A chattering of coughs

Ahem. Here I am again! I am writing after a long time on a medical subject and its ‘cough’ this time. Cough can be a symptom for a diversity of diseases. Ahem! The sound of clearing your throat or a solicited cough is also used to attract attention and express disapproval, or embarrassment.

A cough can be dangerous in certain places and social contexts. For instance, I remember an incident when I was a cadet in the National Cadet Corps (NCC). During an army attachment camp, we were given a class on various war tactics including ambush. During the discussion on selecting the ambush team, the grey-haired Havaldar Major said, “Make sure no one in your ambush team has a cough!” We did not ask him for any reason!

A cough is your body's way of responding to something that irritates your throat or airways. An irritant stimulates nerves that send a message to your brain. The brain then tells muscles in your chest and abdomen to push air out of your lungs to dislodge the irritant.  Thus, a cough is a protective mechanism. It helps the body to expel what it does not need. One example is when you are drinking water and some of it accidently enters your throat or the windpipe. Your body coughs it out. Similarly, you cough out respiratory secretions produced during an infection. Sometimes it can be an irritant. Sometimes it can be a wrong signal. For instance, wax in your ear can also make you cough as the throat and the ear canal have a common nerve. 

An occasional cough is normal and healthy. A cough that persists for several weeks or one that brings up discoloured or bloody mucus may indicate a condition that needs medical attention.

Almost every child in Ladakh has managed to get ‘Spitchham’ (spring flu/cold) after almost two years of a COVID-19-imposed school break. At present, children are once again being exposed to various infections, which is helping their bodies build up their immunity. This did not happen over the past two years as schools were closed and children remained in the relative isolation of their family homes.  

A cough that follows a viral infection may last for periods ranging from a week to three weeks. I often wonder about the best treatment for a viral infection: Medication or time? Many doctors would argue that time is the best cure as our body needs a few days to treat a viral infection as it develops immunity against the virus. So, is it necessary for us to visit a doctor? I would argue that one should visit a doctor who can then check the kind of cough and ensure that it is not associated with any form of pathology.

Some coughs last for a short time but some persist and linger. I often meet parents who say, “Everything is ok. My child goes to school, sleeps well and eats well but has been coughing for the last two weeks.” I sometimes wish I could respond by saying, “Sorry, I can’t do anything for this cough!” On an average, such coughs will last for one short week if treated or seven long days if left untreated!

Many parents give their child a cough syrup for a cough before they decide to visit a doctor. And they are rarely satisfied until the doctor changes the cough syrup during their visit. In my experience, we need to be more careful with the use of cough syrups. I find that cough syrups are a very typically Indian response to cough! We must remember that many cough syrups have been banned and many contain an irrational combination of drugs. Then there is a cough variant asthma. The symptoms are not like classic asthma, which includes shortness of breath and wheezing. Cough variant asthma is diagnosed based on being treated with certain medication and family and individual medical history that includes different forms of allergy. I would use the kind of medication that comes in the form of inhalers for a frustrating cough when other forms of treatment fail to treat the symptoms.

However, there are challenges related to the use of inhalers that we cannot ignore. Generally, many people have a misconception that inhalers are only meant for the elderly, which means many people refuse to use them. Others fear that inhalers are habit forming with various kinds of side effects. In my experience, inhalers are helpful and the drugs they contain have minimal side effects as they are in micrograms and very target specific i.e. they are delivered only where they are supposed to work.

Let me explain this with an example. Generally, a bitter-tasting drug is supposed to dilate the airways or supress a cough. However, if we ingest them orally they will first go to the stomach. Such medications are often laced with sugar and flavours to appeal to children and people sensitive to various tastes. The medication enters the stomach, where it may cause some irritation and in some cases even cause a child to vomit. It will then be absorbed into the blood and reach every part of the body. As it passes through the brain, it can make a child sleepy or drowsy. It can cause other such side effects on its way to the lung where it is supposed to act. In contrast, when you take the same drug through an inhaler, it goes directly to the airways and dilates them.

In the COVID-19 era, cough has received a lot of attention! Recently, researchers have started experimenting with the use of artificial intelligence (AI) to analyse different kinds of data to assist with diagnosis of various diseases. For instance, experiments are being conducted where cough sounds are being analysed by AI algorithms to detect and diagnose different types of known diseases such as pneumonia, pulmonary oedema, asthma, tuberculosis (TB), COVID-19, pertussis, and other respiratory diseases. I have my reservations with this approach to screening patients and diagnosis. There is a wise saying about coughs. It advises, “Cough of more than two weeks can be tuberculosis.” And the most reliable way of diagnosing tuberculosis is through a simple sputum examination. Tuberculosis of lung alone can produce a variety of coughs depending on the location of the infection. Thus, the use of cough sounds and recording as a screening tool may not be sensitive to such differences and so remain unreliable.

In addition, one can also have what is called a psychogenic cough, which is also called habit cough. We have all experienced situations where you know you should not cough and you try to supress your cough. Then you finally cannot supress it anymore and end up coughing much to your embarrassment. Nowadays, coughing of any kind attracts a lot of attention in public places each time there is a spike in COVID-19 cases.

Finally, there is the COVID-19 and the non-COVID-19 cough! Over the last two years people have developed their own methods of differentiating between the two and its often ‘more effective’ than many diagnostics tests and AI algorithms. Simply put, when someone else is coughing, it is a COVID-19 cough unless proven otherwise! At the same time, the cough one is having is always a non-COVID-19 one, which is generally ‘caused’ by a banana, beer or cold water!

By Dr Spalchen Gonbo

Dr. Spalchen Gonbo is a Paediatrician based in Leh.