Cough is defined as explosive expiration providing a protective mechanism for clearing the tracheobronchial tree of secretions and foreign material and is necessary to aid normal oxygenation. Interruption of the cough reflex—as in certain neuromuscular disorders or excessive coughing, which can cause cerebral ischemia and thus interfere with respiration, can impair this process.

The cough is one of the most common reasons people seek medical attention. It can indicate a minor airway irritation or a serious underlying disorder. Coughs are generally diagnosed into one of two categories:

• Acute cough (less than three weeks duration)—usually from viral/bacterial upper respiratory tract infections (URIs)
• Chronic cough (more than three weeks duration)—attributable to underlying factors. One-fourth of patients have multiple contributing disorders, making systematic evaluation essential.

• Viral or bacterial URI
• Inhaled irritants, such as cigarette smoke, airborne pollutants, or noxious fumes
• Gastroesophageal reflux disease (GERD)
• Asthma
• Bronchitis
• Upper-airway secretions
• Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers
• Aspiration (bulimia, alcoholism, stroke)
• Congestive heart failure
• Stimulation of neural receptors in the pleura, pericardium, or ears (severe wax impaction) may cause chronic coughs.

• Chronic cough—appears in 14% to 23% of adult nonsmokers and in 25% to 50% of adult smokers, increasing proportionately with the number of cigarettes smoked per day
• Occupational exposure to airborne environmental pollutants
• Immunosuppressive diseases
• IV drug user

A cough can be accompanied by the following symptoms/conditions:

• URI
• Postnasal drip
• Wheezing (cough variant asthma)
• Heartburn (GERD)
• Regurgitation (bulimia)
• Fever/chills/night sweats (pulmonary tuberculosis)
• Edema (congestive heart failure)
• Weight loss (cancer)

• Chronic bronchitis
• Pertussis (whooping cough)
• Asthma
• Granulomas
• GERD
• Bronchogenic carcinoma/carcinoid tumor
• Irritation of cough receptors in the ear
• Cystic fibrosis
• Congestive heart failure
• Parenchymal lung diseases (pneumonia, lung abscess)
• Compressed airways due to external masses

Acute or persistent cough causing the patient concern or anxiety

• Sputum analysis (for chronic bronchitis, pneumonia, lung abscess, endobronchial tumor)
• Esophageal pH monitoring (for GERD)
• Tuberculosis skin test (for those at high risk, including IV drug users, immunosuppressed individuals, homeless persons, prisoners, immigrants)

Dependent upon underlying disorder or cause

• Chest/sinus radiography
• High resolution computed tomography (HRCT)

Step-by-step evaluation, from most common cause to least common cause:

• Elicit careful and detailed history.
• Examine cough reflex receptor sites (nose, nasopharynx, lungs).
• Eliminate cigarette smoke and occupational or household exposure to airway irritants.
• Discontinue ACE inhibitors and beta-blockers; substitute alternative class of drug.
• Identify chronic bronchitis.
• Treat empirically according to etiologies to help avoid invasive and expensive diagnostic methods.
• Perform radiography, CT scans, bronchoscopy, or laboratory analyses to identify lung carcinoma, chronic lung infections, interstitial lung disease, or aneurysm if patient nonresponsive to treatments.
• Fiberoptic bronchoscopy
• Special tests include sweat chloride tests for cystic fibrosis in children who experience recurrent pneumonia and fail to thrive; barium swallow; and pulmonary function tests.

Treating the cough without treating the cause may be detrimental, as the cough reflex is necessary to keep airways clear. Symptomatic therapy becomes necessary when etiology is unknown, specific treatment is not possible, or the cough performs no useful purpose. Treatment, determined by underlying pathology, may include the following:

• Elimination therapy (of airway irritants or medications that trigger cough reflex)
• Pharmacotherapy
• Surgery
• Immunotherapy (allergy shots)
• Air humidification

• Antitussives—suppress cough reflex at the medullary cough center in the brain or the site of irritation. Oral (codeine [15 mg qid] or dextromethorphan [15 mg qid]), inhaled anticholinergic agent (ipratropium bromide [2 to 4 puffs qid]), inhaled glucocorticoids (beclomethasone or triamcinolone [8 to 16 puffs/day]), and benzonatate peripherally acting anesthetic antitussive.
• Expectorants/bronchodilators—reduce viscosity of mucus, facilitating its movement from the tracheobronchial tree with antitussive effect (inhaled ipratropium [Atrovent])
• Antibiotics/antihistamines/decongestants—for URIs
• Antihistamines/decongestants: for postnasal drip; intranasal steroids if no improvement
• Antibiotics—for chronic sinusitis (amoxicillin-clavulanate potassium [Augmentin], trimethoprim-sulfamethoxazole [Bactrim, Septra], oral cephalosporin)
• Bronchodilators, beta-agonists, or corticosteroids—for asthma
• Intranasal steroids—for allergic rhinitis
• Antibiotics (often prolonged)—for Haemophilus influenzae
• High doses of proton-pump inhibitors (omeprazole) and H₂-blockers for complete suppression

