This webinar was recorded on  January 11, 2024

Did you know that coughing is one of the most common reasons people visit a doctor’s office? When coughing persists longer than eight weeks in adults, it’s considered a chronic cough. People with this condition often have uncontrollable coughing episodes and feel the need to cough or have a tickle in their throat beforehand. People with chronic cough find it difficult to communicate the frequency and impact of their cough to healthcare providers. While coughing is often associated with lung diseases, chronic coughing may not always have an obvious cause and can be resistant to treatment. In this webinar, Dr. Nancy Joseph will discuss the potential causes, implications, and treatments for chronic cough.

Speaker:

  • Nancy Joseph, DO

Dr. Nancy Joseph is double board certified in general pediatrics and allergy/immunology and is currently based in Massachusetts. She is a consultant and medical advisor for the Allergy & Asthma Network. Dr. Joseph is a member and fellow of the American College of Allergy, Asthma and Immunology and the National Medical Association (NMA) in which she is active locally and nationally. She is the immediate past Chair of the Allergy, Asthma, and Immunology Section of the NMA. She has collaborated with the NAACP speaking about COVID-19 during the height of the pandemic and has been featured on NMA talks as an expert panelist discussing asthma in the African American community. Dr. Joseph hosts the “How Do You Medicine” podcast highlighting healthcare professionals doing medicine their way. This podcast is under her brand, They Dynamic Doc, which she created to inspire and empower others to live life on purpose for a purpose. Dr. Joseph has been awarded Top Physician Under 40 by the NMA.

This Advances webinar is a partnership with the American College of Asthma, Allergy, and Immunology. ACAAI offers CME’s for this webinar.


CNE for nurses, and CRCE’s for Respiratory Therapists is available through Allergy & Asthma Network’s Online Learning HQ

CME is available through ACAAI for this webinar.


Sponsored by the American College of Allergy, Asthma and Immunology

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Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.

Lynda: I will go ahead and get started. Thank you for joining us. I am the CEO of allergy and asthma network, welcome to this webinar about chronic cough, presented by Dr. Nancy Joseph. All participants will be on mute. We will be recording this webinar and posting on our website in a few days. You can find our recorded webinars on our homepage, if you scroll down to the bottom of the page and you will see the list of recent and upcoming webinars. You will get a follow-up email. This webinar will be one hour in length, including time for questions. We will take questions at the end, but you can put your questions in the Q&A box at any time. It is at the bottom of your screen. We have someone monitoring the Q&A and chat if you have questions or need help. We will try and get as many questions as we can. This webinar is presented in partnership with the American College of allergy, asthma and immunology. We have a certificate of attendance if you need it for records. A few days after the webinar, you will receive any mail with supplemental info, in this case about chronic cough and a link to the recording. We will try to upload the link to the certificate of attendance in the chat. Let’s get started. Today’s topic, not everything that coughs is asthma. When chronic cough persists for more than eight weeks in adults, it is considered chronic. There are different treatments. It’s my pleasure to introduce Dr. Nancy Joseph, double board certified in general pediatrics, allergy and immunology, currently based in Massachusetts, a consultant and advisor for asthma and allergy network, a fellow of the National medical Association, in which she is active locally and nationally. She’s a chair of the asthma section of the NMA and hosts the, How do you medicine? Podcast, under her brand to inspire and empower others to live life on purpose, for purpose. She has been awarded the top physician under 40 by the NMA.

Dr. Joseph: thank you. Good morning and good afternoon. Thank you for the wonderful introduction. I will share my screen. I will have to change my galley review to see the chat. Let me know if anyone is having issues seeing my screen. I will go ahead and get started. Got it, thanks. Had to look for the thumbs up emojis. We will talk about coughing. I like catchy titles. Everything that coughs, well, not everything. But the common things. We will talk about allergy and asthma network. It’s the main mission to end needless death and suffering to the asthma and allergy conditions through research. This is the education arm. There should be info later in the talk about how to get more involved or more information about the AAN. I am double board certified. I am a pediatrician and allergist. I work in both capacities. I am an urgent care pediatrician and a consultant for AAN. I am active in the National medical Association, a voice for African-American physicians and patients. I chaired that and am the chair of that section. No disclosures for me. That’s the intro. Let’s get started on what you can expect today, to learn from this talk. Let’s get started. Let’s talk about why we are talking about cough. There are many things in medicine that bother people. Cough is one of the most common medical complaints and accounts for 30 million clinical visits per year. Also it’s annoying. It decreases quality-of-life. With the era of COVID, if you sort of cough, everyone’s like, are you OKa/ — OK? Cough is important to learn about. In general, it has so many effects, decreasing quality-of-life, in general being annoying.

