Understanding Chronic Cough:

Causes, Symptoms, and Diagnosis

Coughing is a natural defense mechanism that enables secretions produced in the

bronchial tract and tree to be cleared to eliminate any inhaled foreign particles that
may be physical or biochemical. In addition, it is a common respiratory reaction, or
symptom, for diseases that are either easily identifiable or covert.

Chronic cough differs from acute cough, characterized as having a known cause
that can be eliminated by managing the underlying cause. Chronic cough,
however, is the only symptom, and there is no clear presence of a disease
etiology. Chronic cough is characterized as a cough that lasts more than eight
weeks. It can produce marked suffering for patients and present a diagnostic
problem for clinicians when the disease is not apparent.

The pathogenesis of chronic cough

Ther all three phases of a cough. These consist of an inhalation phase which
produces enough volume and pressure to produce an effective cough. The second
phase is compression, characterized by increased pressure against the larynx
because of a contraction of the chest wall, abdominal muscles, and diet. The final
phase is expiratory, characterized by the opening of the glottis, which results in
airflow.

Coughs can either be voluntary or involuntary. A voluntary cough is produced on

demand (initiation) or can result in the suppression of a cough (inhibition). An
involuntary cough, by contrast, is caused by the autonomic system and is produced
by the stimulation of the vagal afferent nerves. Through simulation of the cough
receptors in the airway and other regions of the upper body, impulses are
generated, which travel through the vagus nerve to the medulla, which the higher
cortical centers control.

Afferent signals (signals toward the effector muscles) are then transmitted down
the phrenic (a mixed nerve carrying motor, sensory and sympathetic fibers. It is the
only nerve that provides motor innervation to the diaphragm) and afferent nerves
(any nerve that carries impulses from the central nervous system toward the
periphery, such as a motor nerve to produce the response) to the muscles which
control expiration to produce the cough.

A chronic cough may be stimulated by abnormalities of the cough relaxation and

the sensitization of both the central and afferent components, which produce an
exaggerated cough reflex sensitivity to stimuli that would otherwise not produce a
cough (cough hypersensitivity syndrome).

Causes of chronic cough

There are several causes of chronic cough; however, the most prevalent are
asthma, postnasal drip, and acid reflux. Postnasal drip refers to secretions
produced in the nose dripping or flowing into the back of the throat from the nose.
These secretions, which contain microbes and other bactericidal components, can
irritate the throat, triggering a cough. This can occur in people who develop
allergies, colds, rhinitis, and sinusitis.

Asthma is considered the second most frequent cause of chronic cough in adults
but the leading cause in children. Alongside coughing, patients often experience
shortness of breath and wheezing. Some patients with asthma have a comorbid
condition, cough variant asthma, in which a cough is the only symptom presented.

Acid reflux occurs when stomach acid flows from the stomach into the esophagus.
Many people with gastro-oesophageal reflux disease experience chronic cough
due to acid reflux. Chronic cough also accompanies heartburn; however, people
with gastro-oesophageal reflux disease may only have cough as their symptom.
Coughing is worsened during or after eating, talking, and bending.

Other causes of chronic cough are varied but include respiratory tract infection,
bacterial tracheobronchitis, or bacterial sinusitis after a viral upper respiratory tract
infection. Approaching all bacterial tracheobronchitis patients experience a cough
that produces sputum. In addition, patients may have sinus congestion which
causes nasal secretions that drip or flow into the back of the throat.

Another cause of chronic cough is treatment with angiotensin-converting–enzyme

(ACE) inhibitors. ACE inhibitors are favored by healthcare professionals as they
produce highly efficacious effects in patients. However, a common side effect is
persistent coughing which occurs in approaching 20% of people who take an ACE
inhibitor to treat high blood pressure and heart failure. Although cough is a
common side effect, several patients opt to continue with treatment if it is mild;
coughs may also reduce in severity if switched to a different ACE inhibitor. ommon
Causes of Chronic Cough

Several Less common causes of chronic cough include airborne environmental

irritants, aspiration (the act of drawing something, such as a liquid or a foreign
object, into the respiratory tract when taking a breath) during swallowing, heart
failure; pertussis (whooping cough), lung cancer, infections, and other lung
infections; and psychological disorders. Those that are common in smokers include
tobacco smoke, lung cancer, and infections.
A high proportion of adults in Europe
do not have protective antibody
concentrations against diphtheria
In a recent study published in the Eurosurveillance Journal, researchers conducted
a retrospective analysis of seroprotection against tetanus and diphtheria among
residents in Austria following an increase in diphtheria cases since 2022 in Europe.

