Hello, I'm Dr. Robert Bastian of Laryngopedia and Bastian Voice Institute (BVI). Our subject
is coughing in the context of Covid-19. Covid-19 has intruded into our lives in innumerable ways.
We've lost a lot of our fellow citizens. Others contracted the virus and were very ill from it,
including with pneumonia or bronchitis, and hard coughing was a part of the fight to recover
completely, and they are now fully recovered. A second group has recovered in general, and they're
weeks or months passed the acute infection, but they are experiencing a lingering and somewhat
productive cough. For this second group, it is as though a viral hurricane hit weeks or months ago,
and now for some, the high winds have been- are gone—the acute infection is gone—but there's a
lot of damage and debris. It's like the limbs and the roof shingles that have been blown off by the
hurricane, even though the sun is out—those things have to be cleared away.
So for some of these people, there is coughing that continues for a time even after they're
relatively well, as inflammation resolves. So it still has a purpose; (the cough) it's
cleaning up after the storm. A third group—the illness is gone and the lungs are tidied up.
They're healed and clean, there's nothing being produced, but the person continues to cough.
It isn't a cough like during the hurricane or immediately after clearing out debris. It's just
a cough that serves no purpose. It no longer is solving a problem of clearing things away
but the cough is the problem—it's interfering with quality of life.
So what's the explanation if there's no active infection and there's no debris to clean up?
This third group may have damaged or sensitized sensory nerve endings in the larynx. Here's the
vocal cords in the trachea. So the trachea here, the larynx here, and in the pharynx. Those areas
may have damaged sensory nerve endings. So these traumatized, damaged nerve endings are irritable
and twitchy. They go zing for no apparent reason and demand that you cough. Such persons with
Covid-19 nerve ending damage may have a specific cough diagnosis called Sensory Neuropathic Cough
that not a lot of people still know about. Now I have described sensory neuropathic cough in
detail in prior videos and on my teaching website Laryngopedia. I've also published on the subject,
and I've worked with general post-viral sensory neuropathic cough for 25 years, and I believe the
Covid-19 infection has simply taken its place along some of those earlier viruses as a cause
of sensory neuropathic cough. Well to review what I've described previously, key features of
sensory neuropathic cough are that each episode of coughing is initiated by a stereotype sensation;
a zing. People say it's a tickle, a dry patch, an itch, a pinprick, a dripping sensation. It's
like it happens again and again. The commonest location is at the sternal notch. The sternal
notch is right here. It's right at the base of the neck. The sternal notch, right there. That's
the most common. A second would be at the level of the larynx itself, and then there's some where
it's higher up here in the throat. And there are a few where it's kind of central chest down in here.
Now when that zing happens, it can initiate a single cough so a person could go
and they're just doing that dozens or hundreds of times a day.
Or it could be a few seconds of coughing, they get that zing and they kind of go
and then they're done. Or, unfortunately, sometimes it will trigger a violent and protracted
episode of talk- coughing that could go on for 30 seconds, a minute, and even longer.
So stereotype sensory disturbance, that's kind of this tickle, or itch, or something. Number
two is that the cough is out of proportion to anything produced by that cough. The cough is dry
or it produces mucus only after hard coughing, and I'm not sick at all I haven't been sick,
but if I sit here and force myself to cough really hard I will produce a surprising amount of mucus.
So the person asks in exhaustion, "Who coughs this much to produce that little amount of mucus,
or coughs that long before the mucus comes up?" The person may even cough hundreds of times a day,
mostly briefly, but they also can have those agonizing protracted and exhausting
episodes several times a day, to the point of embarrassment in public or even humiliation.
And that's not overlooked that some have it also interrupting their sleep a time or two, and
sometimes many times people are awakened at night, fortunately not all. So sensory disturbance,
cough out of proportion to anything you produce, and trigger phenomena. While coughing spells
can occur spontaneously, certain actions make that "zing!" more likely to happen. So people say things
like, "You know, I have a big laugh and I don't dare laugh in my usual way because every time I
do that it makes me cough." Or "If I talk a while on the phone," or "If I go outside in the cold
and I breathe in that first breath of cold air," or "I smell something really strong, a cleaning
solution," or "I swallow." Change your position. "I get in bed at night," or "When I get up at
night to use the bathroom I- it makes me cough." Or they'll say "If I touch right there it makes
me cough." Those are trigger phenomena. Fourth is the seeming futility of usual treatments. Taking
an expression from the film Casablanca, remember the french chief of police says to his underlings
at one point, "Go round up the usual suspects." Well those are allergy, acid reflux and asthma,
when people have this kind of chronic cough, and the treatment for those things does nothing.
Steroids may help but only while you're on them, and narcotic cough suppressants may provide some
relief, but that's not a good long-term treatment if the cough is going to go on and on and on for
months and months. Well what is the best approach? It's to target the irritable nerve endings.
Medications like Amitriptyline or Desipramine, Gabapentin, Citalopram, Mirtazapine, Venlafaxine,
Capsaicin spray, all of these have been described, I think most of them are on my
website, Laryngopedia. Usually one of the first two, if you're under 65, it would be
Amitriptyline or Gabapentin, usually one of those is effective. May not abolish the cough totally
but it's usually much much better. Persons with resistant cases may need to work their way down
a longer list beyond the first two, and so, you have to be patient to just work your way
through this series of medications. Occasionally injection of a long-acting local anesthetic—I
use Mepivacaine or Bupivacaine—combined with a locally acting steroid—the same
kind of thing you would have in a sore shoulder, or injected into your knee,
or that kind of thing—that is injected into a sensitized area and sometimes that can help.
Well what are the practicalities of finding help for sensory neuropathic cough after Covid-19?
Well first, if you're still very early after the infection and you're congested and bringing up
mucus and material, stay the course with the normal treatments of hydration,
cough suppressants and so forth. If the infection was weeks ago and you're feeling reasonably well,
but the main impediment to recovery and return of quality of life is your cough,
it seems like it's a cough that's the problem; not solving anything. Then educate yourself more fully
about sensory neuropathic cough. Laryngopedia has many articles, videos, patient interviews that
you can find by typing "COUGH" into the search window. Or, you can read an article—I'll link here
below—on the subject. It's a peer-reviewed article found in an open source medical journal—that is,
it's not behind a paywall because I wanted people to be able to
to get it anywhere around the world. And then raise the question with your personal physician,
"Is it possible I have sensory neuropathic cough?" and hand the article.
Consider that article because your doctor may not have encountered this diagnosis before.
And in that article, the treatment protocol is clearly outlined.
Think about doing advanced work before you go see a doctor. Call the group ENT or pulmonary and ask
to speak to the triage nurse. Say "I need that conversation before I decide whether or not I'm
going to come." And then ask him or her, "So any of your doctors treat sensory neuropathic cough?"
If the answer is no, or you get this kind of awkward response that lets you know they don't,
then call the next group with the same question. If you exhaust all local sources of help,
consider a teleconversation with an expert who lives far away from you. There are a number of
physicians across the country who are now aware of this diagnosis, but you may have
to do a little work to find them. Do your internet search and find people like us at Laryngopedia or
you are welcome to work with any of our doctors at Bastian Voice Institute in the suburbs of Chicago.
Now doctors at BVI would also be glad to help you in person if you live near Chicago.
Well here is wishing you a speedy resolution of your cough and hoping, along with you,
that it is only a brief aftermath of Covid-19. If, on the other hand, you are struggling with
coughing that won't go away, and after many weeks and despite many tests and treatments,
then I hope this discussion has helped give you a direction. Thank you for listening!