Why do we even cough? The short answer is because we have to. It’s a defense mechanism, expelling threat, excess mucus and things like that, which trigger the cough reflex arc. Getting into the anatomy of coughing, more needy greedy info — basically, various things trigger cough. Smoke, noxious fumes, dry air, eating, exercise, any kind of throat irritation. Those triggers trigger the receptors in your respiratory tree. Pharynx, larynx, trachea. Those receptors send signals to the cortical center, your brain, which tells your muscle system to activate. He/she needs to cough. Simplest terms. Trigger, signal, signal back, urge to cough, cough happens. Basically, these Delta fibers, c fibers, basically, certain fibers receive certain info. These first fibers are mechanical stimuli. Particular mucus, passive, a rapid drop in pH — acid, all those things can trigger that fiber. It goes to your brain. OK cough. C fibers, chemical irritants, pollutants, smoke, cigarette smoke. Signals go to your brain. There are various ways that can happen. It activates respiratory muscles via motor, then you cough. This on the right is a more detailed view of the brain. Lynda mentioned chronic cough.

Let’s talk about different categories. Creamy city of anything — c hronicity of anything is based on time, that the ration. Acute or chronic depends on the disease. Anything less than three weeks is called acute cough. Common causes, your typical respiratory infection. Could be viral, bacterial, sinusitis, whooping cough. We will talk more about that later. Over three weeks but less than eight weeks, subacute cough. After you get a cold, you might have a post infectious cough. Cough is one of the last symptoms to go away when you have had an infection. That can last over three weeks. If it is under eight weeks, it is still subacute. Same with a seasonal allergy cough. You may be an early spring person. Symptomatic but only in early spring. That could be less than eight weeks and fall into subacute category. Now, chronic cough is more than eight weeks. That can be a lung disease or asthma cough. We will talk more about that later.

This talk is called not everything that coughs is asthma. But of course, we will touch on asthma as well. After all, it’s the allergy and asthma network, so we want to touch on asthma and the implications from that perspective. Reflux can be a cause, environmental allergies, medication, irritants. People always say, if they smoke, they have a smokers cough. That is chronic cough as well. Let’s get into it. I love this table. It does a good job separating the most common causes of coughing by age group. That’s important. What could it possibly be? Let’s take the first common cause. Ace inhibitor. That’s unlikely to see that in a child. Most children are not on ace inhibitors, which is antihypertensive. If you hear chronic cough in a child, your first would not be ACE inhibitor. They are unlikely to be on that medication. Asthma is on both. Environmental allergies, both, but less common in children. Foreign body, specifically younger children. Unlikely in adult, although there are certain syndromes that increase chances of aspiration, which then a foreign body becomes higher in your differential. Reflux is in both. I want to bring your attention to other things that may be flying under the radar. TTo Rett syndrome — tourette syndrome. Interstitial lung disease, tuberculosis. I want to bring your attention to, when you think about coughing, when you are trying to figure out the reason for chronic cough, having the age group of whatever that patient is, that you are managing, treating, assessing is important. Basically, I will show you a picture later, sinuses are holes in your face. There lined with mucus. That’s great. Mucus lining is protective. Like everything else, your body doesn’t typically do unnecessary things. There sinuses trap foreign particles. Yay! That’s great. Anything -itis typically means inflammation. Infection, allergies, anything, that inflamed mucus lining has an increased mucus production. That mucus gets produced, drains into the back of your throat and now becomes a trigger in rotation, but we talked about, in coughing. I love pictures. I’m a visual learner. You will see a number of pictures. It helps to hammer home the point.

