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Chronic cough syndrome is one of the most common causes of chronic coughs. It is a term used to describe the different syndromes related to coughing the 3 main ones being; Upper airway cough syndrome, Asthma and Gastroesophageal Reflux Disease. It occurs in the upper airway of the respiratory system. Generally, a cough lasts around 1-2 weeks however, the cough syndrome can persist for an extended period of time defined as 6 weeks or longer. Carrier of the cough syndrome often experience more than one cause present. Due to the nature of the syndrome the treatments that are used are similar however there is a subsequent number of treatments available.

Mechanics of Coughing
Coughing is a mechanism of the body that is essential to normal physiological function of clearing the throat which involves a reflex of the afferent sensory limb, central processing centre of the brain and the efferent limb. In conjunction to the components of the body that are involved, receptors are also used. These receptors include rapidly adapting receptors which respond to mechanical stimuli, slow adapting receptors and nociceptors which respond to chemical stimuli such as hormones in the body. To start the reflex, the afferent impulses are transmitted to the medulla of the brain this involves the stimulus which is then interpreted. The efferent impulses are then triggered by the medulla causing the signal to travel down the larynx and bronchial tree. This then triggers a cascade of events that involve the intercostal muscles, abdominal wall, diaphragm and pelvic floor which in conjunction together create the reflex known as coughing.

Types of Coughs
By diagnosing which type of cough is present during the chronic cough syndrome, individuals can further identify the cause of the chronic cough syndrome. These coughs include the following. A Dry cough is a persistent cough where no mucus is present, this can be a sign of an infection. A chronic wet cough is a cough where excess mucus is present and depending on the colour of the phlegm, bacterial infections may be present. A stress cough is when the airways of the throat are blocked to the point that causes a reflexive spasm. A whooping cough is when a ‘whooping’ sound is present, this is a normally an indication of infection.

Symptoms
Common symptoms present in chronic cough syndrome include: A runny / stuffy Nose, a feeling of liquid running down the back of your throat (postnasal drip), frequent throat clearing (coughing) and sore throat, Hoarseness, Wheezing / shortness of breath, Heartburn / sour taste in your mouth, Rare cases also include coughing blood.

Causes
Possible causes alone or in conjunction can cause the chronic cough syndrome which include:


 * Postnasal drip is when excess mucus is produced in the sinus of the nose, mucus can drip back towards the throat causing a cough reflex also known as upper airway cough syndrome. Can be caused by direct irritation of the post nasal drip or an inflammation of cough receptors in the upper airway. 34% of postnasal drip cases contribute to the cause of chronic cough syndrome.
 * Asthma affects the upper respiratory tract. Other causes such as cold air or chemicals breathed in can also induce coughing.
 * Gastroesophageal reflux disease (GERD) Is a common condition where the backflow of stomach acid between the throat and the stomach causes an irritation that can lead to chronic cough syndrome.
 * Infections such as symptoms of pneumonia, flu, cold or other Infections in the upper respiratory tract include coughing that can persists even after the infection has subsided. Commonly mistaken as a symptom of the infection can be chronic cough known as whooping cough
 * Blood pressure drugs such as Angiotensin Converting Enzyme which is commonly prescribed to individuals with high blood pressure and cardiac failure are known to have a side effect cause of chronic cough.
 * Chronic bronchitis is an inflammation in the major airways such as the bronchial tubules that causes the coughing of coloured sputum. Most carrier of chronic bronchitis have a history of smoking. Due to the nature of chronic bronchitis it is on a spectrum of smoking-related lung disease also known as chronic obstructive pulmonary disease. Because of this spectrum other lung diseases on the spectrum such as Emphysema can co-exist with COPD. Accounts for 5% of chronic cough syndrome individuals.
 * Chemical Irritants such as cigarette smoke or other irritants is a common factor for chronic cough syndrome. These irritants typically contribute towards chronic bronchitis.
 * Other notable rare causes include: Aspiration, Bronchiectasis, Bronchiolitis, Cystic Fibrosis, Laryngopharyngeal Reflux, Lung Cancer, Non-asthmatic Eosinophilic Bronchitis, Sarcoidosis.

Complications
Long-term coughing and constant irritation of the upper airway can be problematic for individuals that have chronic cough syndrome. Due to the consistent coughing, this can interfere with a individuals daily life. This interference can thus cause additional problems such as: effecting their ability to ensure a consistent sleep, daytime fatigue, difficulty concentrating at work or school, headache, dizziness. Other more sever but rare complications include: fainting, urinary incontinence, broken ribs (excess coughing).

Diagnosis
There are 3 main types of chronic cough syndromes which are the following:
 * Upper Airway Cough Syndrome is the most common cause of chronic coughing. It is diagnosed when the secretion of excess mucus from the nose / sinus drains into the pharynx or the back of the throat causing an induced cough.
 * Asthma is the main way to identify the chronic cough syndrome as a cause from asthma is that the airflow is obstructed when coughing causes a shortness of breath, wheezing, dyspnea and coughing.
 * Gastroesophageal Reflux Disease (GERD) is identified with 2 mechanisms which are the distal esophageal acid stimulating the esophageal-treachebronchial cough reflex due to the vagus nerve and the microbial esophageal contents of the pharynx and tracheobronchial causing a cough reflex.

