Lydia Hart, Specialist Speech and Language Therapist coughing

Cough Education Group

What happens when you cough?

Coughing occurs in the larynx, which is the ‘voice box’. This is part of the upper airway. Coughing is an important reflex to protect the airway. The cough reflex is controlled by nerves that connect to the brain. Coughs can either be voluntary (controlled) or reflexive (uncontrolled).

Coughing occurs as follows:

  1. The cough reflex nerve is triggered, sending a signal to the brain that you need to cough
  2. You inhale sharply and fill the lungs with air
  3. The vocal cords shut tightly, temporarily closing off the airway(i.e. holdingyour breath)
  4. The muscles of your tummy and ribs squeeze hard to push the air through theclosed vocal cords (which is why you can pull a muscle from coughing)
  5. The vocal cords ‘bash together’ strongly as you cough


What is chronic cough?

Chronic cough describes a cough which has persisted for some time, and/or has been resistant to treatment. Some people have a chronic cough for weeks or months, other people for years.

A common factor in chronic cough is cough hypersensitivity, sometimes referred to as cough reflex hypersensitivity, laryngeal hypersensitivity, or cough hypersensitivity syndrome.

What causes cough hypersensitivity?

There may be underlying medical causes for a chronic cough, such as respiratory condition, post-nasal drip or acid reflux, but cough hypersensitivity can occur on its own. There is usually an initial trigger for the cough, such as a cold or chest infection, but sometimes a cough persists even after the initial trigger has resolved.

Coughing is a reflex controlled by a nerve response (e.g. if there is something in the airway). When you cough repeatedly it can result in ‘overstimulation’ of the nerve, causing the nerve to become hypersensitive, which means it triggers more frequently than normal. A number of factors, including viruses and certain medications, can also have a direct impact on the cough reflex nerve, making it more sensitive.

Chronic coughing also causes changes in the brain – the neural pathways. People with cough hypersensitivity have increased sensitivity to cough triggers (e.g. perfume), and decreased ability to control or suppress their cough.

Repeated coughing causes the vocal cords to ‘bash together’, which irritates them. It also causes tension in the muscles of your throat. This irritation and tension can make you want to cough or clear your throat more, and can cause a sensation of throat tightness, something stuck in your throat, or a hoarse voice.

How is cough hypersensitivity diagnosed?

Cough hypersensitivity will be diagnosed after detailed assessment of your symptoms and their history.

Initially, your lungs will be investigated in case there is an underlying respiratory cause. You may also be investigated for acid reflux. You are then likely to be referred to a specialist speech and language therapist for cough therapy.

You may not have heard the term cough hypersensitivity syndrome before. This is because it is a relatively new diagnosis, which is still being researched and understood.

Cough control strategies

The following techniques can help manage and reduce coughing, by helping to reduce irritation and ‘break the cycle’.

  1. When you feel the urge to cough, try to stop yourself and swallow instead
  2. If you have a tickle or irritation, avoid focusing on the sensation as this is likelyto make it worse
  3. If you have a drink (preferably water) to hand, take a sip of fluid when youfeel the urge to cough. Try to to carry water with you at all times.
  4. Blow out through tightly pursed lips. If there is an irritation or tickle in thethroat, this can help dissipate it
  5. Sucking a sugar-free sweet or chewing sugar-free gum will encourageswallowing, soothe your throat, and give your brain a different sensation to

    focus on

  6. If you do have to cough, clear your throat gently with a ‘huff’ or quiet ‘pop’ ofair – then swallow or take a sip of fluid. This will minimise the irritation and


  7. Focus on slow, controlled breathing through the nose

With time and persistence, these strategies should help you to reduce the amount you are coughing.

Upper airway health

General ways to look after your upper airway, which will help minimise irritation and coughing.

  1. Keep well hydrated. Aim to drink 1.5-2 litres of fluid a day, the majority being water. Avoid caffeine and sweet or fizzy drinks, and drink alcohol in moderation.
  2. Don’t clear your throat. This causes a vicious cycle of irritation and tension in your throat. Sip and swallow instead.
  3. Steam inhalation is an excellent way of hydrating the throat, and can help sooth feelings of dryness, irritation or tickling. You can buy cups called ‘steam inhalers’
  4. Protect your throat from acid reflux. Symptoms of reflux can include heartburn and/or indigestion, but also coughing or throat clearing, excess mucous, or a feeling of a lump in your throat. This is caused by the acid ‘burning’ the throat. Avoid problematic foods, such as fatty, spicy or sugary foods; caffeinated, fizzy or acidic drinks, and leave 3-4 hours between eating and going to bed. Tilting yourself in bed, with a foam wedge or bricks under the legs at the head end, can help minimise acid reflux at night. Gaviscon Advance is the most effective over the counter treatment.
  1. Avoid irritants. Chemical fumes (e.g. cleaning products or perfumes) and dusty atmospheres are irritants of the throat. Wear a mask if you work in environments with fumes/dust. Cigarette smoke is especially harmful and can cause voice changes, long term damage and ultimately cancer. Stop smoking, and avoid smoky atmospheres.
  2. Breathe through your nose. The nose acts as a filter which cleans, warms and humidifies the air as we breathe in. Breathing through our mouths means that cold, dry air enters our throats which can cause dryness and irritation. Nose breathing also activates the diaphragm, and increases the amount of oxygen your body absorbs. If your nose is blocked, congested or runny, or if you have post-nasal drip, a salt water rinse (NeilMed) or spray (Sterimar or Vicks Vapospray) can help.
  3. Be aware of the atmosphere. Very cold air, dry atmospheres and air conditioning can all affect the throat, causing dryness, tightness and irritation. Breathing through your nose will help warm the air. If you are outside in the cold, wear a scarf around your mouth and nose. If you are in a dry or air- conditioned environment, try to get fresh air by opening the windows, use a humidifier, or use indoor plants to clean and humidify the air.

Healthy Breathing

It is common for people to ‘shallow breathe’ – rapid breathing into the upper part of the chest. Learning diaphragmatic low breathing will help to relax your upper airway.

  1. It is often easiest to first achieve this breathing when lying down. Otherwise sit in an upright chair, with your bottom to the back of the chair, and let the backrest support you. Place both feet flat on the floor, in line with your hips.
  2. To start with, place one hand on your stomach, just above your belly-button. Breathe through your nose. Closing your eyes may help.
  3. As you breathe in, feel the air travelling all the way down to the bottom of your lungs. You should feel your stomach expand underneath your hand. Imagine a balloon filling with air. As you breathe out, your stomach will gently move back in as the ‘balloon’ empties.
  4. Try and reduce the amount of movement in your upper chest and shoulders. Keep the shoulders relaxed and down – they may want to rise as you breathe in – but this will stop your diaphragm from working fully.
  5. Think of the breath being low and gentle, it is not a ‘big’ breath or gasp.
  6. Slow your breathing down, trying to lengthen each inhale and exhale.
  7. Allow the breath to flow – try not to hold your breath at any point, althoughthere can be a small ‘pause’ in between breaths.
  8. Practisediaphragmaticbreathingfrequentlythroughtheday.Itisparticularly

beneficial if you are feeling stressed, to help relax the mind and body.