Here are sinuses. Frontal sinus, F1, maximal, all that. They are holes in your face. They are lined with mucus. If you have increased production of mucus, these spaces are occupied by mucus, hence that pressure sensation, sinus pressure. Acute sinusitis, you get that pain pressure, thick nasal discharge, pick and be worse on one side versus the other. We will talk about red flags later. Severe headache, redness, swelling around the eyebrow or eye, right, you get pressure there, then you notice redness around the eye, things like that, we want to call that an emergency. You want to make sure you seek emergency care for that. Your condition may have advanced to the point where you need advanced care. I like this picture. It’s a view that allows me to start talking about sinus drainage and how it relates to cough. Your sinuses are lined with mucus. Yay, good day. Great. Just enough to do what we need to do. This is great. If we are making too much, let’s talk about drainage patterns. Depending on the sinus, that determines where it first rains. They eventually end up to the first drain — they eventually end up in the same place. The frontal sinus or go to the sinus frontal pathway first. The F1 drains posterior ially. You see the pattern. I circled this nasal cavity and nasopharynx, but it’s important to realize they all drain eventually to your nasopharynx. Why is that important? Aha! Lad you asked, glad you asked. When you are stuffy or congested, turbinates are swollen. We call it turbine a edema, which is what makes it hard to breathe through your nose when you have whatever, infections, allergies, that type of thing. Nasopharynx, we talked about how things drain. You remember that picture, it went like this. What is down here? That is going down to your throat. Those receptors. Pharynx was one of those places with that receptor, cough receptors. All that mucus drains to your nasopharynx, triggers cough reflex, then that pathway, then triggers you to cough. That’s why a sinus infection, sinusitis, anything that causes inflammation here, that is how that causes cough. Let’s talk about details, how you treat a typical acute cough. It depends. Viral?Bacterial ? Time will tell. If it is viral, which is common, it is self-limiting. Supportive care, increased water, home remedies, make you feel better. Anyone less than four years old, we don’t want to use a cough suppressant. Anyone older, you can use a suppressant. Typically, infections are viral and there is nothing to do except for support your fluid. However, it could become bacterial. That’s where antibiotics come. It’s important to realize not all infections are bacterial. Not all infections will be treated by antibiotics.

That is something we will get to later as well. Let’s talk about the color. I’m sure everyone has heard about, oh no, my mucus is yellow. I need antibiotics! Not necessarily. What does yellow mucus mean? The main point is two things. It can mean a number of things. Two, it doesn’t automatically mean antibiotics. You get infections, irritation, that increases mucus. Infection, Audis, you get clear mucus. There is nothing to do. Yellow colored mucus, what does that mean? It could mean coughed up mucus or from your nose. It means your immune cells are doing their job. It is immune cells and microbes. Immune cells are your fighters. They do their thing. They doing their thing, that’s all that means. Microbes can be viral or bacterial. Which one it is depends, determines what you do. If it is viral, no antibiotics. Bacterial, you need antibiotics. How do I know? The answer is time will tell. If you have been feeling terrible the past three days, oh no, I have yellow mucus. Unlikely you need antibiotics. Typically, we worry about a bacterial infection, once you have had issues for 10 days or more. Typically, you would go to your doctor. You are at day four at this point. You feel terrible. You were waiting through the work week. You started feeling terrible Tuesday. Now it’s Friday. I took off today. Can you prescribe me antibiotics? The answer is you likely have a viral infection so you don’t need antibiotics. In the vein of being good stewards, we do not want to over treat or inappropriately treat viral infections with antibiotics. Antibiotics are not indicated with a viral infection. We do not want to promote resistance to anything. Home remedies, things like that, home care, then if it’s going on, like yeah, it’s been two weeks now, then we are concerned it may be a bacterial infection. That is when antibiotics would be discussed. Let’s get into chronic cough. Asthma, reflux, allergic rhinitis, iatrogenic, which is medication induced. We will talk about their treatments and do a summary after that. Let’s talk about asthma. Sometimes it can be the only symptom. Coughing. So much so, part of the guidelines, not just diagnosing asthma but in assessing control, somebody have asthma, one of the things we use is nocturnal coughing. Cough is important in the realm of asthma. It is used as a factor to try and determine if this person has asthma. We will talk about the red stars player. — later. Typically, asthmatics have a nighttime cough. Cough variant asthma is a variation of asthma and those patients only have the cough. The mechanism of coughing from asthma goes — asthma is airway inflammation. Your airways get inflamed. There is increased mucus. You get bronchial constriction. Then you get constriction, increased mucus. That’s why you get wheezing. It’s the sound of the air trying to squeak through narrowed airways but also increased mucus, bronchial constriction and coughing. I am an immunologist. This is near and dear to my heart. Simply put, pollutants, bacteria, virus, allergies can cause, can cause epithelial damage, which sends various signals. These are interleukins, immune cells that do various things.