Background
Diphtheria is an infection caused by Corynebacterium diphtheriae resulting in the
inflammation of mucous membranes in the throat and nose.

While an increase in the incidence of diphtheria among migrants in Europe was

observed beginning in August 2022, recent studies also found that the
concentrations of antibodies against diphtheria in adults in approximately 18
countries in the European Union were negligible.

Although no diphtheria outbreaks have been reported among the general

population of European Union countries, the low seroprotection increases the risk
of disease outbreaks.

Estimating the seroprevalence among the population could help determine the risk
of a diphtheria outbreak and increase awareness about the importance of vaccines
to ensure continued protection against diphtheria and various other diseases.

About the study

In the present study, the researchers measured the concentrations of antibodies
against tetanus and diphtheria to estimate the seroprotection prevalence among
Austrian residents.
The study included 10,247 individuals who volunteered to get tested for
concentrations of anti-diphtheria and anti-tetanus toxoid immunoglobulin G (IgG)
between 2018 and 2022.

Additionally, the extent of diphtheria toxoid and tetanus toxoid antibody waning was
also examined for individuals who had antibody concentration measurements for
two-time points since the last vaccination. Enzyme-linked immunosorbent assay
(ELISA) was used to determine the concentrations.

The results were categorized as non-protective, inadequately protective, or

adequately protective against tetanus and diphtheria. A generalized linear model
was used to log-transform the antibody concentrations with sex and age categories
as independent variables.

Additionally, geometric mean concentrations were calculated, and the waning of

antibody concentrations was analyzed separately for the diphtheria toxoid and
tetanus toxoid, with covariates including sex and age and the within-subject
variable of time elapsed since the last vaccination.

Results
The results indicated that the overall seroprotection prevalence against diphtheria
was 63.96%, and that against tetanus was 95.99%. Furthermore, the protection
against tetanus was seen to be long-term based on the antibody concentrations,
but the protection against diphtheria did not show similar patterns.

When analyzed according to sex, males were seen to have 1.13 times higher
seroprotection against diphtheria than females.

The seroprotection levels also varied according to age groups, with individuals
above 60 years having the lowest seroprotection against diphtheria and individuals
between the ages of 15 and 59 years having the highest seroprotection
prevalence.
The geometric mean concentrations of the antibodies against the tetanus toxoid
were 7.9 times higher than that against the diphtheria toxoid. Additionally, the
concentrations of the antibodies against the diphtheria toxoid waned in 89
individuals by approximately 2.9%.

Furthermore, when age groups analyzed the waning of antibody concentrations,

the findings reported that the diphtheria toxoid antibody concentrations decreased
at 16.5% for each increase of 10 years in age.

Austria introduced childhood vaccination against diphtheria in 1945, and the

occurrence of diphtheria in the general population had drastically reduced by the
late 1960s.

However, 72 cases of diphtheria were reported among migrants in Austria in 2023,

and the low levels of protection against diphtheria due to the waning of vaccine-
induced immunity pose a risk of diphtheria outbreaks.

The researchers believe that the low levels of protection could be due to various
reasons, such as missed booster vaccine doses, waning antibody levels, and low
levels of vaccine-induced immunity.

While the antibody concentrations against the tetanus toxoid decreased annually
by 6.9%, the high initial concentration of antibodies against the tetanus toxoid
implied that the antibody concentrations would not reach the inadequate protection
threshold before 50 years from the last vaccination.

Furthermore, the drastic difference in the levels of anti-diphtheria toxoid antibodies

and anti-tetanus toxoid antibodies indicated that either the diphtheria toxoid content
in the booster vaccine doses for adults is low or that individuals preferred the
monovalent tetanus vaccine for emergency care.