies as well to try to identify on the cellular level what could be causing their chronic cough.

Rachel Taliercio, DO:

So most likely when patients are evaluated for chronic cough, at a minimum they should expect to have a chest x-ray if they haven't had one within the past year, they should anticipate breathing tests, and they should also be looking for and asking for a stepwise guideline-based approach to evaluation and management.

Michael Ghobrial, MD:

That's correct. That's correct. We try to avoid the kitchen sink approach where you go to a provider and without even having a chest x-ray or doing any further testing, you will be leaving with three or four medications and “come and see me in six months.” So that's not what we typically would do for patients, and I would advise patients to advocate for themselves. If you aren't comfortable with the diagnosis, please do not get a treatment just because someone prescribed it. Try to understand what's going on, why am I coughing, and how is this treatment supposed to help me.

Rachel Taliercio, DO:

Make sure you understand the root cause of the cough so that you can best help to manage it.

Michael Ghobrial, MD:

That's exactly correct.

Rachel Taliercio, DO:

What are your thoughts on over-the-counter remedies, herbal medications? You know, patients share a lot with us in clinic about what they've tried, non-prescription based. Is there a role for these sorts of therapies?

Michael Ghobrial, MD:

That's definitely important and as you mentioned you try to get to the root cause for the cough. These urban meds and over-the-counter cough medications are primarily for the acute and subacute cough. So if you think of it as you have an upper respiratory tract infection and now you have this lingering cough for the last three, four days and you want to take something that can ease the cough burden in you and provide you with some sleep, taking over-the-counter cough medications or some herbal remedies is quite appropriate. I would advise against over-the-counter cough medications and herbal medications for chronic cough because it might be masking something serious that needs to be taken care of. So even if it would provide some relief, it may be prolonging or delaying the time until you see a provider and get a diagnosis for a serious chronic condition. So they have pros and cons. If it's an acute type of cough, it's okay to use some of these medications. They will provide relief and that's what they are approved for. If it's for a chronic cough, I would advise against them.

(15:27)

Rachel Taliercio, DO:

When we think about the severe forms of chronic cough, the chronic cough that's not getting better where we've evaluated and treated for common causes, we know that there is a lot of exciting drug development in this area. Can you tell me a little bit about what you're excited for in research in chronic cough?

Michael Ghobrial, MD:

I'm definitely excited now that there are at least some Phase III clinical trials for medications. The last treatment prescribed, or last treatment approved by the FDA, for chronic cough was in 1958. So it's quite a long time since then that we need to have some new treatments and some effective treatments for this patient population. The prevalence of chronic cough in the US is about 10%. It's pretty significant, and there are a number of patients who are in need of treatments. There is a new medication that's effective on certain receptors in the airways called P2X3 receptor. This medication is in currently Phase III clinical trials. We should get some results about how significant this medication is for patients with severe refractory chronic cough.

There is another medication that targets certain opioid receptors. It's actually opioid agonist and antagonist, so it doesn't really significantly have any addictive concerns, and this medication has shown significant reduction of chronic cough by about 50% in patients who have idiopathic pulmonary fibrosis. So these patients have been having significant cough and it impacts their oxygen saturation, it impacts their overall well-being. Getting a medication that can provide them with significant cough relief is quite promising and we are all excited about it.

Rachel Taliercio, DO:

There's tremendous need, as you said, for approved therapies in chronic cough. In the meantime, we know that there's research, there's a lot of interest in drug development in this area. Patients may be offered what we call off-label medication. What does off-label mean, and what should patients know about this treatment approach?

Michael Ghobrial, MD:

So in the off-label treatments, mainly we call them neuromodulators. There have been several studies showing that patients with chronic cough could share certain properties similar to patients who have chronic pain, and when we treated these patients with chronic pain with what we call neuromodulators, so these are medications that can calm down the sensitivity of these nerve endings. These patients have significant improvement in their pain score. We could use some of these medications as being off-label to treat certain types of chronic cough, especially when we are talking about this cough reflex hypersensitivity. Some of these medications in the right context, in the right clinical setting, can provide significant relief for some patients. We have to be careful about their side effects, and we have to really do our due diligence to rule out and maximally treat other conditions that could be causing chronic cough before we embark on off-label therapies.