They are your immune messengers, among others. Depending on the interleukin, it determines what immune cell it talks to. We have various cells. Etc. etc. They do different things. One of which being, bronchial constriction. These are your muscles that cause constriction here. That is what these epithelial damage, because these interleukins to be secreted, and they talk to different cells. The cells, depending what they are, and the world of allergy, you are hearing things like TH2 profiles. This leads to IEG formation, globulin E, one of your quintessential allergy immunoglobulins. To avoid getting into the nitty-gritty, nerdy immunology detail, I will stop there. That is what this picture is supposed to demonstrate. On your right, you see normal airway, asthmatic airway, you have inflammation going, then some wall thickening. Here, you have wall thickening during attack. Increased mucus. Bronchial constriction happening here. That makes it hard to breathe. That is what an asthmatic airway looks like. Let’s talk about treatments. For asthma, how you treat it depends largely on severity and frequency of symptom. Once in a blue moon, if you are the type of person, you will get a symptom, they will give you an as needed medication versus a maintenance medication if your symptoms are more frequent. The main objective, no matter what you use, is to decrease inflammation in your airways. We don’t want this. This is an inflamed airway. RoBronchial constriction, it is super uncomfortable. We will talk about what it is if you don’t treat that. But let’s dilate bronchioles, make sure more air comes in, it makes the body more comfortable. More air, yay, then we want to decrease inflammation. Inflammation is not good. We don’t like inflammation. If we can decrease it, that would be great. This looks overwhelming but the purpose of this is to say, really hammer home the importance of asthma treatment, so much so, there are various guidelines, different guiding bodies for it, but this is what the GINA guidelines are. The purpose is to hammer home how important asthma treatment is but it is so driven by the frequency and severity of symptoms, that we call it a step wise intervention. It depends on your symptoms. Those symptoms determine which step you are going to be in. These are the newest ones, the 2023 guidelines for adults and adolescents. That’s what you see here. Whether you are in step three, with a dual inhaler, which has a steroid, long-acting medication in it or if it just has a steroid, that’s what this is for. Let’s talk about why treatment is important. We run into people who are like, I don’t have symptoms over time. They are frequent enough. I use my rescue inhaler. I’m fine. Why do I need to be on something? Why do we make such a big deal about making sure you are well controlled? Uncontrolled asthma symptoms can lead to lung remodeling. Airway remodeling is something you cannot reverse. We don’t want that. As much as we can avoid that, is what we want to do. Look at all that wall thickening. So much different. We don’t want that. We don’t want remodeling of our airway. In order to prevent that, we want to be proactive for asthma treatment. Let’s jump into allergic rhinitis and coughing. One thing I noticed about Massachusetts, being not from here, me and my allergies do not like Massachusetts, rather, Massachusetts allergies do not like me. I am incredibly familiar with this pathway. Basically, you get irritations from allergens, which triggers cough, inflammation ensues, increased mucus and we back in that cycle we talked about.

