Cough

A cough is not an illness but a defence: it is how the airways clear out mucus, dust and anything else that does not belong there. There is no need to silence it at any cost. After an ordinary cold a cough often lasts two or three weeks, sometimes as long as a month, even once the nose is clear and the temperature has settled — the airways heal more slowly than a runny nose does. What is worth thinking about is not the cough itself but two questions: how long it has been going on, and what comes with it. The answers decide whether to wait at home, book an appointment this week, or call an ambulance now.

How long an ordinary cough lasts

Time is the main landmark, and it is how doctors sort coughs out.

• Under three weeks. Almost always a viral infection of the airways. Such a cough tends to be dry for the first days and productive later, is worse in the evening and clears on its own.
• Three to eight weeks. Usually the tail of an infection already over: irritated airways stay touchy to cold air, to talking, to laughing. But this is the window in which more serious causes start being looked for, especially in smokers.
• Longer than eight weeks. This is a chronic cough and it will not clear by itself: it has a cause, and the cause is found by investigating.

Phlegm changes colour in almost any lingering cold, and yellow or greenish phlegm on its own does not mean a bacterial infection and does not call for an antibiotic. Other things matter more: how much phlegm there is, whether there is blood in it, breathlessness, and a temperature that lasts more than a few days or returns after you had improved.

What actually helps while a cough settles

Chemists sell a great deal for coughs, and most of it has no convincing evidence behind it. It is simpler to rely on a few plain things.

• Warm drinks and rest: fluid soothes the throat and loosens phlegm, and rest speeds recovery.
• Honey. In adults and in children over one year, honey — including in warm water with lemon — works as well as most cough syrups. Honey is not given to babies under a year because of the risk of botulism.
• Cool, moist air in the bedroom: dry, overheated air makes a night cough worse.
• Stopping smoking, e-cigarettes and smoky rooms included. With a so-called smoker's cough this is the one measure that genuinely changes the picture.
• Painkillers and fever medicines from the usual over-the-counter groups if the throat hurts or the temperature is up. They do nothing for the cough itself.
• A raised head of the bed if the cough is worst at night.

What is not worth doing: treating syrups and lozenges as a cure, mixing several cold remedies at once, or finishing off an antibiotic left over at home. For a viral cough an antibiotic neither shortens the illness nor prevents complications.

When to call an ambulance

Call an ambulance — the single European number 112 works in Spain, Italy, Portugal, Poland and Ukraine — if an adult or a child develops any of the following:

• breathing is hard work, there is not enough air at rest, the person cannot finish a sentence;
• lips, face or tongue have gone blue, or the skin has turned grey;
• a child is breathing fast, the spaces between the ribs and the hollow above the breastbone pull in with each breath, there is a whistle or a harsh noise on breathing in, and the child cannot drink or cry;
• the cough started suddenly while eating or playing with a small object, which may have gone into the airway;
• coughing up blood, especially with breathlessness, chest pain or a very fast heartbeat;
• severe chest pain, fainting, confusion;
• swollen lips and tongue, a nettle rash and wheezing after a medicine, a sting or a food — this is an allergic reaction.

When a cough is not "just a cold"

Dangerous causes of cough are not common, but they are far easier to deal with when found early. Book an appointment rather than waiting it out if any of the following is present.

• A cough lasting more than three weeks, and particularly in a smoker or ex-smoker, or in anyone over forty. A persistent cough in a smoker is the commonest situation in which lung cancer is caught at an early stage, and it is also the one most often written off as "the usual smoker's cough".
• Blood in the phlegm, in any amount and even once.
• Unexplained weight loss, loss of appetite, night sweats.
• Breathlessness on your usual exertion or at night, especially if you have to sleep propped up and wake short of air; with it, swollen ankles.
• Wheezing that has appeared for the first time.
• Hoarseness lasting more than three weeks, or difficulty swallowing.
• Chest pain on breathing in, a temperature lasting more than a few days, or fever returning after you had improved.
• A weakened immune system — chemotherapy, long-term steroids, HIV, a transplant. That cough is looked at sooner and more thoroughly.
• Contact with someone who has tuberculosis, or living or spending a long spell in a country where it is common.
• Work with dust, asbestos, flour or lacquers, and a cough that eases on holiday and returns at work.

Medicines that make you cough

Hardly anyone thinks of this, yet it is a common cause and a completely reversible one. Angiotensin-converting enzyme inhibitors are a very widely used group of drugs for high blood pressure and heart failure, and their names end in "-pril". In roughly one person in ten they bring on a dry, nagging cough with a tickle in the throat, no phlegm, and worse on lying down.

