The Curbsiders 'Hot Takes'

Chronic Cough: The Long Haul Approach

The Curbsiders


December 22, 2020

This transcript has been edited for clarity.

Matthew F. Watto, MD: Hey guys, we're back. Believe it or not, we are three board-certified internal medicine physicians. I'm Dr Matthew Frank Watto.

Stuart K. Brigham, MD: I'm Stuart Brigham.

Paul N. Williams, MD: And I'm Dr Paul Williams. In this video, we are going to talk about highlights from our episode on chronic cough with the great Dr Bradley Hayward.

Watto: He is a board-certified pulmonologist, a palliative medicine physician, and an expert on chronic cough. What is your pearl from this episode?

Williams: My overall pearl is that I probably don't use inhaled corticosteroids as empirical therapy often enough. Every so often I will. But Dr Hayward recommends leading with that if you are going to be doing empirical therapy because it can rule out steroid-responsive conditions if they don't respond. Common things that cause chronic cough, like cough-variant asthma, or nonasthmatic eosinophilic bronchitis, would actually respond to steroids. So they are a reasonable first line to help narrow your differential, and they may make the patient feel better. So I think I may lean on those a little more heavily moving forward when I have a patient whose cough I can't quite figure out.

Brigham: One thing about inhaled corticosteroids kind of blew my mind. We all know that postviral cough can last up to 8 weeks. Dr Hayward actually recommends using inhaled corticosteroids to help ameliorate the symptoms, which I found interesting and incredibly practical in the COVID era. We have a lot of post-COVID patients with a postviral cough, so I found the information very useful.

Watto: We specifically pushed back and asked about albuterol, because that's what everybody uses. The patients know that if they have cough or shortness of breath, "give me an albuterol inhaler." Hayward would not say yes to that, saying instead, "I would just give them steroids." I loved it. It was definitely something that I haven't done, but right now, this is great information to have. That's probably the better route to go. He even went so far as to say that if they were recovering from COVID and had prolonged symptoms of cough, in some cases if they had been really sick, he would give them prednisone (oral steroids), not just an inhaler.

We talked about the big three with chronic cough: upper-airway cough syndrome (which used to be called "postnasal drip"), gastroesophageal reflux disease (GERD), and cough-variant asthma. We talked about picking which one you think is most likely, and trying to treat it. You have to counsel the patient. I love this counseling. We see a lot of patients with chronic cough. Dr Hayward tells patients, "I'm in it with you for the long haul. We're going to have to try a lot of things. There's a lot of testing along the way. This could take months." He said it's almost like a battle of wills to see who will give up first.

Brigham: We were saying that just the threat of a bronchoscopy may cure the cough.

Watto: Paul, you made the great point that patients are just worried. I like your theory. Patients often think they have cancer, and sometimes if you just tell them they don't have cancer, they're like, "Well it doesn't bother me that much. I just thought it was something serious." They just want to rule out something serious.

The bottom line is, just counsel the patient with their expectations, and tell them you will be there with them. Even if you choose the right therapy, it takes a long time. Often, the cough will just go away before you figure it out; we don't know why.

We got into all the ins and outs of testing and treatment with Dr Hayward. If you want to hear those, click to hear our full conversation with Dr Bradley Hayward, #241 Chronic Cough, or find the Curbsiders' podcasts on iTunes. You can read our show notes and join our mailing list.

Thank you for watching.

The Curbsiders are a national network of students, residents and clinician educators from across the country representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge and bad puns. Learn more about their contributors and follow them on Twitter.

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