1. Thinking you have to 'just live with' a chronic cough, or that it is somehow 'normal.'
There is a medical cause for virtually every chronic cough, and no patient should just accept the cough unless it has been thoroughly evalutated by a physician and all measures taken to eradicate it.
2. Assuming the cough 'must come from the lungs' or is a 'lung condition'.
While many cases of chronic cough are from lung conditions, the vast majority are not. Most cases of chronic cough arise from post nasal drip, which in turn is from inflammation of the nasal passages and/or sinuses.
3. Undertreating the condition.
Often a doctor will prescribe medicine but the patient doesn't take it, or doesn't take it for the right length of time, or in the proper dose. Some coughs require a long time before they fully respond to treatment. A corollary of this error is when the physician doesn't give 'enough' medication or undertreats the cough (e.g., some cases of chronic sinusitis require 3 weeks of antibiotics, but only a week is prescribed; sometimes the dose of steroids given for chronic sinsuitis is too low).
4. Smoking while suffering from chronic cough.
I see many patients who continue to smoke while complaining of chronic cough. Sure, they admit to being addicted, or "I just can't stop", but there is still no excuse. Smoking could either be the direct cause of chronic cough (from chronic bronchitis), or greatly retard recovery from sinusitis/rhinitis (cigarette smoke impairs clearing of mucus). I tell my patients it's like complaining of a headache while banging your head with a hammer. Duh!
5. Fear of prescribing oral steroids.
Doctors are often reluctant to prescribe oral steroid medication (prednisone, methylprednisolone), yet many times it is the only drug that will effectively treat chronic upper airway inflammation. Steroids are effective for two out of the three most common causes of chronic cough (PND and asthma) and are also effective for many cases of bronchitis. As to side effects, the aim is to use oral steroids for less than two weeks; a short period will greatly minimize the side effects. If steroids work, the degree and rapidity of response will help to confirm the diagnosis; if they fail, little will have been lost. If the cough comes back off oral steriods, an inhaled steroid can be tried next, which might be effective and will have much less long term side effects.
6. Using second generation antihistamines for non-allergic rhinitis.
Second generation antihistamines (Allegra, Claritin, Zyrtec) are for allergic rhinitis .Yet they are often prescribed for patients with who do not have allergic cause of chronic cough; the drugs are ineffective in such cases.
7. Not considering dual causes of chronic cough.
In fact, many patients have more than one cause of their chronic cough. As a result, the cough may only partially improve with specific treatment. Rather than abandoning that treatment, another cause should be considered. Often, simply adding another drug, even if empiric treatment, will help treat the cough.
8. Diagnosing GERD to the exclusion of other causes without appropriate studies
GERD (gastroesophageal reflux disease) is a fashionable diagnosis, and is surely over diagnosed. To be certain of GERD, the patient should have a gastric pH study, which requires a stomach tube and in fact is rarely done. Instead, the diagnosis is often made by looking in the back of the throat for acid effects (an unreliable method), or by obtaining a history of heart burn or worsening of cough on recumbency (also unreliable for diagnosis of GERD-related cough). Such incorrectly-diagnosed patients are often treated with anti-GERD drugs. The main problems with this 'shoot from the hip' approach are that: a) GERD is an uncommon cause of chronic cough and on a purely statistical basis is unlikely to be the cause; and, b) the most common cause (PND) will not be considered, delaying proper treatment.
9. Not obtaining sinus CT scan or ordering just plain x-rays of sinuses.
The best way to reliably diagnose sinusitis is to get a sinus CT scan. We do a simple 'screening CT' which is just a few views of the sinuses, and sufficient for ruling out or diagnosing sinusitis. Plain x-ray of the sinuses is not nearly as good as a simple screening CT, and cannot be used to rule out sinusitis if it is negative. This opinion is at odds with a study that appeared in the medical journal Chest ( The Role of Sinus Imaging in the Treatment of Chronic Cough in Adults, Pratter MR, et. al. Chest 1999;116:1287-1291. ) In that study, done on only 36 patients, 35 had plain sinus x-rays and one had a sinus CT scan; no patient had both. The authors report that "no cases of sinusitis were missed" by the plain sinus x-rays. However, 5 patients did not improve, and thought the clinical course suggested sinusitis was not the diagnosis, there is really no way to know since the gold standard for imaging the sinuses (the CT scan) was not done. Also, the authors did not address the issue of cost, as many patients with a plain sinus film end up having a CT done later on. The point is: if you are going to do an x-ray of the sinuses, and CT imaging is available, DO NOT WASTE TIME AND MONEY on plain x-ray; just get the CT scan.
10. Not following through to resolution.
Too often the patient or physician gives up on chronic cough. There is a diagnosable cause of almost every case of chronic cough. Don't give up.
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