There are number of symptoms you can have. Seasonal elegies. One of which is postnasal drip. Nasal posterior trip, your mucus drips. Mucus lining doesn’t like things. How they expressed that is they increase production. Postnasal drip, itchy, watery eyes, nose, typically, then coughing. It drips in the back of your throat. This red star, postnasal drip cough, typically, not always, there is nothing hard and fast or always in medicine, there can always be exceptions, typically it is worse when you’re laying flat. What you would clear your throat, laying flat, it drips down the back of your throat when you lay down. OK, it has nowhere to go. It’s in the back of your throat. You don’t typically clear it because you are sleeping or something, or it makes everything worse and now you cough worse when you lay flat or in a particular season. May be in summer I am fine but in spring, I always get a cough. It irritates the back of your throat. That’s why coughing happens. We are back to that picture. Basically postnasal drip. Nasal cavity, nasopharynx,y coughing. I wanted to visually bring home what this means. Your nasal cavity, coughing, allergies, etc. Turbinates get swollen. Imagine if these swell because a valid use, infection, etc. Your cavity gets closed off. You get stuffy. You feel like you cannot breathe through your nose. Let’s talk about treatment. The most important thing is to avoid triggers as much as possible. The ways are various. Keep your windows closed, if you are pollen allergic. Keeping windows open allows pollen to get inside. Keep your windows closed when pollen levels are high. You want to wear glasses to keep pollens from going in your eye. Grass is a pollen. If your gardening, may be mowing, you want to wear a mask, maybe eye wear. If you are an indoor allergen person, like myself, dust mite covers would be helpful with a humidifier. Wash your hands after touching your animal. These are all environmental avoidance measures you can take. Aside, there are medications that are helpful. Intranasal steroids. You see those nose sprays that can help with stuffiness. There is antihistamines that are oral or in your nose. Luckily, all these are over-the-counter now. Intranasal antihistamine used to be prescription only. Now it is over-the-counter. Also you can refer to an allergist, such as myself, then we can do further evaluation, treatment, etc. You want to avoid the long-term use of decongestants. Now you are back where you started even worse. If I don’t use it, I get stuffy. If I do use it, it perpetuates the cycle. We don’t want that. Let’s talk about reflux. A rapid drop in pH makes something more acidic. It stimulates your cough reflex. It’s a trigger. That’s — reflux means it is coming from your stomach content. That is acidic. It is going straight up. That is causing your pH in your esophagus to drop, it stimulates your cough. Typically, these people will have coughing after meals. Especially acidic meals, tomato-based. Sometimes you wake up with a sour taste in your mouth in the morning. How do you treat it? Diet modification is important. Proton pump inhibitors or H2 blockers. There are different mechanisms by which you can treat reflux. That modification being super important. What works for you depends on who you are. Let’s get into the last category, the iatrogenic causes of cough. There are a number of medications that can cause chronic cough.

The most notorious, ace inhibitors like Lisinopril. If you notice, you were living life, everything was fine, then you started medication. A good question is, any new medication? Oh yeah, my blood pressure this and this, my doctor started this. Oh OK. ARBs, blockers, which are related. You want to avoid those if you developed a cough with lisinopril. The way you treat it is to stop the medication and use an alternative. You don’t want to restart or switch to something that is a similar class. That would defeat the purpose. You just got chronic cough, that will take months to go away. You don’t want to switch to something that would cause the same cough. Other causes include smoking, pollutants, environmental your tents and bronchiectasis. Outside the scope of this but it can raise concern for immune deficiency. You want to make sure you will refer appropriately for those patients. In general, the main treatment for causes of chronic cough, we want to avoid the sugars. If you know the trigger, avoid the trigger. Smoking cessation smoking cessation smoking cessation is important. In general, it causes unhappy lungs, irritation and things like that. Environmental modifications, if you have environmental allergies. If you want to know more about that, see an allergist. You can go from there. Keep your windows closed during certain seasons. There are times when you have poor air quality days. If you can, you want to avoid going outside during those times but you do the best you can. Awareness is key. I won’t spend too much time on this. It’s a good flowchart, how to work up somebody with chronic cough. They cough. Take a history. Is the cause suggested? Yes OK. Stop those. No, I don’t really know why. Maybe you can investigate. What you think it is, you treat it that way. If there is no response, go back to the drawing board. Upper airway cough syndrome. Asthma. Giving them inhalers, that type of thing. You get the point. It says the common causes here, sorry, common treatments. You don’t want long-term use of injections. Asthma, reflux, that type of thing. Whether or not it got better determines what you do. EKG, bronchoscopy, echocardiogram, pH monitoring, etc.. I want to remind everyone, I’m sure you see this everywhere. Remember to cover your cough. Cough into your elbow, cover your mouth and nose with a tissue, when you cough or sneeze, sneeze into your elbow. Never your hand. Put it into a wastebasket.