Rachel Taliercio, DO:

So with off-label therapies, make sure as a patient that you understand the risks and the benefits. You want to start these medications at a low dose, monitoring very closely for side effects and making sure you have close follow-up.

Michael Ghobrial, MD:

Correct. Correct. And don't settle for the last. If you are really not getting any benefit, then this line of medication may not be the most appropriate thing and it could prompt you to go back to your provider and say, "What's next? What do we need to do next?" There are some procedures that some patients may benefit from. When we would refer patients to our ear, nose, and throat colleagues to provide certain type of injections, these would be discussed with your provider on a case-by-case basis. Again, you have to understand the risks and the benefits and which provider would provide these types of injections. It's not really something that you should simply, you have to have a very thorough discussion and evaluation by providers who are specialized in chronic cough before you would embark on some of these treatments.

Rachel Taliercio, DO:

Absolutely. Lastly, I want to acknowledge something I hear from patients in clinic a lot. While they are reaching out for help, they often want their medication list to shrink, not expand. You know, what can we do in managing chronic cough that is, you know, outside of drug therapy, or what else do you have to offer patients?

(20:14)

Michael Ghobrial, MD:

Important to understand? That's a great question. Important to understand that not all treatments for chronic cough are medication-based and they are not all procedures, and definitely not something that I would ask patients to go for surgery for. One option of treatment that we offer here in our chronic cough clinic is what we call behavioral cough suppression therapy. When you mention these off-label medications, there isn't really a strong solid evidence that these medications would work magic for patients, but we have strong clinical evidence from randomized controlled trials that this behavioral cough suppression therapy is effective and can lead to significant decrease in the cough burden, and also can provide patients with immediate control of cough in situations when they feel that they are in a restaurant or in a speech or in a church or in a setting where they need to get their cough under good control.

Behavioral suppression cough, cough suppression therapy, has shown to be effective in these situations, and this treatment can be provided virtually as well as in person. And I tell my patients that I refer to this treatment, this is a treatment that has no side effects. It's very unlikely that you will have any problems with it. It's likely to give you significant benefits without any significant side effects or complications.

Rachel Taliercio, DO:

And most likely best-case scenario, it helps patients get control over their cough.

Michael Ghobrial, MD:

Correct.

Rachel Taliercio, DO:

In conclusion, and this has been so helpful, Dr. Ghobrial, you mentioned how important it is for patients to advocate for themselves, for family members and friends to advocate on behalf of their patients. What are your key takeaways? What do you want to make sure that patients, family members, friends walk away from after listening to this?

Michael Ghobrial, MD:

So it's important to really see a provider who would provide the time and is interested in treating your chronic cough condition. I hear from patients that they saw providers and these providers weren't really interested. That's okay. That doesn't mean that you have to live with the cough. You just have to find the provider who is interested and is invested to take care of this condition along with you and your family members. Do not settle for less. Do not follow the kitchen sink approach. Sometimes less means more. It's not the provider who prescribes more medications that's interested to treat you, but really the person who is taking the time, explaining what's going on, providing adequate and appropriate testing, and providing treatments with explanation how these treatments would work.

:

It's important to set expectations that we may not be able to completely wipe your cough completely away, but we are aiming for significant reduction that would allow you to enjoy life and enjoy activities, being around people without feeling any sense of shame or guilt that you are coughing. You're not guilty, it's not your fault. It's a condition that needs to be investigated, needs to be treated, and we go from there.

Rachel Taliercio, DO:

These partnerships are a journey, and it's about us together, working together to help manage this cough and really improve patients' lives.

Michael Ghobrial, MD:

That's absolutely correct.

Rachel Taliercio, DO:

Wonderful. Thank you so much.

Michael Ghobrial, MD:

Thank you for having me.

(23:38)

Raed Dweik, MD:

Thank you for listening to this episode of the Respiratory Inspirations podcast. You can find additional podcast episodes on our website, clevelandclinic.org/podcasts, or wherever you get your podcasts.