May be necessary to remove masses, carcinomas, aneurysms

While coughs due to severe underlying pathology require pharmacologic treatment, alternative therapies can be useful in treating coughs secondary to viral URI, allergens, irritants, and asthma. Alternative therapies can also be used concurrently with pharmacologic treatment to optimize recovery.

• Eliminate known allergenic foods. IgG ELISA food allergy testing can help to determine food allergies.
• Reduce intake of mucus-producing foods, (e.g., dairy, citrus, wheat, and bananas). Increase fresh vegetables, fruits, and whole grains.
• Vitamin C (1,000 mg tid to qid), zinc (30 mg/day), and beta-carotene (100,000 IU/day) support the immune system.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Herbs can be used in combination for symptomatic relief and cough resolution while addressing the underlying etiology. A well-balanced formula contains herbs from several categories to increase the effectiveness of the cough (by stimulating expectoration or calming an irritable cough reflex), soothe irritated tissues, and support immune function. Tincture combinations should be taken at 30 drops tid to qid. Infusions are made with 1 heaping tsp. of herbal combination, steeped covered for 10 minutes, and drunk 3 to 4 cups/day. Licorice root should be avoided in hypertension.

• Strong expectorants: Horehound (Marrubium vulgare), thyme (Thymus vulgaris), and mullein (Verbascum densiflorum).
• Gentle expectorants: Fennel (Foeniculum vulgare), sweet violet (Viola odorata), ginger (Zingiber officinale), and balm of Gilead (Populus candicans)
• Antitussives: Wild cherry bark (Prunus serotina), colt's foot (Tussilago farfara), and linden flowers (Tilia cordata)
• Immune support: Purple coneflower (Echinacea purpurea), licorice root (Glycyrrhiza glabra), garlic (Allium sativum), and onion (Allium cepa)
• Tonification: Indian tobacco (Lobelia inflata) is especially useful for smokers; elderberry (Sambucus nigra), elecampane (Inula helenium), plantain (Plantago lanceolata), and gumweed (Grindelia camporum).

Essential oils:

• Thyme, eucalyptus, and pine oils can be applied to ease bronchial spasm and help thin mucus.
• Chest rubs with 2 to 4 drops of essential oil in 1 tbsp. of food grade oil (e.g., olive, flaxseed, sesame, almond oils)
• Castor oil pack with 4 to 6 drops of essential oil
• Chest poultice—flaxseed oil with baume de Canada, frankincense, mustard, oregano, or thyme oils

Note: Exposure to essential oils may antidote homeopathic remedies and their actions.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

It is imperative that the underlying condition is addressed; however, homeopathic remedies can be helpful in acute coughs or chronic coughs that fail to resolve.

• Aconite for sudden onset of cough or croup
• Spongia tosta for harsh, barking cough
• Drosera for dry, spasmodic cough
• Rumex crispus for dry, shallow, ticklish cough
• Ipecac for deep, wet cough with gagging from the cough
• Phosphorous for tight chest with cough
• Causticum for cough with raw painful feeling in chest
• Antimonium tart for rattling cough with dizziness

Acupuncture can be very helpful for acute and chronic coughs.

Systematic evaluation and treatment applied in progressive steps is effective in managing patients with persistent, chronic cough.

• Consider psychogenic cough if no pathology (nervous tic or attention-seeking device).
• Rib fractures may indicate presence of osteoporosis.

• Elimination of airway irritants
• Exercise, ample rest, nutritious diet, vitamins, minerals, herbs, and other supplements (particularly C, A, zinc, echinacea, garlic) to boost immune system and decrease risk of viral/bacterial infections
• Immunization with pneumococcal vaccine; annual influenza vaccination

Sleep disruption, rib fractures, cerebral ischemia, bronchospasms, urinary incontinence

• Dependent upon etiology/underlying cause
• Acute cough usually dissipates upon recovery from infection but may persist for several weeks.

Check for medication contraindications.

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