The catch is that the cough may not begin with the first tablet but weeks or even months into steady treatment, so nobody connects it with the medicine. The person is investigated, treated for bronchitis and for allergy, when changing the drug would have done it. Never stop a blood pressure medicine on your own. Tell your doctor about the cough: the tablet is usually swapped for one of similar effect from a different group, and the cough goes over a few weeks, occasionally up to six.

Other drugs make coughing worse too: some inhalers irritate the throat, and beta blockers can trigger airway spasm in people with asthma. This is why it is worth bringing a full list of what you take to the appointment.

What lies behind a long-standing cough

When a cough drags on beyond two months and the chest film is clear, the cause is nearly always one of a short list — and in non-smokers the first three account for most cases.

• Mucus running down the back of the throat from a prolonged runny nose or sinus inflammation: worse in the morning and lying down, with a lump in the throat and constant throat-clearing.
• Asthma, including the cough-predominant form, in which there is no wheeze and no attack of breathlessness, only a dry cough at night, towards morning, in cold air, on exertion and in dust.
• Acid coming up from the stomach: coughing after meals and when lying down, a sour taste, morning hoarseness — although there may be no heartburn at all.
• Smoking and chronic obstructive pulmonary disease: a productive morning cough and breathlessness that keeps increasing.
• Whooping cough. It starts like a cold and then turns into bouts of coughing to the point of vomiting and of running out of air, and it drags on for months. Adults vaccinated in childhood catch it too, often in a blurred form, and babies catch it from them, for whom it is dangerous.
• Bronchiectasis: a steady large volume of phlegm and repeated chest infections.
• Heart failure: cough and breathlessness at night, swelling, being unable to lie flat.
• Tuberculosis, with a cough of more than three weeks together with sweats and weight loss.

Cough in a child

Children cough a lot, and most of the time it is the ordinary viral infections they get eight or ten times a year. But a few patterns need to be recognised on sight.

Croup. A barking, seal-like cough, a hoarse voice and a harsh noise on breathing in. It usually starts at night and frightens more than it harms: it is a viral inflammation of the voice box, mostly between six months and three years. Pick the child up, hold them upright and calm them, since crying makes it worse. Call an ambulance if the noisy breathing in is there at rest, if the child is clearly struggling, if the spaces between the ribs pull in, if they go pale or blue, if they cannot swallow their saliva, or if they sit leaning forward with the mouth open.

Wheezing. A whistle on breathing out in a baby under one during a cold, with fast breathing and poor feeding, is usually bronchiolitis; in older children repeated wheezing and a night cough point towards asthma. A wheeze appearing for the first time is always shown to a doctor.

A sudden cough in a well child with no cold, especially while eating or playing with small parts, is an inhaled object until proved otherwise.

Bouts of coughing to the point of vomiting or going blue, and pauses in breathing in a baby: that is what whooping cough looks like, and in the first months of life it is dangerous. Vaccination against it is in the schedule of every country we work in — the first doses in the first year of life, boosters after that, with exact timings set by the national schedule.

Cough medicines and combined cold remedies are not given to small children: they bring no benefit and their side effects can be serious.

What happens at the appointment

The doctor will ask how long the cough has lasted, whether it is dry or productive, when it is worse, what medicines you take, whether you smoke, what your work involves and whether you have been in contact with anyone unwell. Then they will listen to your chest, look at your throat and nose, and measure the oxygen level in your blood.

What follows depends on the picture. A chest X-ray is done for a cough of more than three weeks, for blood in the phlegm, in smokers, with weight loss and where pneumonia is suspected. Spirometry shows how the lungs are working and is needed when asthma or chronic obstructive disease is suspected; phlegm is examined when tuberculosis is a possibility. An antibiotic is not prescribed just in case, but when there are signs of bacterial infection or a high risk of complications.

Online consultation

A cough is exactly the kind of problem that is convenient to start online. From the timing and the accompanying signs the doctor can work out which of the three groups your case falls into: wait at home, be seen this week, or go in straight away. They will also go through your medicine list separately, because sometimes spotting a blood pressure tablet on it explains a cough that has lasted half a year. They will say which tests make sense, talk you through X-rays and results you already have, and help parents tell an ordinary cold cough from croup and from wheezing. And if your account shows that an examination or urgent care is needed, they will say so at once and plainly.

This material is for information only and does not replace medical advice.