Imaging Tests

 * X-rays is used to check for lung cancer, pneumonia and other lung diseases are contributing to the chronic cough syndrome. X-rays on the sinus also provide evidence of an infection in the area.
 * Computerised Tomography (CT) scans is used to check the conditions of the patients lungs and to check sinus cavities for infections.
 * Lung Function Test is a simple test where the patient inhales / exhales into a spirometer normally used to diagnose asthma or chronic obstructive pulmonary disease.
 * Lab tests is a sample of the patients mucus is tested for bacteria
 * Scope tests is used if the above tests are not able to diagnose the chronic cough syndrome, a special test may be used involving a thin, flexible tube which contains a light and camera. This is then inserted within the patient through the respiratory tract. A bronchoscope is used for the lungs and air passages, whilst a biopsy is used for the linings of your airway. Additionally, a rhinoscope can be used to examine the upper airway tract.
 * Children are typically diagnosed with chest x-rays or spirometry

Typical evaluation of chronic cough begins with diagnosing the persons lifestyle choices such as smoking, environmental exposure or medication. From this doctors can opt to use chest radiography if the patient does not smoke, take any angiotensin-converting enzyme inhibitor, or have a persistent cough after the period of medication.

Treatment

 * Upper Airway Cough Syndrome treatments include avoiding environmental irritants (chemicals) and offending antigens. This involves treating the sinus with antibiotics to stop nasal drip. Individuals should avoid decongestants found in off the shelf pharmacies to allow rhinitis medicamentosa to work. In severe cases where the cause is not clear, patients should use empiric therapy which is a combination of antihistamine and decongestants. Results typically show within 2 weeks of therapy but can take up to several months for results to show. Absence of standard clinical procedure that test for rhinorrhoea and excess sputum production should not preclude an empiric trial with antihistamine decongestants as they are not effective in treating upper airway cough syndrome.


 * Asthma patients need to go under treatment to see if their airflow obstruction is reversible. This is done by undergoing spirometry and Broncho provocation. After initial treatment, patients should take beta-2 agonists and inhaled corticosteroids. This treatment general yield positive results within a week however complete treatment can take up to 8 weeks.


 * Gastroesophageal Reflux Disease (GERD) treatments include intense monitoring with a dual channel 24-hour pH probe for diagnosis of the severity of GERD. Other monitors such as nasopharyngoscopy can reveal glottis changes associated with the refluxes that occur. Acid suppressive medication can be taken which include histamine 2 (H2) blockers, proton pump inhibitors (PPI) and prokinetic agents. This medication tends to show results within 2 weeks however 6-8 weeks is ideal for conclusive results. Patients are to remain on treatment for up to 6 months.

Home Remedies
Chronic cough syndrome can be alleviated at home with household supplies. Although it is recommended to seek a professionals opinion, these home remedies can be used. Staying hydrated can help the body with more fluid to help with thin mucus. Salt gargles which include a mixture of salt with warm water can be used to soothe the throat, the gargle can also cleanse the throat. Inhaling steam in the shower humidifies the throat allowing the relief of a dry throat. Store bought cough drops such as lozenges can reduce the irritation of the throat. Honey and ginger can be prepared with hot tea to help clear nasal passages and chronic cough. Herbs such as eucalyptus and mint provide a cool feeling to relieve symptoms. Elevating the head can help with breathing at night, this can be done by using extra pillows.

Medical Professional Advice
A prolonged cough such as one that falls under the chronic cough syndrome can become a medical emergency. The following symptoms that occur in conjunction with chronic cough syndrome symptoms should be taken into account. These symptoms are: A fever that exceed 103F, Coughing of blood or blood present in mucus, Irritable chest pain, Difficulty of breathing, Appetite loss, Excess mucus being coughed, Fatigue, Night sweats, and Unexplained weight loss.

Risk factors
Developing a chronic cough syndrome can occur from different life style choices. These include smoking cigarettes that the individual smokes themselves or breathes from second-hand exposure. Long-term exposure to smoke can irritate airways and lead to chronic cough syndrome and in severe cases lung damage. Other risk-factors that can affect the risk of developing chronic include exposure to the air. Individuals that work in factories or laboratories that deal with chemicals have a chance of developing chronic cough syndrome from long term exposure.

Prevalence
The prevalence of cough in many communities in Europe and USA is 9-33% of the population from surveys. Chronic cough syndrome is more prevalent in those who smoke by threefold compared to people who never smoke. Data analysis shows that exposure to tobacco smoke in a home environment is a risk factor for children due to second hand smoke inhalation. Other causes of chronic cough include higher PM10 concentrations have been related to increase cough and sore throat in children. An increase in nitrogen dioxide has also show a rising association with chronic cough syndrome.

Chronic Cough Syndrome in Children
A cough that is 4 weeks or longer in duration is considered chronic for children. Most common causes for children include asthma, respiratory tract infections and GERD. Other causes typically diagnosed differently include viral bronchitis, post-infectious cough, cough-variant asthma, upper airway cough syndrome, psychogenic cough and GERD. Due to the way of diagnosis being invasive, typically children are not suitable for diagnosis under the ages of 15. However the bare minimum tests include chest radiography and spirometry.