Suddenly appeared. First, discreetly: a slight throbbing in the chest that, diligently, transformed into a light cough. However, the cough soon mutated into a relentless alien that for four weeks has invaded the life of the person who writes this. An intense, guttural and uncontrollable cough, capable of taking on different facets, each more striking. Because, as Ramón Gómez de la Serna already described in his Greguerías, cough has many faces: it can be “the barking of the lungs,” or “a cough with a trigger that erupts in shots” or “a cough with cogwheels.” .
As with the voice, there is only one cough; ours: “There are as many types of cough as there are people,” explains Dr. Antoni Rosell. This expert, clinical director of the Chest Area at the Germans Trias i Pujol University Hospital, also remembers the first lesson on tussis in the Faculty of Medicine. "The first thing they explain to us is its physiological part: cough is a reflex, a defense mechanism that the body has to respond when something irritates the throat or airways." The mechanism (“ultra-fast, defensive”) stimulates the nerves, which send a message to the brain. The brain then tells the muscles in the chest and abdomen to release air from the lungs, expelling the irritant.
Cough, adds the pulmonologist, is a symptom: “That is the second thing they explain to us: that it is a manifestation of various diseases.” Indeed, there are coughs caused by tuberculosis, a serious disease that, before the discovery of antibiotics and the universalization of vaccines, caused millions of deaths. As is also whooping cough: another highly contagious bacterial infection of the respiratory tract, which manifests itself through a dry, intense cough that is followed, when inhaled, by a series of chilling high-pitched sounds, which resemble screams. Whooping cough is current, as outbreaks are occurring that affect children who have not been vaccinated and adults who have lost immunity.
“There are more than twenty diseases that cause cough that a pulmonologist needs to know about,” summarizes Dr. Rosell. In addition to the two mentioned, we must not forget “the cough caused by common colds and the flu, the cough caused by swallowing a foreign object; "that caused by rare diseases - such as fistulas between the esophagus and the trachea -, by intestinal diseases or by cancer." The list would quickly reach “twenty-five or thirty conditions.” “We all have our cough and our job as doctors is to identify patterns, because the person does not always have one hundred percent of what the manual says. Doctors have to ask, understand and fit the context in which the cough occurs,” says Rosell.
The thing is that, unlike another very common symptom, such as fever, cough is often not considered something serious enough to consult. And you can spend days, even weeks, falling prey to it before taking action.
Today we cough more than ever? A recent Washington Post article, titled Can't Stop Coughing?, described the presence of a “persistent cough” that has made this virus season “exhausting.” Although the report admitted that cases of cough of this type are not officially controlled - making it impossible to compare - some doctors interviewed claim that they detect a higher incidence of prolonged coughs. The text cites specialists who describe patients “kidnapped by a cough that lasts one or two months,” who arrive at the consultation “exhausted by lack of sleep and with muscle tears from coughing so much.”
According to the article, the coronavirus could be a cause of this phenomenon. In part, because since the pandemic, people pay more attention to respiratory symptoms. But, as Dr. Rosell also points out, it is not just that: “I would approach it from a point of view of scale: millions of people have been infected with covid and there is a percentage that has been left with this bronchial hyperreactivity.” Consequently, there would be more coughing: “Because there have been millions of people who have had viral infections that they had not had before. It is a question of scale,” he reiterates.
Without forgetting the pollution factor, which “without a doubt,” says this specialist, influences the population's cough. “Depending on the type of toxicant in the air, there are many more people affected. Like those days of so many cruises in Barcelona or when, due to thermal inversion, the layer of pollution grows.” Although some deny it, all these pollutants are attacks that the body detects and, to avoid them, reacts... by coughing.
This is the case of Montse, a woman from Barcelona who started coughing last Halloween (“due to a poorly cured cold”) and ended up in the emergency room after Christmas, with a diagnosis of pneumonia. “He coughed and coughed, especially at night. It was a hateful cough, but it was based on syrup, paracetamol and ibuprofen. I felt terrible, but I let it go, because it seemed to me that it was no big deal and I was embarrassed to abuse the system for something like... a cough. Plus, I'm a smoker." Queta is another Barcelonan who has been coughing for weeks. A “dry, irritating” cough, she describes, that has presented itself without any other symptoms and that has led to a month of “generalized bad life” and sleepless nights. Like Montse, she is embarrassed to go to a doctor: “Also, I already went once and the answer was: 'It's just a cough,' implying that she had to put up with me. It is not a priority and, in part, I understand that.”
This modesty is common in consultations, as well as a certain disregard on the part of doctors in the face of what, in effect, is a vulgar symptom. “In part, this happens because there is a lot of consultation about the same thing. There is a saturation, but this would be, we would say, bad practice,” says Dr. Rosell. Because, no matter how common and repetitive it may be, with cough you would have to start “from scratch” with each patient: “Even if you have seen eight of the same ones that day.”
And for the patient: What would be the red lines to go to the doctor without delay? “First, time: a cough that lasts more than three weeks must be consulted,” says Rosell. “The second factor would be the intensity: if the cough prevents you from speaking or sleeping, you should also consult, because it affects your quality of life. And, of course, if it is accompanied by any important sign, such as choking, expectoration of blood, persistent chest pain and purulent, dense, yellow or greenish mucus.”
“The truth is that there are few medications that really stop coughing: basically, codeine, which is a classic treatment from a hundred years ago,” says Rosell. A treatment, he adds, that they don't give you without a prescription: “It is a derivative of morphine and, in addition to stopping the cough center, it slows down the breathing center. So codeine works very well and is our action drug, but it is not magic either.” In any case, this expert points out that things are changing: “Today we talk about chronic cough, which is defined when you have already finished the entire possible list of diagnoses. Those who suffer from it have a kind of hypersensitivity and everything makes them cough, so the industry is working to address the nervous, sensory receptors that cause this reflex. We will see how it evolves.”
Without forgetting corticosteroids, whose function is to reduce inflammation. Inflammation of the airways is one of the clear effects of coughing and also one of the reasons why it can last so long. Rosell provides an analogy of this phenomenon with what happens to the skin when it burns in the sun: “You are left wounded, inflamed, and it bothers or hurts for days… Well, when you have a viral infection, something similar happens: the endings Sensory sensations are altered and everything is exposed and inflamed.” And when the respiratory system is so sensitive, normal things (like laughing, breathing quickly, cold air, and even talking) cause coughing: “It's as if the response threshold of the cough reflex has been lowered, and that's why “Every now and then, you cough.”
Reduction of inflammation is a slow process, for which inhaled cortisone is increasingly prescribed; the 21st century answer to traditional pills. Rosell also mentions bronchodilators, medications that make the bronchus return to its original size.