If you have a cough, wear a mask. Make sure you wash your hands with soap and water or hand sanitizer. I won’t spend too much time on this. This is a chart I made that I found to bring home, if you don’t remember anything else, like whew this went over my head, so wait a minute, how do I know? Just focus on this chart. Woosah. Basically, characteristics of cough on your left and common causes of coughing. I will quickly go through them. Acute or subacute? How long? We talked about medical training. How long has it been going on? A week. That is unlikely to be these things. OK. Now what kind of cough is it? Acute or subacute, that puts you infection higher on the list. Wet or productive. They have a fever, that type of thing. If his viral, supportive care. Bacterial, antibiotics. A few months now, now you are in chronic cough categories. If it’s nighttime or occurring around certain things, here tents, there is some wheezing, maybe shortness of breath, now you are worried about asthma. If it is seasonal, I’ve been having this since spring started, commonly people start at the change of seasons, man, it keeps me from going to sleep. I’m clearing my throat. Throat clearing cough is hot postnasal drip. You can get stuff like that whenever you have a cold. Those are things to worry about. Itchy watery eyes, OK, seasonal allergies. Reflux, you worry about it tends to happen after meals. I wake up with a sour taste in my mouth. Ah. Reflux. If none of that is the case, and the only thing you can find is they just started medication, look at their history and see if they are on ace inhibitors. You want to stop the medication because that is the cause. Red flags for coughing. Anytime someone is coughing up red flag red flag red flag, they need to get evaluated. If they are cop coughing up blood, emergency room. Hypoxia, emergency room. If there is no response to treatment, you have to reevaluate if your diagnosis is correct or your treatment is an effective. Now we are short of breath, we have fevers, frequent bacterial infections. You may be dealing with an immune deficiency. That is also a red flag. These are places you can find me. I am on some things social media. I have a website and podcast. This is where you find me. I will take questions. I think I finished with enough time for questions. I will leave this up. I will let you take it away.

Lynda: Thank you Dr. Really appreciate that thorough presentation about all things cough. A lot of questions for you. A lot of attendees are school nurses. This raises questions about children under their care. Some questions are in reference to what they could advise may be the families of children who have certain symptoms. The first is unrelated. Psychogenic cough and how that fits into this talk.

Dr. Joseph: Meaning? Give me more.

Lynda: That was the only thing they asked. How does chronic cough fit into how to diagnose and treat it and the options available?

Dr. Joseph: I will be honest. I am less experienced with psychogenic cough as opposed to, obviously, some common causes in primary care or allergic and asthmatic reasons. So I would not be well-versed in the treatment of psychogenic cough, the diagnosis and treatment.

Lynda: What meds are available to treat viral cough? Symptomatic treatment?

Dr. Joseph: What makes you feel better and warm inside. When it comes to viral cough, your body is doing the best it can. In terms of helping your body. Water, vitamin C. Don’t overload yourself with vitamin C. You don’t need to give all the vitamin C in the world. Time is the healer. It takes time to gather the troops, attack and do its thing, secrete all the thing it needs to do to kill it. There’s a lot of over-the-counter home remedies things you can do that could help you, depending on your symptoms. If you are stuffy, there are things that. There are cough suppressants you can use because maybe it is going to take time but you need to go to work. Or you want something to make you feel better. What you use is just to help you get through the journey, it’s not necessarily, if I don’t use this, it won’t be treated. If you have asthma, your asthma can flare with a viral infection. That is different. Your asthma was triggered. It’s not that we treat the viral infection, but we have to support your asthma to get you through the journey.

Lynda: One of the school nurses asked about chronic throat clearing in one of their students. How does that fit in?

Dr. Joseph: Chronic throat clearing could be a number of things. That could be a tick. It could be seasonal allergies. I can get chronic throat clearing on-and-off. I have a perennial allergy. My allergens are thankfully available all year round. Throat clearing the patient is doing, I would advise, seeing your PCP, because they would determine whether or not it is in allergy or it is something else that then needs a different subspecialist. Chronic throat clearing could easily be looked into. You could also advise that patient, maybe you should see your doctor. That could be some things. I just attended a lecture. Maybe see your primary care.

Lynda: One of the school nurses mentioned one of her students was prescribed albuterol inhaler and it made the cough worse. Would that happen for a reason you can explain? Should she talk to the parents?

Dr. Joseph: I don’t know that it is ever wrong to talk to parents per se, if you have a concern. That’s just communicating your concern. I don’t know if it is a pediatrician thing. We adequately advocate for spacers. One of the inhalers in my picture was attached to a tube thing, which is a spacer. That helps with distribution of medication. Oftentimes, these are the ones we are used to, the puffer. Oftentimes people use it, straight to mouth. Depress, inhale, you get some. The distribution can be stuck in the back of your throat or irritate your throat. You can diminish that by using a spacer. That helps the flow and delivery of medication to get to where it needs to go. That is something I typically would ask my patients if they are having technique issues. Albuterol is a bronchial dilator. You worry about use rather than anything else.

