Some people have a chronic cough. That is very stressful for themselves and those around them

Frequent coughing every day. So much that it bothers you. And that for longer than eight weeks. That’s chronic coughing. As many as one in ten Dutch people struggle with this, according to a Dutch-Belgian study from May 2023. For some, the clinical picture is extreme: they cough for hours every day, often at night, and sometimes so hard that they vomit and feel like they are choking. For others the picture is milder: they clear their throat or cough constantly, sometimes partly unconsciously.

In all cases, chronic coughing is very stressful – for the patient and his or her environment, says pulmonologist José de Kluijver of the Reinier de Graaf hospital in Delft. “It is a misunderstood condition,” she says. “Many doctors do not see the seriousness, or do not know what to do with it. While chronic coughing can often be treated effectively.”

De Kluijver runs a specialized cough clinic at Reinier de Graaf, with branches in Delft and Voorburg. In addition to the pulmonologist, two ENT doctors and a gastroenterologist work here, plus (perhaps most importantly, according to De Kluijver) two cough speech therapists. The clinic in Delft started in 2009 as the second specialized cough clinic in the Netherlands; there are now five, who work closely together.

Coughing often has an identifiable cause, such as an infection, smoking, asthma or COPD (chronic obstructive pulmonary disease). The use of certain medications, especially so-called ACE inhibitors, also worsens coughing. But, the pulmonologist emphasizes: “We find no underlying cause in more than half of chronic coughers. That cause once existed but has been resolved – or it never existed. In other words, there is something else that is perpetuating the cough.”

The impact of chronic coughing is great, De Kluijver emphasizes. “People don’t sleep well and they get muscle pain, headaches and hoarseness, for example. There is often involuntary urine loss. People become frustrated, anxious, depressed, ashamed, and avoid social occasions. Many people also report relationship problems or problems at work. All this can lead to a downward spiral, with more and more complaints.”

To explain it better, De Kluijver includes a picture. It shows the chest and lungs, the mouth and throat area, but also the brain and the nerve pathways that connect all those areas. “Coughing is normally a defense mechanism,” she says. “It protects you against choking or inhaling something harmful. The coughing stimulus is therefore a warning signal. Very useful. But in people who have a chronic cough, the system is set too sensitively. The stimulus warns against something that is in fact innocent.”

Everyone constantly experiences all kinds of stimuli in the throat area: for example due to heat or cold, due to something mechanical, or due to something chemical, such as spicy food or a perfume smell. Talking or laughing can also be a stimulus. “Normally, these signals are filtered,” says De Kluijver, “so you don’t cough at every stimulus.”

This filtering takes place at different levels. It happens through the nerve pathways that conduct the stimulus to the brain, it happens in the brain itself, and it happens in the nerve pathways that control the actual coughing from the brain. With chronic coughers, things are disrupted in that entire chain. “The details of this are not yet fully known,” says De Kluijver. “But in any case there are changes in the nerve endings. Certain receptors are abnormal.”

Our patients have been coughing for an average of seven yearsJosé de Kluijver pulmonologist

A recent British-American review article in the trade magazine Clinical Translational Medicine also mentions other changes. Brain scans show, for example, that the parts of the cerebral cortex that are involved in unconsciously suppressing stimuli are less active in chronic coughers. All in all, this article speaks of ‘cough hypersensitivity’: a hypersensitivity of the nervous system to cough stimuli, and a reduced ability to suppress the cough.

“Our patients have been coughing for an average of seven years,” says De Kluijver. “Some have even been there for over thirty years. We manage to reduce coughing satisfactorily in 70 to 80 percent of these people. Then the complaints decrease to below 4, on a scale of 0 to 10. And we also have good examples of people who get rid of their complaints completely.”

Stopping coughing is not the goal of the treatment, emphasizes Heleen van Woudenberg, speech therapist at the Cough Clinic. “The goal is for people to cough less and gain more control over it. We teach people to take control as soon as they feel a coughing stimulus. As a result, they gradually become less bothered by coughing. And that works for most people.”

How does that treatment work? Van Woudenberg, who now has more than 35 years of experience with this, takes a seat. “First, the pulmonologist conducts an extensive examination,” she says, “to rule out underlying medical causes, or, where necessary, to administer medication for asthma, nasal complaints and heartburn, for example. If necessary, the ENT doctors or gastroenterologist are also involved. If that doesn’t help enough, people come to me.”

As a first step, Van Woudenberg explains to the patient about chronic coughing. About how coughing normally works, and what happens differently with chronic coughing, with ‘overstimulated cough nerves’ as the cause. And about the fact that chronic coughing is a disease in its own right, regardless of any possible cause in the past – and therefore must be treated separately.

How can speech therapy help with this? “Chronic coughing is often accompanied by a lot of tension in the throat area,” says the speech therapist. “Because of the overstimulated cough nerves, people are constantly ready to cough. They have tensed all their muscles in that area. As soon as they notice a tickle, they start fighting not to cough. But that actually makes them cough.”

The solution therefore starts with relaxation. “It may sound contradictory, but it is not the coughing stimulus that should come to your attention, but the relaxation. The relaxation system needs to come on.”

You can achieve this, for example, through breathing, but also by consciously relaxing your jaw, throat and tongue muscles. This often reduces the need to cough. “In addition, patients learn certain control techniques in order to gain control over their coughing.”

An important part of the treatment is coaching of behavior and thoughts. People can learn to respond differently to a stimulus, Van Woudenberg emphasizes. “A positive attitude is very important,” she says. “Looking at what works. For example, saying: ‘I’m coughing less now’, instead of: ‘I’m still coughing’. That gives hope. What also helps is the thought: ‘I can cough just once, because I have learned to stop’. People learn to break the domino effect. That thought gives a lot of peace.”

De Kluijver: “In the vast majority of cases this works very well. New medicines have also recently been developed that work on these nerve receptors. We hope that we can start prescribing them soon. In any case, there is a world to be won. And that is a message that we are very happy to convey.”

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