Lynda: Some nurses immediately said they love that chart you put up.

Is there a way — Dr. Joseph: Which one?

Lynda: Toward the end.

Dr. Joseph: The summary. Thanks I did it myself!

Lynda: [LAUGHTER]

Dr. Joseph: Something about having medical knowledge. I don’t know what it is. That’s up to you guys. I’m happy if you want to share that one slide, that’s fine. If you want to take a picture of it, let me know.

Lynda: That is an option.

Dr. Joseph: Thumbs up.

Lynda: We would have to get permission from you and the college to do it. This might be something we will try and accommodate after.

Dr. Joseph: Then never mind with the picture. For me, it is fine. AAN, we will work and see, if we can just get that slide, but also I believe the recording of this will be available later.

Lynda: It will.

Dr. Joseph: You can also listen, it’s the visual record?

Lynda: It’s both visual and audio.

Dr. Joseph: You can always relisten and take a screenshot or whatever but at least a recording would be available.

Lynda: We will look into whether we can share it in the follow-up email you will be getting and if not, you will have access to the recording if you want to do your own thing. Somebody asked his cough variant asthma considered chronic cough?

Dr. Joseph: It is a cause of chronic cough. It is a diagnosis. As opposed to saying, asthma is a chronic cough, I have a chronic cough because I have cough variant asthma. I’m still treating it as an asthmatic, meaning various inhalers depending on frequency of symptoms. That’s a reason to have a chronic cough. I hope that makes sense.

Lynda: Yeah. What are your recommendations for kids with chronic cough but no history of asthma or allergies? What should they advise families?

Dr. Joseph: Without being someone’s position and being able — physician and being able to take a history, to have a child in school with chronic cough, just that information, all I know is that this child attends a school I am a nurse at and has a chronic cough. That’s not enough info to suggest anything in particular unless someone has a cold, this is the first time not having a fever so now they can come to school and now they have a cough because of the cold. We’ve already determined they had a cold. They have a post infectious cough. Cool. That’s a sliver of the puzzle. To just say, there’s a student at my school, has a cough all the time, what do I tell the parents? The answer is, I’m trying to think of the right word, but there is not anything informative without any more knowledge. You would need way more knowledge. Even as a physician,,, my child has a chronic cough, what should I do, that’s not enough information for me to advise anything.

Lynda: Follow-up question. With there being a potential numerous number of reasons —

Dr. Joseph: You can say, I notice your child has a chronic cough. I attended a webinar. There could be a number of things going on. I recommend you starting with a pediatrician to figure out the cause. There are a lot of causes that are treatable and we can stop this. You can say, I feel like he or she, it really affects him or her. I would maybe see your doctor. That type of thing. I would recommend them to see the doctor. There is typically a good amount of treatment options depending on what your doctor thinks the cause to be. Please see your pediatrician.

Lynda: Thank you. Someone asked about vocal cord dysfunction and how that fits into this picture.

Dr. Joseph: In a number of ways. You typically want to see ENT. You can get a cough but oftentimes people get hoarse from that. It depends what kind of dysfunction happens. ENT is kind of like synonymous with that. In order for vocal cord dysfunction to enter the conversation in a significant manner, we want to see that the cord is dysfunctional. The person who visualizes that is typically an ENT. If you’ve been diagnosed, that can present itself in various ways. It is moving in an aberrant way. I’ve had people develop shortness of breath. You can have a hoarse voice. It depends. Your vocal cords are supposed to be doing things in synchronicity. When they do asynchronous things, what you get from that depends on the a synchronicity.

Lynda: It is 1:00. I want to thank you so much for this conversation about chronic cough. Helping out the school nurses that have children with cough under their care. Thank you. We have two webinars coming up next week. First Dr. Kimberly Blumenthal presenting on the importance of proactively addressing and the labeling antibiotic allergy on January 29. Dr. Kelly Maples will be presenting on dermatitis on favorite 20th at 4 p.m. I want to thank everyone, especially Dr. Joseph, to get us up to speed on chronic cough and with that, thank you for joining us and we will see you next time. Bye for now.

Dr. Joseph: Thank you everyone.